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Spouse involvement in a residential treatment program for alcoholics Bond, Catherine R. 1978

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SPOUSE INVOLVEMENT IN A RESIDENTIAL TREATMENT PROGRAM FOR ALCOHOLICS by CATHERINE R. BOND B . A . , U n i v e r s i t y of B r i t i s h Columbia , 1976 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES (Department of Psychology) We accept t h i s t h e s i s as conforming to the r e q u i r e d s tandard THE UNIVERSITY OF BRITISH COLUMBIA J u l y , 1978 © Cather ine R. Bond, 1978 In p r e s e n t i n g t h i s t h e s i s in p a r t i a l f u l f i l m e n t o f the requirements for an advanced degree at the U n i v e r s i t y o f B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r reference and s tudy . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f th is thes is f o r s c h o l a r l y purposes may be g r a n t e d by the Head o f my Department or by h i s r e p r e s e n t a t i v e s . It i s u n d e r s t o o d that c o p y i n g or pub l i ca t ion of t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i thout my w r i t t e n p e r m i s s i o n . Department o f Psychology The U n i v e r s i t y o f B r i t i s h Co lumbia 2075 Wesbrook P l a c e V a n c o u v e r , Canada V6T 1W5 D a t e July 3 1 , 1978 i i ABSTRACT T h i s study compared the treatment outcomes of th ree groups of a l c o h o l i c c l i e n t s which v a r i e d i n the ex tent to which t h e i r spouses were i n v o l v e d i n a 26-day r e s i d e n t i a l t reatment program. The t h r e e groups c o n s i s t e d of 24 c l i e n t s whose t reatment inc luded a one-day c o n j o i n t spouse involvement program, 35 c l i e n t s whose t reatment i n -c luded a f i v e - d a y c o n j o i n t spouse involvement program, and 22 c l i e n t s whose spouses d i d not p a r t i c i p a t e i n the treatment program. S e l f -r e p o r t measures at 9.3.months fol low-rup i n d i c a t e d t h a t s i g n i f i c a n t l y more of the c l i e n t s who p a r t i c i p a t e d i n the f i v e - d a y ^ s p o u s e i n v o l v e -ment program were c o n t r o l l i n g t h e i r d r i n k i n g than c l i e n t s i n e i t h e r of the other two groups. I t was suggested that l o n g e r , more i n t e n s i v e spouse involvement may be the p r e f e r r e d a l t e r n a t i v e . f o r a l c o h o l p r o -grams w i t h a c o n t r o l l e d d r i n k i n g g o a l . In comparing the p resent f i n d i n g s w i t h the e x i s t i n g l i t e r a t u r e , i t was a l s o suggested t h a t spouse inolvement may be most b e n e f i c i a l f o r those programs w i t h modest success r a t e s , but of l e s s b e n e f i t to those programs w i t h h i g h success r a t e s . i i i A b s t r a c t Table of Contents L i s t of Appendices Acknowledgements I n t r o d u c t i o n Method R e s u l t s D i s c u s s i o n References TABLE OF CONTENTS Page i i i i i i v v 1 13 19 24 35 i v LIST OF APPENDICES Page Appendix 1. Appendix 2. Fo l low-Up Ques t ionna i re 42 P e r s o n a l O r i e n t a t i o n Inventory : P r e t e s t and Ad jus ted P o s t t e s t Group Means: M u l t i v a r i a t e A n a l y s i s of V a r i a n c e and Ana lyses of Covar iance 47 Appendix 3 . P r e t e s t , F o l l o w - U p , and Change Score Group Means and Standard D e v i a t i o n s : Ana lyses of Va r iance Appendix 4. Appendix 5: Appendix 6. Appendix 7. Appendix 8. Group Means and Standard D e v i a t i o n s f o r F i r s t P r i n c i p a l Component Scores on M a r i t a l , Work, S o c i a l , Home, and L i f e S a t i s f a c t i o n R a t i n g s : A n a l y s i s of Va r iance Ana lyses of Va r iance of P r o p o r t i o n s : F r e - . quency Data of Persons Unemployed, Separated or D i v o r c e d , At tended AA, Consumed A l c o h o l s i n c e Treatment, A b s t i n e n t i n L a s t 90 Days as a F u n c t i o n of Group Fo l low-Up Group Means and Standard D e v i a t i o n s : M u l t i v a r i a t e A n a l y s i s of V a r i a n c e F o l l o w - u p Group Means and Standard D e v i a t i o n s : H o t e l l i n g s T 2 D r i n k i n g Index: Number of A b s t i n e n t Days i n the 90 Days P r i o r to Follow-Up/Amount of A l c o h o l Consumed on an Average D r i n k i n g Day 49 51 52 53 54 55 V ACKNOWLEDGEMENTS I would l i k e to thank Dr. Char les Aharan and the s t a f f a t the V i c t o r i a L i f e Enrichment S o c i e t y f o r t h e i r c o o p e r a t i o n and a s s i s t a n c e i n c a r r y i n g out t h i s s tudy . I would a l s o l i k e to acknowledge the members of my t h e s i s committee, Drs . Park Dav idson , David Lawson, and James R u s s e l l , f o r t h e i r h e l p f u l comments. S p e c i a l thanks are due to Judy Hawkins f o r t y p i n g t h i s manusc r ip t . Th is r e s e a r c h was supported by Non -Med ica l Use of Drugs D i r e c t o r a t e Grants 1213 -9 -13 and 1 2 1 6 - 9 - 7 5 . 1 INTRODUCTION AND LITERATURE REVIEW R a t i o n a l e f o r Spouse Involvement i n A l c o h o l Treatment In su rvey ing the a l c o h o l t reatment l i t e r a t u r e p u b l i s h e d between the years 1951 to 1973, C o s t e l l o (1975) found f o r the 58 s t u d i e s t h a t had a f o l l o w - u p of one year that an average of 25% of the a l c o h o l i c s were s u c c e s s f u l i n moderat ing or t e r m i n a t i n g t h e i r d r i n k i n g , 53% were s t i l l d r i n k i n g w i t h an a s s o c i a t e d problem, 10% were dead, and 21% were l o s t to f o l l o w - u p . Such d i s c o u r a g i n g success r a t e s have prompted many c l i n i c i a n s and r e s e a r c h e r s i n the f i e l d to experiment w i t h a l t e r n a t e treatment approaches. One such approach tha t has gained i n c r e a s i n g support i n recent years i s that of i n v o l v i n g the spouse of the a l c o h o l i c i n t reatment . Much of the i n t e r a c t i o n between the spouse and the a l c o h o l i c i s thought to c o n t r i b u t e to or exacerbate the d r i n k i n g problem. M a r i t a l c o n f l i c t , poor communication p a t t e r n s , and the spouse 's i n a p p r o p r i a t e coping behaviour are f r e q u e n t l y c i t e d as f a c t o r s c o n t r i b u t i n g to the a l c o h o l i c ' s d r i n k i n g ( c f . , P r e s t o n , 1960; W e s t f i e l d . , 1972; Cataranzo , P i s a n i , Fox , & Kennedy, 1973; E s t e s , 1974; Ewing & Fox , 1968). By i n v o l v i n g the spouse i n therapy i t i s hoped tha t m a r i t a l c o n f l i c t can be reduced, communication p a t t e r n s improved, and a p p r o p r i a t e coping behaviours , l e a r n e d , w i t h a r e s u l t i n g improvement i n the d r i n k i n g problem. The spouse ( p a r t i c u l a r l y the w i f e ) i s a l s o thought to g a i n d i r e c t l y from her own involvement i n tha t a spouse group o f f e r s her a p l a c e where she can g a i n support and unders tanding — as w e l l as express her f e e l i n g s ( W e s t f i e l d , 1972; Sands & Hanson, 1971) . 2 Al though i t has been f r e q u e n t l y contended tha t the spouse of the a l c o h o l i c p l a y s some r o l e i n the a l c o h o l i c ' s d r i n k i n g , the exact nature of t h a t r o l e has been open to c o n j e c t u r e . In the 1940's when s o c i a l caseworkers f i r s t began working w i t h a l c o h o l i c s and t h e i r f a m i l i e s , they n o t i c e d c e r t a i n common behaviour p a t t e r n s c h a r a c t e r i s t i c of the wives of a l c o h o l i c s . These behav iours were thought to be the r e s u l t of some u n d e r l y i n g p e r s o n a l i t y s t r u c t u r e common to wives of a l c o h o l i c s and there was f u r t h e r s p e c u l a t i o n tha t women w i t h t h i s p a r t i c u l a r p e r s o n a l i t y chose a husband who was a l c o h o l i c or p r e a l c o h o l i c , i n order to s a t i s f y t h e i r unconscious needs. I f her husband's d r i n k i n g d i s c o n t i n u e d , the woman's p e r s o n a l i t y needs would no longer be met and she would "decompensate" or show a marked d e t e r i o r a t i o n i n her p e r -s o n a l i t y and behaviour (Futterman, 1953). Thus i t was to her advan-tage tha t her husband m a i n t a i n h i s d r i n k i n g . Ev idence f o r t h i s " d i s t u r b e d - p e r s o n a l i t y " theory was l a r g e l y based on c l i n i c a l i m p r e s -s i o n s ( c f . Boggs, 1944; K a l a s h i a n , 1959; P r i c e , 1945; Whalen, 1953) . However, r e s e a r c h i n the area has f a i l e d to support the t h e o r y . Not on ly have wives of a l c o h o l i c s f a i l e d to show any c h a r a c t e r i s e t ic p e r s o n a l i t y p r o f i l e ( B a l l a r d , 1959; Kogan, Fordyce , & J a c k s o n , 1963; T a r t e r , 1976) , but the p r o f i l e s t h a t they have shown on v a r i o u s psychometr ic t e s t s have l a r g e l y scored w i t h i n the normal range ( B a l l a r d , 1959; Corder , H e n d r i c k s , & Corder , 1964; P a o l i n o , McCrady, Diamond, & Longabaugh, 1976; Rae & Forbes , 1966; T a r t e r , 1976) . I t has been shown, however, tha t wives of a l c o h o l i c s show more d i s t u r b e d p e r s o n a l i t y p r o f i l e s and r e p o r t more p s y c h o p h y s i o l o g i c a l symptoms when they are l i v i n g w i t h d r i n k i n g as opposed to a b s t i n e n t a l c o h o l i c s 3 (Kogan & J a c k s o n , 1965; B a i l e y , Haberman, & A l k s n e , 1962; Haberman, 1964). These s t u d i e s suggest tha t the c h a r a c t e r i s t i c behaviour of the a l c o h o l i c ' s w i f e may be more a r e a c t i o n to the s t r e s s of l i v i n g w i t h a d r i n k i n g husband r a t h e r than the r e s u l t of a d i s t u r b e d p e r -s o n a l i t y . Researchers have begun to examine the ways i n which wives cope w i t h the s t r e s s of l i v i n g w i t h an a l c o h o l i c and the e f f e c t s t h i s has on the a l c o h o l i c ' s subsequent d r i n k i n g . Jackson (1954) i d e n t i f i e d seven s u c c e s s i v e stages tha t she b e l i e v e d most wives went through i n t h e i r attempts to cope w i t h t h e i r husband's a l c o h o l i s m , w h i l e Or fo rd and G u t h r i e (1968) i s o l a t e d f i v e d i f f e r e n t coping s t y l e s i n wives of a l c o h o l i c s . In a l a t e r s tudy , O r f o r d , G u t h r i e , N i c h o l l s , Oppenheimer, E g e r t , & Hensman (1975) found that c e r t a i n coping behav iours of w ives of a l c o h o l i c s were a s s o c i a t e d w i t h poor p rognos is f o r the a l c o h o l i c w h i l e other coping behav iours were a s s o c i a t e d w i t h good p r o g n o s i s . The r e s u l t s of t h i s l a t t e r study suggest tha t the coping behaviour of wives may be a good t a r g e t f o r i n t e r v e n t i o n i n therapy . S t u d i e s . h a v e a l s o shown t h a t the i n t e r a c t i o n between the a l c o h o l i c and h i s spouse i s an important v a r i a b l e i n the maintenance of d r i n -k i n g . Burton and Kaplan (1968) hypothes ized tha t the a l l e v i a t i o n of m a r i t a l problems would l e a d to decreased d r i n k i n g i n the a l c o h o l i c . In order to t e s t t h i s h y p o t h e s i s , they f o l l o w e d - u p 47 a l c o h o l i c s and t h e i r spouses who had p a r t i c i p a t e d i n c o n j o i n t group ^mar i ta l c o u n s e l i n g , the focus of which was to reduce m a r i t a l d i s c o r d r a t h e r than to a l l e -v i a t e the d r i n k i n g problem. They found t h a t a r e d u c t i o n i n f a m i l y pathology (as measured by the number of areas i n which a l c o h o l i c s and 4 t h e i r spouses repor ted c o n s i d e r a b l e disagreement) was moderate ly a s s o c i a t e d (r = .45) w i t h a r e d u c t i o n i n d r i n k i n g , thus p r o v i d i n g sup -p o r t f o r the i d e a that m a r i t a l c o n f l i c t may be a c o n t r i b u t o r to abus ive d r i n k i n g . Bromet and Moos (1977) a r r i v e d a t s i m i l a r c o n c l u s i o n s when they examined the importance of env i ronmenta l resources f o r the t r e a t -ment outcome of a l c o h o l i c s and found t h a t a l c o h o l i c s w i t h s t a b l e m a r i -t a l or work s i t u a t i o n s before e n t e r i n g t reatment had s i g n i f i c a n t l y b e t t e r outcomes i n terms of d r i n k i n g , s o c i a l , and p s y c h o l o g i c a l c r i -t e r i a , than a l c o h o l i c s w i thout these r e s o u r c e s . Us ing the Fami ly Environment Sca le (Moos, 1974), they found that f a m i l i e s w i t h h i g h l e v e l s of c o n f l i c t were a s s o c i a t e d w i t h s i g n i f i c a n t l y poorer outcome (on a l l the outcome v a r i a b l e s ) . F a m i l i e s w i t h h i g h l e v e l s of c o h e s i o n , a m o r a l - r e l i g i o u s emphasis, or lower l e v e l s of c o n t r o l were a s s o c i a t e d w i t h b e t t e r than expected outcome. (Expected outcome scores were c a l c u l a t e d u s i n g r e g r e s s i o n ana lyses based on soeiodemographic i n -f o r m a t i o n , measures of p s y c h o s o c i a l f u n c t i o n i n g , and d r i n k i n g v a r i a b l e s a t i n t a k e . ) O r f o r d , Oppenheimer, E g e r t , Hensman, and G u t h r i e (1976) a l s o found that h i g h l e v e l s of m a r i t a l cohes ion a t i n t a k e were p r e d i c t i v e of f a v o u r a b l e outcome. The i r measure of m a r i t a l cohes ion was based upon husbands'' and w i v e s ' r e p o r t s of mutual a f f e c t i o n , husband i n -volvement i n f a m i l y t a s k s , f a v o u r a b l e spouse p e r c e p t i o n s and expected p e r c e p t i o n s , a n d opt imism about the f u t u r e of the m a r r i a g e . At one year f o l l o w - u p r e l a t i v e l y cohes ive couples were more than tw ice as l i k e l y to f i n d themselves i n the f a v o u r a b l e r a t h e r than the u n f a v o u r -a b l e outcome group. The r e l a t i v e l y non -cohes ive couples were more 5 than three t imes as l i k e l y to f i n d themselves i n the unfavourab le outcome group. The r e s u l t s of these s t u d i e s make a s t rong case f o r involvement of the spouse i n t reatment . I t would seem that s p o u s e - i n v o l v e d t r e a t -ment which focuses on reduc ing c o n f l i c t and i n c r e a s i n g cohes ion w i t h i n the m a r i t a l dyad should f a c i l i t a t e improvement i n the a l c o h o l i c . Other r e s e a r c h e r s have attempted to i d e n t i f y s p e c i f i c p a t t e r n s of d y s f u n c t i o n a l i n t e r a c t i o n c h a r a c t e r i s t i c of couples i n which one member i s an a l c o h o l i c . I t i s hoped tha t by i n t e r v e n i n g and teach ing more a p p r o p r i a t e p a t t e r n s of i n t e r a c t i o n , c o n f l i c t can be lessened and m a r i t a l cohes ion enhanced w i t h the r e s u l t of a b e t t e r outcome f o r the a l c o h o l i c . Becker and M i l l e r (1976) compared the i n t e r a c t i o n s of a l c o h o l i c couples to p s y c h i a t r i c couples and found tha t the a l c o h o l i c couples i n t e r r u p t e d each other s i g n i f i c a n t l y more o f t e n than d i d the p s y c h i a t r i c c o u p l e s . A l though normal couples might have been a b e t t e r comparison group, t h e i r data suggest tha t f a u l t y communication p a t t e r n s and, more s p e c i f i c a l l y , e x c e s s i v e i n t e r r u p t i o n s may be r e l e -vant behav iours f o r i n t e r v e n t i o n i n m a r i t a l therapy . S t e i n g l a s s , D a v i s , and Berenson (1977) observed the i n t e r a c t i o n between a l c o h o l i c s and t h e i r spouses w h i l e they were sober and w h i l e e i t h e r one or both were i n t o x i c a t e d . They found t h e i r i n t e r a c t i o n i n both s t a t e s to be r i g i d and l a c k i n g i n v a r i a b i l i t y . Kennedy (1976) concurred w i t h both these r e p o r t s when he compared a l c o h o l i c couples to normal and p s y c h i a t r i c couples on t h e i r i n t e r a c t i o n p a t t e r n s w h i l e p l a y i n g a tax game. He found t h a t w h i l e a l c o h o l i c couples d i d not show any . homogeneous s t y l e of i n t e r a c t i o n , they d i d show more i n e f f e c t i v e or 6 d i s t o r t e d communicat ion, r i g i d i t y , and extremeness i n t h e i r i n t e r a c -t i o n r e l a t i v e to the other groups. By examining the types of s t a t e -ments a l c o h o l i c s and t h e i r spouses made d u r i n g t h e i r i n i t i a l s e s s i o n of group therapy , K o t i s (1968) found tha t on ly 17% of the husbands': and 15% of the w i v e s ' statements expressed a p p r o v a l , whereas 42% of the husbands' and 52% of the w i v e s ' statements expressed blame or defens iveness (the r e s t were m i s c e l l a n e o u s s ta tements ) . These r e s u l t s suggest tha t p a t t e r n s of i n t e r a c t i o n c h a r a c t e r i z e d by r i g i d n e s s , extremeness, and e x c e s s i v e i n t e r r u p t i o n s may be a good focus f o r i n -t e r v e n t i o n i n m a r i t a l therapy . I f couples cou ld l e a r n to be more f l e x i b l e and moderate and express a p p r o v a l r a t h e r than blame i n t h e i r i n t e r a c t i o n s , c o n f l i c t may be more s u c c e s s f u l l y a v e r t e d . T h i s i n t u r n may have some impact on d e c r e a s i n g the a l c o h o l i c ' s d r i n k i n g . To summarize t h e n , the arguments f o r involvement of the spouse of the a l c o h o l i c i n t reatment .seem f a i r l y cogent . From very e a r l y i n the s t u d i e s of t reatment of a l c o h o l i s m i t was n o t i c e d tha t spouses of a l c o h o l i c s show common behaviour p a t t e r n s . Subsequent r e s e a r c h has suggested tha t these p a t t e r n s may be a t t r i b u t e d more to the s t r e s s f u l s i t u a t i o n of l i v i n g w i t h an a l c o h o l i c than to a p r e - e x i s t i n g d i s t u r b e d p e r s o n a l i t y common among spouses. In a d d i t i o n , these behaviour p a t -t e r n s or modes of coping may p l a y a r o l e i n the maintenance of d r i n k i n g . Recent r e s e a r c h has shown that the i n t e r a c t i o n between the spouse and the a l c o h o l i c may a l s o be important i n outcome. I n t e r a c t i o n p a t -t e r n s c h a r a c t e r i z e d by r i g i d n e s s , extremeness, i n e f f e c t u a l communica-t i o n , and l a c k of express ions of approva l can b r i n g about c o n f l i c t and a l a c k of cohes ion i n a r e l a t i o n s h i p . These c o n d i t i o n s are ..... . 7 a s s o c i a t e d w i t h a poor treatment outcome f o r the a l c o h o l i c . Research R e l a t i n g to Spouse Involvement E a r l y case s t u d i e s a s s e s s i n g the e f f e c t s of spouse involvement i n therapy found that spouse involvement had t h e r a p e u t i c e f f e c t s on the spouses themselves . Cork (1956) and Igersheimer (1959) , f o r example, repor ted i n c r e a s e d s e l f - u n d e r s t a n d i n g , r e l e a s e of t e n s i o n , and a f e e l i n g of g rea te r p s y c h o l o g i c a l support i n the spouses i n v o l v e d i n group therapy . S i m i l a r l y , P a t t i s o n , C o u r l a s , P a t t i , Mann, and M u l l e n (1965) found tha t those wives s u f f e r i n g from acute s i t u a t i o n a l a n x i e t y r e c e i v e d support and r e l i e f from involvement i n a spouse group. C l i n i c a l t r i a l s (non -exper imenta l s t u d i e s tha t l a c k c o n t r o l groups) have suggested tha t e i t h e r concurrent or c o n j o i n t spouse involvement i n therapy seems to be b e n e f i c i a l i n dec reas ing d r i n k i n g ( G a l l a n t , R i c h , Bey, & Ter ranova , 1970; Gl iedman, R o s e n t h a l , F rank , & Nash, 1956; Loescher , 1970; Meeks & K e l l y , 1970; P i x l e y & S t e i f e l , 1963; S c o t t , 1959). In a d d i t i o n , there have been r e p o r t s of decreased d e -p r e s s i o n and i r r i t a b i l i t y i n a l c o h o l i c s (Gleidman et a l . , 1956) , and - improved communication between spouses and a l c o h o l i c s (Meeks & K e l l y , 1970; Cheek, F r a n k s , L a u c i u s , & B u r t l e , 1971; S t r a y e r , 1959) f o l l o w i n g spouse- invo lvement i n therapy . Greater f a m i l y cohes ion has a l s o been noted i n c l i n i c a l t r i a l s tha t have i n v o l v e d both the spouse and the f a m i l y (Esser , 1971; P a t t i s o n , 1965). Q u a s i - e x p e r i m e n t a l s t u d i e s a s s e s s i n g spouse involvement i n therapy have a l s o g e n e r a l l y shown f a v o u r a b l e outcomes. Ewing, Long, and Wenzel (1961) compared 16 a l c o h o l i c s and t h e i r spouses who 8 attended concurrent group therapy to 16 a l c o h o l i c s whose wives d i d not w ish to a t t e n d . Three years a f t e r the s t a r t of group the rapy , i t was found tha t more of the s p o u s e - a t t e n d i n g a l c o h o l i c s were a b s t i n e n t or very, much improved (50% as compared to 19% of the no -spouse a t t e n -d i n g g roup) , fewer showed s l i g h t or no improvement i n d r i n k i n g (19% a s . compared to 44% of the no-spouse a t t e n d i n g g roup) , and fewer were l o s t to f o l l o w - u p (31% as compared to 37% of the no-spouse involvement g roup) . However, i t was a l s o found that a l c o h o l i c s w i t h a t t e n d i n g spouses stayed i n t reatment s i g n i f i c a n t l y l o n g e r . T h i s makes i t u n -c l e a r whether i t was spouse invo lvement , the longer d u r a t i o n of t r e a t -ment, or an i n t e r a c t i o n between the two that was r e s p o n s i b l e f o r the b e t t e r outcome. Thomas, G i l l i a m and Walker (1960) s t u d i e d 80 problem d r i n k e r s who were r e f e r r e d by the Court f o r c o u n s e l i n g . Of these , 63 had a r e l a -t i v e who vo lun tee red to p a r t i c i p a t e i n f i v e s e s s i o n s of concur rent c o u n s e l i n g . F o l l o w - u p (t ime u n s p e c i f i e d ) r e v e a l e d t h a t more of the r e l a t i v e involvement group were a b s t i n e n t (18% as compared to 12% of the n o - r e l a t i v e involvement g roup) , more showed improved d r i n k i n g (68% as.compared to 23% of the n o - r e l a t i v e involvement g roup) , and fewer were unchanged or worse (14% as compared to 65% of the n o - r r e l a -t i v e involvement g roup) . In a d d i t i o n 69% of the r e l a t i v e - i n v o l v e d group showed improvement i n f a m i l y and s o c i a l adjustment as compared to 35% of the n o - r e l a t i v e i n v o l v e d group. A l though these r e s u l t s do favour involvement of a r e l a t i v e , i t . s h o u l d be noted tha t a g r e a t e r percentage of the c l i e n t s i n the n o - r e l a t i v e involvement group r e -fused t reatment , suggest ing t h a t the groups may have d i f f e r e d i n 9 terms of t h e i r m o t i v a t i o n f o r t reatment . Smith (1969) a l s o compared a l c o h o l i c s whose wives v o l u n t e e r e d to r e c e i v e concurrent group therapy to a l c o h o l i c s whose wives d i d not v o l u n t e e r . The 15 wives who p a r t i c i p a t e d r e c e i v e d concurrent group therapy weekly f o r s i x months. F o l l o w - u p conducted 16 months a f t e r d i s c h a r g e i n d i c a t e d tha t 40% of the spouse i n v o l v e d group were a b s t i -n e n t , 20% were improved, 33% showed no change, none were dead, and 7% were l o s t to f o l l o w - u p . T h i s group showed s i g n i f i c a n t l y b e t t e r o u t -come than the e i g h t a l c o h o l i c s whose wives d i d n ' t p a r t i c i p a t e . Of t h a t group, 12% were a b s t i n e n t , 38% were improved, 25% showed no change, and 25% were dead. In e v a l u a t i n g a t e n - s e s s i o n e d u c a t i o n a l l y - o r i e n t e d program f o r a l c o h o l i c s and t h e i r spouses, Madden and Kenyon (1975) found at f o l l o w - u p ( ranging from s i x to 36 months) tha t abs t inence was s i g n i f i -c a n t l y r e l a t e d to g r e a t e r s o c i a l s t a b i l i t y , absence of c o n v i c t i o n s , and a d r i n k i n g h i s t o r y of l e s s than 16 y e a r s , but not s i g n i f i c a n t l y c o r r e l a t e d w i t h the attendence of the spouse. T h i s i s the o n l y study found, . in an e x t e n s i v e l i t e r a t u r e rev iew tha t has shown t h a t spouse involvement was u n r e l a t e d to outcome. A p o s s i b l e e x p l a n a t i o n f o r t h i s r e s u l t i s that the program emphasized an e d u c a t i o n a l approach r a t h e r than a t h e r a p e u t i c one. The l i t e r a t u r e suggests tha t i t i s the i n t e r -a c t i o n between the a l c o h o l i c and the spouse — and the spouse 's coping behaviour — tha t i s c r i t i c a l i n m a i n t a i n i n g abus ive d r i n k i n g . I t seems l i k e l y t h a t an e d u c a t i o n a l approach would have l i t t l e impact on i n t e r -a c t i o n p a t t e r n s ; thus spouse involvement i n t h i s type of program may be i r r e l e v a n t . 10 Spouse involvement has a l s o been eva luated i n comparison w i t h no treatment c o n t r o l and w i t h a l t e r n a t e t h e r a p i e s . Cadogan (1973) com-pared 20 a l c o h o l i c s and t h e i r spouses who r e c e i v e d c o n j o i n t group therapy weekly f o r th ree to s i x months to 20 w a i t i n g l i s t c o n t r o l s . At f o l l o w - u p ( ranging from zero to th ree months a f t e r d i s c h a r g e ) , i t was found t h a t s i g n i f i c a n t l y more of the s p o u s e - i n v o l v e d group were a b s t i n e n t (45% as compared to 10% of the c o n t r o l g roup ) , fewer were d r i n k i n g o c c a s i o n a l l y (20% as compared to 25% of the c o n t r o l g roup ) , and fewer had r e l a p s e d complete ly (35% as compared to 65% of the c o n -t r o l g roup) . Thus, spouse involvement i s s i g n i f i c a n t l y b e t t e r than no t reatment . Hedberg and Campbell (1974) compared c l i e n t s randomly ass igned to b e h a v i o u r a l f a m i l y c o u n s e l i n g w i t h c l i e n t s ass igned to th ree other types of b e h a v i o u r a l therapy ( sys temat ic d e s e n s i t i z a t i o n , cover t s e n -s i t i z a t i o n , and e l e c t r i c a l a v e r s i o n t h e r a p y ) . Each type of therapy was g i ven i n s t a n d a r d i z e d s e s s i o n s over one year and c l i e n t s had the cho ice of e i t h e r abs t inence or c o n t r o l l e d d r i n k i n g as a treatment g o a l . Halfway through the program i t was found t h a t b e h a v i o u r a l f a m i l y c o u n s e l i n g showed the best outcome w i t h 74% of the c l i e n t s a t t a i n i n g t h e i r g o a l and 13% showing much improvement. Of the ten c l i e n t s i n t h i s group who chose abs t inence as a g o a l , e i g h t a t t a i n e d the g o a l , one showed much improvement, and one showed no improvement. Of the f i v e c l i e n t s who chose c o n t r o l l e d d r i n k i n g as a g o a l , th ree a t t a i n e d t h e i r g o a l , one showed some improvement, and one showed no improvement. ( I t i s i n t e r e s t i n g to note that c o n t r o l l e d d r i n k i n g , a t l e a s t w i t h spouse invo lvement , seems to be a p o s s i b l e a l t e r n a t i v e to a b s t i n e n c e . ) 11 One study has compared the e f f e c t i v e n e s s of the same t reatment program w i t h and wi thout spouse invo lvement : Corder , Cordery. and L a i d l a w (1972) set up an exper imenta l spouse involvement program i n which c l i e n t s f o l l o w e d the r e g u l a r i n p a t i e n t program f o r th ree weeks and spouses were i n v i t e d to p a r t i c i p a t e i n c o n j o i n t therapy f o r the l a s t four days . Twenty a l c o h o l i c s who. p a r t i c i p a t e d i n t h i s e x p e r i -menta l program were compared to 20 a l c o h o l i c s who had gone through the r e g u l a r four -week program d u r i n g the month p r i o r to the s tudy . A s i x -month f o l l o w - u p r e v e a l e d tha t s i g n i f i c a n t l y fewer of the c l i e n t s from the s p o u s e - i n v o l v e d group had resumed d r i n k i n g (42% as compared to 85% of the no-spouse involvement g roup) , fewer were unemployed (5% as compared to 50% of the no-spouse involvement g roup) , and more were i n v o l v e d i n r e c r e a t i o n a l a c t i v i t i e s (31% as compared to 5% of the n o -spouse involvement g r o u p ) . . T h i s study i n d i c a t e s tha t spouse i n v o l v e -ment may be a u s e f u l a d d i t i o n to an e x i s t i n g program. An a d d i t i o n a l f i n d i n g of the Corder et a l . (1972) study was t h a t s p o u s e - i n v o l v e d c l i e n t s were more f r e q u e n t l y i n v o l v e d i n f o l l o w - u p t reatment . T h i s f i n d i n g together w i t h the r e p o r t by B u r t o n , K a p l a n , and Hudd (1968) tha t f o l l o w - u p r a t e i n c r e a s e d when spouses were i n -v o l v e d , seems to i n d i c a t e the u s e f u l n e s s of spouse involvement f o r m a i n t a i n i n g cont inued contac t w i t h the a l c o h o l i c . To summarize the spouse involvement l i t e r a t u r e : e a r l y case r e p o r t s and c l i n i c a l t r i a l s have suggested tha t spouse involvement can o f f e r support f o r the spouse, decrease d r i n k i n g i n the a l c o h o l i c , f a c i l i t a t e b e t t e r communication w i t h i n the m a r i t a l dyad, and i n c r e a s e f a m i l y c o h e s i o n . S tud ies tha t compared a l c o h o l i c s whose spouses 12 v o l u n t e e r e d to a t tend treatment w i t h those who d i d n o t , have g e n e r a l l y shown f a v o u r a b l e r e s u l t s — a l t h o u g h i n some cases i t i s not c l e a r whether i t i s the spouse involvement per se that accounts f o r the b e t t e r outcome. Spouse involvement has a l s o been shown to be more e f f e c t i v e than no the rapy , o ther b e h a v i o u r a l t h e r a p i e s , and a s i m i l a r therapy program wi thout spouse invo lvement . One i s s u e t h a t has not been touched upon i n the l i t e r a t u r e i s tha t of the most e f f i c i e n t d u r a t i o n of spouse invo lvement . From a c o s t - b e n e f i t p o i n t of v iew , the b r i e f e s t spouse involvement f o r a g i ven t h e r a p e u t i c e f f e c t would seem to be b e s t , because spouse i n v o l v e -ment i s more expensive ( e s p e c i a l l y on an i n p a t i e n t b a s i s ) and i t i s o f t e n inconven ient f o r ; t h e spouse to a t t e n d . Yet i f involvement i s too b r i e f , there may be i n s u f f i c i e n t t ime to teach new s t y l e s of i n t e r -a c t i o n , r e s o l v e m a r i t a l c o n f l i c t , and to o f f e r support f o r the spouse. T h e r e f o r e , the present study was designed to r e p l i c a t e and ex -tend p r e v i o u s r e s e a r c h on the e f f e c t of spouse involvement i n t r e a t -ment programs f o r a l c o h o l i c s . S p e c i f i c a l l y , the study compared the e f f i c a c y of two d i f f e r e n t d u r a t i o n s of spouse involvement to tha t of no-spouse involvement i n an i n p a t i e n t t reatment program f o r a l c o -h o l i c s . Three groups were compared: a no-spouse involvement group, a one-day c o n j o i n t spouse involvement group, and a f i v e - d a y c o n j o i n t spouse involvement group. 13 METHOD Subjects The 81 a l c o h o l i c s s t u d i e d c o n s i s t e d of a l l those mar r ied c l i e n t s who completed the 26-day r e s i d e n t i a l t reatment program operated by the V i c t o r i a L i f e Enrichment S o c i e t y between the months of February and November, 1977. RCMP o f f i c e r s were exc luded from the sample b e -cause of t h e i r involvement i n another r e s e a r c h p r o j e c t . C l i e n t s who attended the program between the months of February and A p r i l and who wished to have t h e i r spouses a t t e n d , p a r t i c i p a t e d i n the one-day spouse involvement group (N=24). Those c l i e n t s a t t e n d i n g the program between the months of May and November who wished to have t h e i r spouses a t t e n d , p a r t i c i p a t e d i n the f i v e - d a y spouse involvement group (N=35). A l though a l l mar r ied c l i e n t s were encouraged to have t h e i r spouses p a r t i c i p a t e there were some whose spouses d i d not a t t e n d . These c l i e n t s formed the no-spouse involvement group (N=22). Time and expense were the two most o f t e n c i t e d reasons f o r the n o n p a r t i c i p a t i o n of the spouse. Some spouses who were employed f u l l -t ime cou ld not get the t ime o f f work and o thers w i t h f a m i l i e s were unable to f i n d b a b y s i t t e r s to take care of the c h i l d r e n w h i l e they attended the program. The spouse involvement programs were a l s o an added expense f o r the c l i e n t s i n c e the one-day program cost an a d d i -t i o n a l $20, . and the f i v e - d a y program an a d d i t i o n a l $100. Because the m a j o r i t y (approx imately 75%) of c l i e n t s a t the agency r e s i d e d o u t s i d e of V i c t o r i a , t r a n s p o r t a t i o n c o s t s were a f u r t h e r expense. The three groups d i d not d i f f e r s i g n i f i c a n t l y w i t h r e s p e c t to 14 age, sex , income, e d u c a t i o n , d u r a t i o n of m a r r i a g e , or l e n g t h of depen-d i n g on a l c o h o l . Of the t o t a l c l i e n t sample, 85% were m a l e s , 15% females ; the mean age was 45 .8 ( range, 24 to 60 y e a r s ) ; mean d u r a t i o n of m a r r i a g e , 19 years ( range, 1 to 37 y e a r s ) ; and mean l e n g t h of dependency on a l c o h o l , 13 years ( range, 2 to 40 y e a r s ) . Average i n -come was between $12,000 and $15,000 per year and a m a j o r i t y of the sample had completed secondary s c h o o l . Because of the i n a b i l i t y to randomly a s s i g n c l i e n t s to groups w i t h i n t h i s agency program, the th ree groups were a l s o compared on the f o l l o w i n g measures which were obta ined on the f i r s t day of the treatment program: c l i e n t s ' r a t i n g s (on f i v e p o i n t s c a l e s ) of t h e i r degree of s a t i s f a c t i o n w i t h t h e i r m a r i t a l l i f e , work l i f e , s o c i a l l i f e , and home l i f e ; the number of a b s t i n e n t days they had had i n the 90 days p r i o r to admiss ion to the program; and the amount of a l c o h o l c o n -sumed on a t y p i c a l d r i n k i n g day d u r i n g tha t t i m e . C l i e n t s a l s o com-p l e t e d the P e r s o n a l O r i e n t a t i o n Inventory (Shostrum, 1962) on the f i r s t and l a s t day of the t reatment program. Program The treatment program focuses on l i f e - s t y l e change through a humanis t i c ( p r i m a r i l y g e s t a l t ) therapy approach. A l though c l i e n t s are f r e e to choose e i t h e r abs t inence or c o n t r o l l e d d r i n k i n g as t h e i r d r i n k i n g g o a l , the program i s o r i e n t e d towards a b s t i n e n c e . C l i e n t s wi thout spouses or those w i t h spouses who d i d not a t tend the spouse program f o l l o w e d the r e g u l a r 26-day program, which i n c l u d e d d a i l y th ree -hour group therapy s e s s i o n s , d i d a c t i c l e c t u r e s . a n d d i s c u s s i o n groups, f i l m s , communication e x e r c i s e s , yoga and p h y s i c a l f i t n e s s , 15 A l c o h o l i c s Anonymous meet ings , and r e c r e a t i o n a l a c t i v i t i e s . C l i e n t s who p a r t i c i p a t e d i n the one-day spouse involvement group f o l l o w e d the r e g u l a r program w i t h the e x c e p t i o n of one F r i d a y i n the t h i r d week. Spouses a r r i v e d the evening before and were j o i n e d by the c l i e n t s f o r a b r i e f l e c t u r e concern ing the goa ls and ph i losophy of the program. The spouse program was presented as an o p p o r t u n i t y f o r p a r t n e r s to hones t l y assess t h e i r f e e l i n g s f o r one another and to eva luate t h e i r r e l a t i o n s h i p ; i t was emphasized that the program would n o t , however, be a p l a c e where m a r i t a l d i f f i c u l t i e s would be r e s o l v e d . F o l l o w i n g the l e c t u r e , couples p a r t i c i p a t e d i n s m a l l group exe rc i ses designed to f a c i l i t a t e communication and p rov ide an o p p o r t u n i t y f o r couples to meet each o t h e r . They were a l s o g iven a s e r i e s of ques -t i o n n a i r e s to be completed f o r the f o l l o w i n g day. The q u e s t i o n n a i r e s were designed to exp lo re four main themes: the extent to which p a r t -ners were f a m i l i a r w i t h each o t h e r s ' behav iours and p e r s o n a l i t y ; p o s i t i v e and n e g a t i v e f e e l i n g s p a r t n e r s had toward each other ; , an assessment of the s t r e n g t h s and weaknesses of t h e i r r e l a t i o n s h i p ; and the p l a n s couples had f o r t h e i r r e l a t i o n s h i p . The f o l l o w i n g day was spent s h a r i n g t h i s i n f o r m a t i o n i n s m a l l groups of couples as w e l l as engaging i n v a r i o u s communication and t r u s t e x e r c i s e s . The spouse program ended on the F r i d a y even ing , and t y p i c a l l y a l c o h o l i c s and t h e i r spouses spent the weekend together w i t h c l i e n t s r e t u r n i n g to the r e g u l a r program f o r the f o u r t h week. C l i e n t s who p a r t i c i p a t e d i n the f i v e - d a y spouse involvement program f o l l o w e d the r e g u l a r program u n t i l the l a s t week. At the beg inn ing of the l a s t week, spouses moved i n t o the t reatment agency. 16 Dur ing the week c l i e n t s and t h e i r spouses at tended d a i l y th ree hour c o n j o i n t group therapy s e s s i o n s , d i d a c t i c l e c t u r e s and d i s c u s s i o n groups, communication and t r u s t e x e r c i s e s , AA and A l - A n o n meet ings , and a meeting w i t h r e p r e s e n t a t i v e s from f o l l o w - u p t reatment a g e n c i e s . The themes f o r the f i v e - d a y spouse involvement program were s i m i l a r to the one-day spouse involvement program, but because of the extended t i m e , were d e a l t w i t h more i n t e n s i v e l y . A g a i n , w i t h the a i d of the q u e s t i o n n a i r e s used i n the one-day program (as w e l l as one a d d i t i o n a l q u e s t i o n n a i r e ) , couples were encouraged to assess t h e i r f e e l i n g s f o r one another , the s t rengths and weaknesses of the r e l a t i o n s h i p , and the k i n d of commitments they were w i l l i n g to make to each o t h e r . Group therapy s e s s i o n s a l s o focused on areas of c o n f l i c t between p a r t n e r s and a p p r o p r i a t e ways that the c o n f l i c t cou ld be r e s o l v e d . A l l a c t i v i t i e s i n both spouse programs were superv i sed by two of the s t a f f members. S t a f f i n c l u d e d two p s y c h o l o g i s t s , a s o c i a l worker , two t r a i n e d l a y c o u n s e l o r s , and a p h y s i c i a n . Fo l low-Up As p a r t of an ongoing program e v a l u a t i o n , the agency had arranged to contact c l i e n t s f o r f o l l o w - u p between the months of February and May, 1978. Because c l i e n t s had attended the program at d i f f e r e n t t imes (from February through November, 1977) but had to be f o l l o w e d - u p d u r i n g the i n t e r v a l from February through May, 1978, f o l l o w - u p p e r i o d s ranged between s i x and 14 months. The mean f o l l o w - u p p e r i o d was 9.26 months. Most of the c l i e n t s were contacted by te lephone , some by m a i l , and one was i n t e r v i e w e d p e r s o n a l l y . A l l of the i n t e r v i e w s were conducted by c l i n i c a l psychology graduate s tudents w i t h the e x c e p t i o n 17 of one conducted by an agency s t a f f member. In a d d i t i o n to the measures used i n the pret reatment assessment , f o l l o w - u p i n f o r m a t i o n i n c l u d e d the f o l l o w i n g a d d i t i o n a l outcome mea^ s u r e s : d r i n k i n g i n d i c e s — i n c l u d i n g the occurrence of any d r i n k i n g ep isodes and any change repor ted i n a l c o h o l consumption s i n c e l e a v i n g the program; any change i n f i n a n c i a l , m a r i t a l , or employment s t a t u s and the nature of t h a t change; number of days absent from work d u r i n g the l a s t three months; extent of involvement i n AA and c o u n s e l i n g s e r v i c e s s i n c e l e a v i n g the program; d u r a t i o n of t ime tha t Antabuse was t a k e n ; a r a t i n g of o v e r a l l l i f e s a t i s f a c t i o n ; and r a t i n g s of the degree of he lp the spouse program prov ided to the c l i e n t and the c l i e n t ' s spouse (see Appendix 1 f o r complete q u e s t i o n n a i r e ) . C l i e n t s Los t to Fo l low-Up Every e f f o r t was made to contact a l l of the c l i e n t s . Those who were not at home or out of town when the i n i t i a l f o l l o w - u p attempt was made were repeated l y c a l l e d u n t i l contact was made. For those c l i e n t s who had moved and l e f t no fo rward ing address , spouses and apartment managers were co nsu l ted f o r fo rward ing addresses , te lephone d i r e c t o r i e s were checked, and s t a f f a t the treatment agency were contacted f o r i n -formation concern ing them. Of the 81 c l i e n t s who p a r t i c i p a t e d i n the program, 70 completed the f o l l o w - u p i n t e r v i e w . Two of the c l i e n t s i n the f i v e - d a y spouse involvement group re fused to p a r t i c i p a t e i h the f o l l o w - u p and one c l i e n t i n the no-spouse involvement group on ly p a r t i a l l y completed i t . In a d d i t i o n , f i v e c l i e n t s i n the f i v e - d a y spouse involvement group, two i n the one-day spouse involvement group, and one i n the no-spouse 18 involvement group cou ld not be l o c a t e d . Thus, complete f o l l o w - u p i n f o r m a t i o n was a v a i l a b l e f o r 28 c l i e n t s i n the f i v e - d a y spouse involvement group, 22 i n the one-day spouse involvement group, and 20 i n the no -spouse involvement group. However, some r e l e v a n t i n f o r m a t i o n was a v a i l a b l e f o r two of the e i g h t c l i e n t s who cou ld not be contacted (one from the f i v e - d a y spouse involvement group and one from the n o -spouse involvement group) . In one c a s e , t h i s i n f o r m a t i o n was obta ined from the c l i e n t ' s spouse and i n the second case from a s t a f f member of the treatment agency who had p r e v i o u s l y contacted the c l i e n t . Th is i n f o r m a t i o n , though incomple te , was of s u f f i c i e n t v a l u e to be i n c l u d e d i n the a n a l y s e s . Moos and B l i s s (1978) have found tha t the t reatment outcome of c l i e n t s who were more d i f f i c u l t to l o c a t e was g e n e r a l l y worse than tha t ..of c l i e n t s who were easy to l o c a t e , but t h i s poorer outcome was accounted f o r by sociodemographic v a r i a b l e s a t i n t a k e . C l i e n t s who were d i f f i c u l t to l o c a t e tended to be younger , s i n g l e or s e p a r a t e d , have l e s s e d u c a t i o n , l e s s income, and l e s s r e s i d e n t i a l s t a b i l i t y . To determine whether c l i e n t s who c o u l d not be l o c a t e d i n t h i s s tudy might be expected to have poorer outcomes than c l i e n t s who were c o n t a c t e d , the two groups were compared on the demographic v a r i a b l e s of age, e d u c a t i o n a l l e v e l , and income. 19 RESULTS A l though c l i e n t s who were not a b l e to be contacted d i d have s i g -n i f i c a n t l y l e s s educat ion , Fj.1-,73) = 4 . 9 1 , _p_ < .03 , they tended to be o l d e r ( n o n s i g n i f i c a n t d i f f e r e n c e ) and have more income ( n o n s i g n i -f i c a n t d i f f e r e n c e ) than those who were c o n t a c t e d . Fur thermore , a l l of those not contacted were m a r r i e d . Th is would suggest tha t by Moos and B l i s s ' c r i t e r i a (1978) , there would be l i t t l e reason to e x -pect that group to have poorer outcome than those who were c o n t a c t e d . C l i e n t s from the f i v e - d a y , one -day , and no-spouse involvement groups were compared on the measures t h a t were obta ined on the f i r s t day of t reatment . A MANOVA showed no s i g n i f i c a n t d i f f e r e n c e s among the groups on t h e i r scores on the 12 s c a l e s of the P e r s o n a l O r i e n t a -t i o n Inventory (see Appendix 2 ) . One-way u n i v a r i a t e ana l yses of v a r i a n c e r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e s among the groups on t h e i r r a t i n g s of m a r i t a l , work, s o c i a l , and home l i f e s a t i s f a c t i o n , the number of a b s t i n e n t days i n the 90 days p r i o r to t rea tment , and the average amount of a l c o h o l consumed on a d r i n k i n g day d u r i n g t h a t t ime (see Appendix 3 ) . However, two t rends were noted on the measures of m a r i t a l s a t i s f a c t i o n and a l c o h o l consumption. C l i e n t s i n the n o -spouse involvement group showed l e s s m a r i t a l s a t i s f a c t i o n (p < .06) and g r e a t e r a l c o h o l consumption (j> < .07) than the other two groups. Us ing the p rescores as c o v a r i a t e s , ana lyses of c o v a r i a n c e were performed on the 12 P e r s o n a l O r i e n t a t i o n Inventory scores obta ined on the l a s t day of t reatment (see Appendix 2 ) . Only s c a l e e i g h t which measures the a b i l i t y to accept s e l f weaknesses, showed s i g n i f i c a n t 20 d i f f e r e n c e s among the groupSj F (2 ,64 ) = 3 . 3 4 , JP K -04 w i t h the one-day spouse involvement group showing lower scores than the f i v e -day spouse involvement group (p_ < .03) and the no-spouse involvement group (p_ < .02) ( s i n g l e degree of freedom c o n t r a s t s ) . S ince t h i s was but one of 12 s t a t i s t i c a l t e s t s performed on c o r r e l a t e d measures, i t i s p o s s i b l e tha t t h i s comparison cou ld have reached s t a t i s t i c a l s i g n i f i c a n c e by chance a l o n e . A c c o r d i n g l y , c a u t i o n should be e x e r c i s e d i n i n t e r p r e t i n g t h i s f i n d i n g . When both p rescores and f o l l o w - u p scores were a v a i l a b l e , g a i n scores were c a l c u l a t e d and analyzed u s i n g u n i v a r i a t e ana lyses of v a r i a n c e . The g a i n scores r e f l e c t e d changes from befo re t reatment to f o l l o w - u p i n : the degree of s a t i s f a c t i o n w i t h m a r i t a l , work, s o c i a l , and home l i f e , the number of a b s t i n e n t days i n the l a s t 90 days , and the average amount of a l c o h o l consumed on a d r i n k i n g day d u r i n g t h a t t i m e . A l though the p r o b a b i l i t y of a type one e r r o r i s i n c r e a s e d when u n i v a r i a t e ana lyses are performed on c o r r e l a t e d measures, u n i v a r i a t e r a t h e r than m u l t i v a r i a t e ana lyses were chosen because the agency was s p e c i f i c a l l y i n t e r e s t e d i n the e f f e c t s of spouse involvement on each of these i n d i c e s . There were no s i g n i f i c a n t group e f f e c t s on any of the v a r i a b l e s . A t rend (p_ < .06) was noted f o r ga ins i n number of days a b s t i n e n t i n the l a s t 90 days w i t h the one-day spouse involvement group showing more a b s t i n e n t days than e i t h e r the f i v e - d a y or the no-spouse involvement groups (see Appendix 3 ) . A p r i n c i p a l component a n a l y s i s was performed on the f o l l o w - u p r a t i n g s of m a r i t a l , work, s o c i a l , and home l i f e s a t i s f a c t i o n and an ANOVA was done on the f i r s t p r i n c i p a l component s c o r e s . No s i g n i f i c a n t 21 d i f f e r e n c e s were found (see Appendix 4 ) . Ana lyses of v a r i a n c e of p r o p o r t i o n s r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e s among the groups on any of the f o l l o w i n g dependent v a r i -a b l e s : percentage c u r r e n t l y unemployed; percentage who had separated or d i v o r c e d ; percentage who had at tended AA s i n c e the program; p e r -centage who had consumed a l c o h o l s i n c e the program; and the percentage who had been a b s t i n e n t i n the l a s t 90 days p r i o r to f o l l o w - u p . There was a s i g n i f i c a n t d i f f e r e n c e , however, i n the percentage of c l i e n t s who had been p r a c t i s i n g c o n t r o l l e d d r i n k i n g , d e f i n e d as four ounces or l e s s of a l c o h o l (40% by volume) per day, i n the 90 days p r i o r to f o l l o w - u p ( x 2 = 9 . 0 6 , df_ = 2 , p_ < . 0 1 ) . The f i v e - d a y spouse i n v o l v e -ment group showed more c o n t r o l l e d d r i n k i n g than e i t h e r the one-day spouse involvement group (p_ < .05) or the no-spouse involvement group (p_ < .01) ( M a r i s c u i l o 1 s l a r g e sample c h i square analogue of Schef fe type m u l t i p l e compar isons) . A MAN0VA r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e s among the groups on the f o l l o w i n g outcome measures: change i n f i n a n c i a l s i t u a t i o n s i n c e complet ion of the program; change i n a l c o h o l consumption s i n c e the program; number of days absent from work i n the l a s t th ree months; l e n g t h of t ime on Antabuse; and number of c o n t a c t s w i t h a counse lo r s i n c e the program (see Appendix 6 ) . C l i e n t s from both spouse involvement groups r a t e d the degree of h e l p f u l n e s s they thought the spouse program had been f o r themselves and f o r t h e i r spouses. A H o t e l l i n g ' s T 2 t e s t was performed on the r a t i n g s and no s i g n i f i c a n t d i f f e r e n c e s were found between the groups. On a f i v e - p o i n t s c a l e rang ing from very u n h e l p f u l to ve ry h e l p f u l , 22 c l i e n t s from both groups r a t e d the spouse programs as be ing both h e l p f u l f o r themselves (X = 4 . 1 3 , SD = 1.26) and h e l p f u l f o r t h e i r spouses (X = 3 . 9 8 , SD = 1.36) (see Appendix 7 ) . As mentioned p r e v i o u s l y , i t was necessary to f o l l o w - u p c l i e n t s i n a l l groups d u r i n g the same four -month i n t e r v a l i n s p i t e of the f a c t tha t the programs were conducted s e q u e n t i a l l y . The f o l l o w - u p i n t e r v a l s , t h e r e f o r e , v a r i e d s i g n i f i c a n t l y among the groups. The f i v e - d a y spouse involvement group was f o l l o w e d - u p a f t e r a mean of 7.67 months, the one-day spouse involvement group a f t e r 11.11 months, and the no-spouse involvement group a f t e r 9.45 months. In order to determine whether f o l l o w - u p t ime was a confounding f a c t o r , data from the c l i e n t s who had been f o l l o w e d - u p at the s h o r t e s t and longes t t ime i n t e r v a l s were excluded and the data were . r e a n a l y z e d . When the 13 c l i e n t s w i t h the s h o r t e s t f o l l o w - u p t ime were exc luded from the f i v e -day spouse involvement group, and the e i g h t c l i e n t s w i t h the longes t f o l l o w - u p t ime were exc luded from the one-day spouse involvement group, mean f o l l o w - u p t imes f o r the groups were not s i g n i f i c a n t l y d i f f e r e n t . R e a n a l y s i s of the data w i t h the s m a l l e r sample was c o n s i s t e n t w i t h the r e s u l t s obta ined w i t h the l a r g e r sample w i t h one e x c e p t i o n . A l t h o u g h , i n terms of the number of days a b s t i n e n t d u r i n g the p reced ing th ree month i n t e r v a l , the one-day spouse involvement group s t i l l showed l a r g e r ga ins than the f i v e - d a y and no-spouse involvement groups , the n o n s i g n i f i c a n t t rend shown w i t h the l a r g e r sample was no longer p r e -sent . I t seems l i k e l y tha t the r e d u c t i o n i n sample s i z e and the cor responding r e d u c t i o n in ,power i s the most l i k e l y e x p l a n a t i o n f o r t h i s occur rence . S ince t h i s was the on ly d i sc repancy i n r e s u l t s f o r 23 the large and small samples, the r e s u l t s f or the former w i l l be d i s -cussed. 24 DISCUSSION D e s p i t e the f a c t t h a t the groups were not randomly a s s i g n e d , t h e r e were no s i g n i f i c a n t pret reatment d i f f e r e n c e s among the groups i n terms of demographic v a r i a b l e s , P e r s o n a l O r i e n t a t i o n Inventory s c o r e s , measures of m a r i t a l , work, s o c i a l , and home l i f e s a t i s f a c t i o n , or f requency and amount of d r i n k i n g . Only two d i f f e r e n c e s even approached s i g n i f i c a n c e . C l i e n t s i n the no -spouse involvement group tended to have lower m a r i t a l s a t i s f a c t i o n scores and to consume more a l c o h o l on an average d r i n k i n g day than e i t h e r of the other groups. I t should be n o t e d , however, tha t these t rends were found when m u l t i p l e ANOVA's were performed on c o r r e l a t e d measures, a procedure t h a t i n c r e a s e s the p r o b a b i l i t y of a type one e r r o r . Thus, a l though the p o s s i b i l i t y e x i s t s tha t the groups may have d i f f e r e d ^ s i g n i f i c a n t l y p r i o r to t reatment , there i s no compe l l i ng ev idence to suggest tha t t h i s i s the case . A l though c l i e n t s i n the two spouse involvement groups i n d i c a t e d tha t the spouse programs were h e l p f u l both to themselves and to t h e i r spouses, the r e s u l t s showed that spouse involvement i n t reatment had very l i t t l e e f f e c t . Indeed, i t had no s i g n i f i c a n t e f f e c t on the c l i e n t ' s m a r i t a l l i f e , home l i f e , s o c i a l l i f e , work l i f e , or h i s p e r c e p t i o n of the degree of s a t i s f a c t i o n he f e l t w i t h h i s l i f e i n g e n e r a l . Moreover , i t had no s i g n i f i c a n t i n f l u e n c e on h i s i n v o l v e -ment i n AA or i n f o l l o w - u p t rea tment , nor on the d u r a t i o n of t ime that the c l i e n t took Antabuse. C l i e n t s whose spouses were i n v o l v e d were no more s e l f - a c t u a l i z e d (as measured by the P e r s o n a l O r i e n t a t i o n 25 Inventory) nor d i d they show any g rea te r change i n t h e i r d a i l y consump-t i o n of a l c o h o l than c l i e n t s w i thout spouse invo lvement . There was but one v a r i a b l e tha t succeeded i n d i f f e r e n t i a t i n g the th ree groups. S i g -n i f i c a n t l y more c l i e n t s i n the f i v e - d a y spouse involvement group p r a c -t i s e d c o n t r o l l e d d r i n k i n g d u r i n g the 90 days p r i o r to f o l l o w - u p than e i t h e r the one-day or the no-spouse involvement groups. Only 5% of the no-spouse involvement group and 9% of the one-day sp involvement group p r a c t i s e d c o n t r o l l e d d r i n k i n g d u r i n g the 90 days p r i o r to f o l l o w - u p as compared to 36% of the f i v e - d a y spouse involvement group. These data would suggest tha t i n t e n s i v e spouse involvement ( i . e . , f i v e days) may f a c i l i t a t e the g o a l of c o n t r o l l e d d r i n k i n g f o r the a l c o h o l i c . I t cou ld be argued tha t the pret reatment d i f f e r e n c e s i n a l c o h o l c o n -sumption f o r the th ree groups may account f o r t h i s c o n t r o l l e d d r i n k i n g d i f f e r e n c e . C l i e n t s i n the no-spouse involvement group drank an average of 19.70 ounces of a l c o h o l per day p r i o r to t reatment , as com-pared to 13.64 ounces f o r the one-day spouse involvement group and 14.20 ounces f o r the f i v e - d a y spouse involvement group. I f p o s t -t reatment a l c o h o l consumption were s imply a f u n c t i o n of pret reatment consumption r a t e s , the no-spouse involvement group would be expected to have the lowest post t reatment p r o p o r t i o n of c o n t r o l l e d d r i n k e r s . I f t h i s were the c a s e , however, then the one-day and the f i v e - d a y spouse involvement groups would be expected to have s i m i l a r p o s t t r e a t -ment p r o p o r t i o n s of c o n t r o l l e d d r i n k e r s because of the c o m p a r a b i l i t y of t h e i r pret reatment r a t e s of consumption. In f a c t , the one-day spouse involvement group showed a s i g n i f i c a n t l y lower p r o p o r t i o n of c o n t r o l l e d d r i n k e r s than the f i v e - d a y spouse involvement 26 group. Thus, i t would appear tha t pret reatment a l c o h o l consumption r a t e s do not account f o r c o n t r o l l e d d r i n k i n g . At t h i s p o i n t one can on ly s p e c u l a t e as to why i n t e n s i v e spouse involvement may f a c i l i t a t e c o n t r o l l e d d r i n k i n g . There i s ev idence to suggest tha t the i n t e r a c t i o n between a l c o h o l i c s and t h e i r spouses tends to be r i g i d , extreme, and l a c k i n g i n v a r i a b i l i t y ( S t e i n g l a s s et a l . , 1977; Kennedy, 1976) . One g o a l of the f i v e - d a y spouse i n v o l v e -ment program was to make c l i e n t s and t h e i r spouses more aware of t h e i r s t y l e of i n t e r a c t i o n and to p r o v i d e couples w i t h an o p p o r t u n i t y to experiment w i t h a l t e r n a t e i n t e r a c t i o n . p a t t e r n s . Couples were encou-raged to t r y compromise and n e g o t i a t i o n i n the m a r i t a l i n t e r a c t i o n . H o p e f u l l y , t h i s i n t e r v e n t i o n s t r a t e g y would enable couples to become more adept at problem s o l v i n g and more f l e x i b l e i n t h e i r demands of each o t h e r . Moreover , t h i s , k i n d of t r a i n i n g may have had some e f f e c t on the c l i e n t s ' p e r s o n a l t reatment g o a l s . Dur ing the program, c l i e n t s f r e q u e n t l y commented t h a t they would l i k e to be a b l e to resume d r i n k i n g whereas spouses t y p i c a l l y p ro fessed tha t they would not t o l e r a t e any d r i n k i n g . A p o s s i b l e compromise f o r these two extreme p o s i t i o n s would be t h a t of c o n t r o l l e d d r i n k i n g : c l i e n t s cou ld resume d r i n k i n g p r o -v i d i n g t h a t t h e i r d r i n k i n g was moderate and d i d not c r e a t e problems w i t h i n the r e l a t i o n s h i p . I f the c l i e n t was s u c c e s s f u l i n h i s attempts at c o n t r o l l e d d r i n k i n g , then t h i s would be a more m u t u a l l y a c c e p t a b l e g o a l f o r the c l i e n t and the spouse. Future r e s e a r c h examining the spouse 's a t t i t u d e s towards the a l c o h o l i c ' s d r i n k i n g , f o l l o w i n g i n t e n -s i v e spouse involvement i n therapy may p r o v i d e f u r t h e r ev idence f o r the hypothes is t h a t . i t i s ..the g r e a t e r f l e x i b i l i t y and w i l l i n g n e s s to 27 compromise t h a t accounts f o r the s i g n i f i c a n t l y g r e a t e r i n c r e a s e i n c o n t r o l l e d d r i n k i n g f o l l o w i n g i n t e n s i v e spouse involvement i n therapy . C l i e n t s i n the one-day spouse involvement group showed somewhat g rea te r (a l though n o n s i g n i f i c a n t ) ga ins i n number of a b s t i n e n t days from pret reatment to f o l l o w - u p than d i d c l i e n t s from e i t h e r of the other two groups. Th is t rend suggests t h a t b r i e f spouse involvement ( i . e . , one day) may f a c i l i t a t e the g o a l of abs t inence f o r the a l c o -h o l i c . The one-day spouse involvement program d i f f e r e d from the f i v e -day spouse involvement program i n t h a t i t d i d not o f f e r the same o p p o r t u n i t y f o r p a r t n e r s to experiment w i t h new i n t e r a c t i o n p a t t e r n s . Compromise and n e g o t i a t i o n , e s p e c i a l l y w i t h r e s p e c t to the c l i e n t ' s d r i n k i n g g o a l , would then be l e s s l i k e l y to have occur red i n the one -day spouse involvement group w i t h the r e s u l t t h a t many more of the c l i e n t s may have chosen a b s t i n e n c e as t h e i r g o a l . Both spouse involvement programs d i d , however, p r o v i d e an o c c a s i o n f o r p a r t n e r s to share t h e i r f e e l i n g s , assess the s t r e n g t h s and weak-nesses of the r e l a t i o n s h i p , and to make p lans f o r the f u t u r e . Many c l i e n t s (from both spouse groups) commented both d u r i n g therapy and a t f o l l o w - u p tha t they f e l t g r e a t e r support and unders tanding from t h e i r spouse when they l e f t the program, f e e l i n g s t h a t may i n c r e a s e the l i k e l i h o o d tha t the c l i e n t ' s p e r s o n a l d r i n k i n g g o a l w i l l be m a i n -t a i n e d . In the case of the one-day spouse involvement group, the more l i k e l y d r i n k i n g g o a l might have been a b s t i n e n c e , whereas i n the f i v e -day spouse . involvement group e i t h e r abs t inence or c o n t r o l l e d d r i n k i n g may have been chosen. I f t h i s t rend of g r e a t e r ga ins i n abs t inence 28 f o l l o w i n g b r i e f spouse involvement i n therapy i s r e p l i c a t e d , i t would suggest tha t b r i e f spouse involvement f u r t h e r s the g o a l of a b s t i n e n c e . C l i e n t s from t h i s study w i l l be f o l l o w e d - u p aga in at twelve months, thereby p r o v i d i n g a second o p p o r t u n i t y to assess t h i s apparent r e l a -t i o n s h i p . A l though 62% of the c l i e n t s i n the no-spouse involvement group were a b s t i n e n t i n the 90 days p r i o r to f o l l o w - u p , t h i s group d i d not show as much g a i n i n abs t inence as the one-day spouse involvement group and showed s i g n i f i c a n t l y l e s s c o n t r o l l e d d r i n k i n g then the f i v e - d a y spouse involvement group. The f o l l o w - u p data (see Appendix 8 ) , i n d i c a t e d tha t there was g rea te r v a r i a b i l i t y i n outcome f o r the no-spouse involvement group than the other two groups: c l i e n t s w i t h -out spouse involvement seemed e i t h e r to be a b s t i n e n t or d r i n k i n g e x c e s s i v e l y . Having the spouse i n v o l v e d i n t h i s t reatment program may serve as a moderat ing i n f l u e n c e ; that i s , i f the c l i e n t e x p e r i -ences a s l i p , the spouse may be more l i k e l y to o f f e r the support necessary f o r the c l i e n t to e i t h e r stop or to c o n t r o l h i s d r i n k i n g . Without tha t suppor t , he may r e l a p s e and r e t u r n to h i s o l d p a t t e r n s of e x c e s s i v e d r i n k i n g . A l though spouse involvement d i d have a s i g n i f i c a n t impact on c o n t r o l l e d d r i n k i n g and may have had some e f f e c t on ga ins i n a b s t i -nence, no d i f f e r e n c e s were found on most c r i t e r i o n measures between c l i e n t s whose spouses attended and those who d i d n o t . The r e s u l t s i n t h i s study seem r a t h e r d i s c r e p a n t w i t h other s t u d i e s tha t have eva luated spouse involvement i n the treatment of a l c o h o l abuse. One e x p l a n a t i o n f o r t h i s d i sc repancy may be the h i g h success r a t e of the 29 program r e g a r d l e s s of spouse invo lvement ; tha t i s , the no -spouse involvement treatment program may have had such a h i g h success r a t e a l r e a d y , tha t a c e i l i n g e f f e c t occur red whereby spouse involvement d i d not add s u b s t a n t i a l l y to the program's success . In rev iew ing the 15 most s u c c e s s f u l outcome s t u d i e s i n the a l -coho l i sm treatment l i t e r a t u r e , C o s t e l l o (1975) found , at one year f o l l o w - u p , tha t 45% of the a l c o h o l i c s i n those s t u d i e s were s u c c e s s f u l i n moderat ing or t e r m i n a t i n g t h e i r d r i n k i n g , 44% were s t i l l d r i n k i n g w i t h an a s s o c i a t e d problem, 1% were dead, and 10% were l o s t to f o l l o w -up. The present e v a l u a t i o n of the no-spouse involvement group f o r t h i s program showed that at an average of 9.26 months f o l l o w - u p , 63.5% were s u c c e s s f u l i n moderat ing or t e r m i n a t i n g t h e i r d r i n k i n g (59% a b s t i n e n t , 4.5% c o n t r o l l e d d r i n k i n g ) , 32% were s t i l l d r i n k i n g w i t h an a s s o c i a t e d problem, and 4.5% were l o s t to f o l l o w - u p . Whi le i t might be argued that the b e t t e r outcome f o r t h i s agency may be due to s h o r t e r f o l l o w - u p t i m e , t h i s i s u n l i k e l y i n v iew of Hunt and G e n e r a l ' s rev iew (1973) of a l c o h o l r e l a p s e r a t e s , which showed almost no change i n r e l a p s e r a t e s between n ine and 12 months f o l l o w - u p . Thus, i t would appear tha t the outcome f o r the r e g u l a r t reatment p r o -gram i n t h i s agency surpasses (the average o f ) the most f a v o u r a b l e outcome c i t e d i n the l i t e r a t u r e . I t i s w i d e l y known that c e r t a i n c l i e n t c h a r a c t e r i s t i c s are good p r o g n o s t i c i n d i c a t o r s of success i n a l c o h o l t reatment programs (see rev iew by Baekeland , 1977). In p a r t i c u l a r , o c c u p a t i o n a l and m a r i t a l s t a b i l i t y and h i g h socioeconomic s t a t u s have been r e p e a t e d l y shown to be p o s i t i v e l y r e l a t e d to s u c c e s s f u l outcome. I t i s p o s s i b l e t h a t 30 the b e t t e r outcome at the V i c t o r i a program may s imply be a f u n c t i o n of more favourab le c l i e n t c h a r a c t e r i s t i c s . C l i e n t s i n c l u d e d i n t h i s . study were indeed a s e l e c t group: a l l were m a r r i e d , the m a j o r i t y cou ld be c l a s s i f i e d as midd le c l a s s (mean income above $ 1 3 , 0 0 0 ) , most of the sample had completed h igh s c h o o l , and on ly 7% were unemployed. Furthermore, c l i e n t s who showed any over t psychoses or n e u r o l o g i c a l d i s a b i l i t i e s were excluded from the program. An examinat ion of the 15 s t u d i e s showing the best outcome i n C o s t e l l o ' s r e v i e w , however, r e v e a l s an e q u a l l y s e l e c t group. Most of these s t u d i e s i n d i c a t e d tha t they exc luded h i g h r i s k c l i e n t s such as v a g r a n t s , t r a n s i e n t s , and c l i e n t s . w i t h s e r i o u s p h y s i c a l or menta l d i s e a s e , and a l l but one of the s t u d i e s r e p o r t i n g on socioeconomic s t a t u s of the c l i e n t s i n d i c a t e d tha t they were of midd le or upper c l a s s s t a t u s . S tud ies r e p o r t i n g on m a r i t a l s t a t u s i n d i c a t e d that 70-100% of t h e i r c l i e n t s were mar-r i e d , and th ree other s t u d i e s s p e c i f i e d that c l i e n t s had to have c o n -t a c t w i t h r e l a t i v e s or be a b l e to demonstrate good i n t e r p e r s o n a l r e l a t i o n s h i p s i n order to q u a l i f y f o r the program. Thus, i t would seem u n l i k e l y t h a t c l i e n t c h a r a c t e r i s t i c s adequate ly account f o r the b e t t e r outcome at the V i c t o r i a program. The type of outcome measures u t i l i z e d were a l s o comparable to those reviewed by C o s t e l l o (1975). The measures i n the present study were based upon the c l i e n t ' s s e l f - r e p o r t . Outcome measures i n the s t u d i e s reviewed by C o s t e l l o were a l s o based on s e l f - r e p o r t s of the c l i e n t , a c o l l a t e r a l , or b o t h . Moreover , the l i t e r a t u r e suggests t h a t a l c o h o l i c s ' s e l f - r e p o r t s are both h i g h l y r e l i a b l e and v a l i d ( S o b e l l , 1976; S o b e l l , S o b e l l , & Samuels, 1974; S o b e l l & S o b e l l , 1975) 31 and tha t a l c o h o l i c s ' and c o l l a t e r a l s ' s e l f - r e p o r t s u s u a l l y concur (Maisto., S o b e l l , & S o b e l l , 1977). In comparing the abs t inence r a t e of the no-spouse involvement group at the V i c t o r i a program to those of other no-spouse involvement groups r e p o r t e d i n the l i t e r a t u r e , f u r t h e r d i f f e r e n c e s are found. Compared to the 59% abst inence r a t e at the V i c t o r i a program, Corder et a l . (1972) found 15% of t h e i r c l i e n t s a b s t i n e n t i n t h e i r no-spouse involvement group; Ewing et a l . (1961) found 19% a b s t i n e n t ; Smith (1969) , 12% a b s t i n e n t ; and Thomas et a l . (1960) , 12% a b s t i n e n t . These d i f f e r e n c e s cannot be r e a d i l y e x p l a i n e d by the methods of o b t a i n i n g outcome measures or by d i f f e r e n c e s i n c l i e n t c h a r a c t e r i s t i c s . A l l of the s t u d i e s used e i t h e r the c l i e n t ' s or the c l i e n t ' s and c o l l a -t e r a l ' s s e l f - r e p o r t s . C l i e n t c h a r a c t e r i s t i c s were a l s o comparable. A l l of the c l i e n t s i n the s t u d i e s by Corder et a l . Ewing et a l . , and Smith were mar r ied and i n the study by Thomas et a l , 75% were mar r ied and on ly those c l i e n t s who gave evidence of s t a b i l i t y and f a m i l y support were i n c l u d e d . In terms of o c c u p a t i o n a l s t a b i l i t y , Corder et a l . and Thomas et a l . r e p o r t e d t h a t 90% and 94% of t h e i r c l i e n t s were employed and Ewing et a l . noted t h a t the m a j o r i t y of t h e i r c l i e n t s were employed and c o n s i s t e d p r i m a r l y of bus iness and p r o f e s -s i o n a l men. Indeed, the 59% abst inence r a t e f o r the no-spouse involvement group at the V i c t o r i a program can be favourab l y compared to spouse-involvement groups i n o ther s t u d i e s . Corder et a l . found 55% a b s t i -nent i n h i s spouse involvement group; Ewing e t a l . found 50% a b s t i -n e n t ; Smi th , 40% a b s t i n e n t ; Thomas et a l . , 18% a b s t i n e n t ; and 32 Cadogan (1973), 45% a b s t i n e n t . These treatment programs hav ing r e l a -t i v e l y modest abs t inence r a t e s i n i t i a l l y , have been a b l e to show s u b s t a n t i a l improvement w i t h the a d d i t i o n of spouse invo lvement . The r e g u l a r program at the V i c t o r i a agency, however, a l r e a d y has a success r a t e exceeding tha t of spouse- involvement programs r e p o r t e d i n the l i t e r a t u r e . Th is would suggest tha t the program may have such an impact tha t spouse involvement does not add s u b s t a n t i a l l y to i t . There are at l e a s t two p o s s i b l e e x p l a n a t i o n s f o r t h i s occur rence . Perhaps there i s a c e i l i n g e f f e c t o p e r a t i n g , tha t i s , the abs t inence r a t e i s a l r e a d y so h i g h that adding d i f f e r e n t components to the p r o -gram ( e . g . , spouse i n v o l v e m e n t ) . w i l l on l y produce s m a l l i nc rements . A l t e r n a t i v e l y , i t i s p o s s i b l e tha t much of what was o f f e r e d i n the spouse programs was a l r e a d y a p a r t of the i n t e n s i v e r e g u l a r program. For example, i n the spouse programs c l i e n t s r e c e i v e d feedback p e r -t a i n i n g to t h e i r i n t e r a c t i o n s t y l e and communication s k i l l s w i t h t h e i r spouses. However, c l i e n t s i n the r e g u l a r program were g i v e n s i m i l a r feedback about t h e i r i n t e r a c t i o n w i t h other c l i e n t s and w i t h s t a f f . I t seems l i k e l y tha t changes t h a t the c l i e n t makes i n h i s i n t e r a c t i o n s t y l e d u r i n g the r e g u l a r program would a f f e c t the c l i e n t ' s m a r i t a l i n t e r a c t i o n . Th is would suggest that i n t reatment programs where i n t e r v e n t i o n i s focused on problems i n i n t e r p e r s o n a l i n t e r a c t i o n spouse involvement may not r e s u l t i n s u b s t a n t i a l ga ins f o r the c l i e n t s . Length of f o l l o w - u p t ime may a l s o have had some i n f l u e n c e on the apparent e f f e c t i v e n e s s of spouse Involvement. Most of the s t u d i e s i n the l i t e r a t u r e conducted f o l l o w - u p immediately a f t e r t reatment ( e . g . , Cheek et a l . , 1971; E s s e r , 1971; Gliedman et a l . , 1956; Hedberg & 33 Campbel l , 1974; Meeks & K e l l y , 1970; P a t t i s o n et a l . , 1965; P i x l e y & S t e i f e l , 1963). Few s t u d i e s r e p o r t e d a f o l l o w - u p of s i x months or more (Corder et a l . , 1972; Burton & K a p l a n , 1968; Ewing et a l . , 1961; Smi th , 1969) . In r e v i e w i n g r e l a p s e r a t e s from a l c o h o l programs, Hunt, B a r n e t t , and Branch (1971) and Hunt and Genera l (1973) noted tha t about t w o - t h i r d s of a l c o h o l i c s r e l a p s e w i t h i n th ree months of t reatment w h i l e o n e - t h i r d . s e e m to m a i n t a i n abs t inence f o r a y e a r . Emrick (1975) has f u r t h e r commented tha t many r e s e a r c h e r s r e p o r t a h i g h d r i n k i n g r e l a p s e r a t e d u r i n g the f i r s t s i x months a f t e r t r e a t -ment. In t h a t most of the p r e v i o u s l y r e p o r t e d e v a l u a t i o n s of spouse involvement have been conducted immediately f o l l o w i n g t rea tment , the extent to which i t s e f f e c t s are mainta ined i s l a r g e l y unknown. P e r -haps the absence of any s u b s t a n t i a l e f f e c t w i t h spouse involvement i n the V i c t o r i a program can be f u r t h e r e x p l a i n e d by the r e l a t i v e l y long f o l l o w - u p p e r i o d of 9.26 months. Fur ther r e s e a r c h examining the r e l a t i o n s h i p between f o l l o w - u p t ime and outcome f o r spouse i n v o l v e -ment i s needed to c l a r i f y t h i s i s s u e . In c o n c l u s i o n , many s t u d i e s i n the l i t e r a t u r e have found tha t i n v o l v i n g the spouse i n treatment appears to have a power fu l impact on the treatment outcome f o r the a l c o h o l i c when compared to no-spouse invo lvement . In t h i s s t u d y , two d u r a t i o n s of spouse involvement were compared to the r e g u l a r t reatment program of no spouse invo lvement . U n l i k e other s t u d i e s i n the f i e l d , the no-spouse involvement group-d i d not d i f f e r from the spouse involvement group on most of the c r i t e r i o n measures, a f i n d i n g tha t may be at l e a s t p a r t i a l l y accounted f o r by the h i g h success r a t e of a l l . . t h e groups . The longer f o l l o w - u p 34 time f o r t h i s study may also p a r t l y explain the lack of s t r i k i n g differences between the groups. The one-day spouse group did show a trend for greater gains i n abstinence than either of the other groups, suggesting that b r i e f spouse involvement may further the goal of abstinence. In contrast, the five-day spouse group showed s i g n i -f i c a n t l y more con t r o l l e d drinking than the other two groups, suggesting that longer, more intensive spouse involvement make make con t r o l l e d drinking a more p l a u s i b l e goal for the a l c o h o l i c . In terms of cost-effectiveness, the one-day spouse program which involves l i t t l e of the spouse's time and minimal a d d i t i o n a l expense may be desirable for programs such as t h i s one emphasizing abstinence. However, programs that have a con t r o l l e d drinking goal might consider the present findings as suggestive of increased benefit with longer or more intense spouse involvement. Further research on t h i s p o s s i b i l i t y would be desirable. F i n a l l y , i t might be suggested from the comparison of these findings to the e x i s t i n g l i t e r a t u r e , that adding spouse involvement may be most b e n e f i c i a l i n those programs that have modest success rates (below 25%) but of less benefit to programs whose success rate without spouse involvement i s already s u b s t a n t i a l (above 50%). 35 REFERENCES Baekeland , F. E v a l u a t i o n of t reatment methods i n c h r o n i c a l c o h o l i s m . In B. K i s s i n & H. 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Q u a r t e r l y J o u r n a l of S tud ies on A l c o h o l , 1970, 3 1 , 399 -413 . Moos, R .H . Fami ly Environment S c a l e P r e l i m i n a r y Manual . P a l o A l t o : 39 Consulting Psychologists Press, 1974. Moos, R. & B l i s s , F. D i f f i c u l t y of follow-up and outcome of alcoholism treatment. Journal of Studies on Alcohol, 1978, J39, 473-490. Orford, J . & Guthrie, S. Coping behaviour used by wives of a l c o -h o l i c s : a preliminary i n v e s t i g a t i o n . (Abst.) International  Congress of Alcohol and Alcoholism, Proc. 28th, 1968, _1, 97. Orford, J . , Guthrie, F., N i c h o l l s , P., Oppenheimer, E., Egerts, S., & Hensman, C. Self-reported coping behaviour of wives of a l -coholics and i t s ass o c i a t i o n .with drinking outcome. Journal  of Studies on Alcohol, 1975, 36y 1254-1267. Orford, J . , Oppenheimer, E., Egert, S., Hensman, C., & Guthrie, S. The cohesiveness of alcoholism-complicated marriages and i t s influence on treatment outcome. B r i t i s h Journal of Psychiatry, 1976, 128, 318-339. Paolino, T.J., McCrady, B. , Diamond,, S., & Longabaugh, R. Psycho-l o g i c a l disturbances i n spouses o f . a l c o h o l i c s . Journal of Studies  on Alcohol, 1976, 37, 1600-1608. Pattison, E.M. Treatment of a l c o h o l i c f a m i l i e s with nurse home v i s i t s . Family Process, 1965, _4, 74-94. Pattison, E.M., Courlas, P.G., P a t t i , R., Mann, B., & Mullen, D. Diagnostic-therapeutic intake group for wives of a l c o h o l i c s . Quarterly Journal of Studies on Alcohol, 1965, 26, 605-616. Pixley, J. & S t i e f e l , J . Group therapy designed to meet the needs of the a l c o h o l i c wife. Quarterly Journal of Studies on Alcohol, 1963, 24, 304-314. Preston, F.B. Combined i n d i v i d u a l , j o i n t , and group therapy i n the 40 treatment of a l c o h o l i s m . Menta l Hygiene, 1960, 44-, 5 2 2 - 5 2 8 . P r i c e , G.M. A study of the wives of twenty a l c o h o l i c s . 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Observat ions of c o n j o i n t l y h o s p i t a l i z e d " a l c o h o l i c c o u p l e s " d u r i n g s o b r i e t y and i n t o x i c a t i o n : 41 I m p l i c a t i o n s f o r theory and therapy . Fami ly P r o c e s s , 1977, 16 , 1 -16 . S t r a y e r , R. Treatment of c l i e n t and spouse by the same caseworker . Q u a r t e r l y J o u r n a l of S tud ies on A l c o h o l , 1959, 20_, 8 6 - 1 0 2 . T a r t e r , R . E . P e r s o n a l i t y of wives of a l c o h o l i c s . J o u r n a l of C l i n i c a l Psycho logy , 1976, 32 , 741 -743. Thomas, R . E . , G i l l i a m , J . H . , & Walker , D.R. Casework s e r v i c e s f o r a l c o h o l i c s i n a M a g i s t r a t e ' s Cour t . S o c i a l Work, 1960, 5_, 3 3 - 3 8 . W e s t f i e l d , D.R. Two y e a r s ' exper ience of group methods i n the t r e a t -ment of male a l c o h o l i c s i n a S c o t t i s h menta l h o s p i t a l . B r i t i s h  J o u r n a l of the A d d i c t i o n s , 1972, 67_, 267-276. Whalen, T. Wives of a l c o h o l i c s ; four types observed i n a f a m i l y s e r v i c e agency. Q u a r t e r l y J o u r n a l of S tud ies on A l c o h o l , 1953, 14, 6 3 2 - 6 4 1 . 42 APPENDIX 1 Fo l low-Up Ques t ionna i re Has ther been any change i n your employment s t a t u s s i n c e l e a v i n g VLES? CHECK EITHER YES OR NO. 1. YES 2. NO (a) I f y e s , what was the nature of the change? CHECK THE APPROPRIATE ALTERNATIVE BELOW: 1. secured f u l l - t i m e employment 2. secured p a r t - t i m e employment 3 . promoted 4. demoted 5 . changed to a d i f f e r e n t job 6. unemployed ( l o s t or q u i t job ) 7. r e t i r e d 8. other ( s p e c i f y ) Has there been any change i n your f i n a n c i a l s i t u a t i o n s i n c e l e a v i n g VLES? CIRCLE ONE ALTERNATIVE BELOW much b e t t e r about the worse much b e t t e r same worse IF YOU ARE CURRENTLY UNEMPLOYED PROCEED TO QUESTION 6. IF YOU ARE CURRENTLY EMPLOYED ANSWER THE FOLLOWING: Rate your performance at work d u r i n g the l a s t 3 months. CIRCLE ONE ALTERNATIVE very good good f a i r poor v e r y . p o o r In the l a s t 3 months have you missed any days of work? 1. . . YES 2. NO (a) i f y e s , how many days? days In the l a s t 3 months have you ever been l a t e f o r work? 1. YES 2. NO (a) I f y e s , how many hours?. hours IF YOU ARE CURRENTLY UNEMPLOYED, how l o n g have you been unemployed? 1. one week or l e s s 43 2. 1-2 weeks 3 . 2 weeks-1 month 4. 1-2 months 5 . 2 -6 months 6. 6 months-1 year 7. more than 1 year Has there been any change i n your m a r i t a l s t a t u s s i n c e l e a v i n g VLES? 1. Yes 2. No I f y e s , what was the nature of the change? 1 . r e c o n c i l e d w i t h spouse 2. mar r ied 3. separated 4. d i v o r c e d 5. other ( s p e c i f y ) We would l i k e to know how s a t i s f i e d you :a.re w i t h a number of l i f e s i t u a t i o n s . INDICATE HOW SATISFACTORY EACH SITUATION IS BY CHECKING ONE BOX PER SITUATION. my m a r i t a l l i f e i s >s u o +J o cd 4-1 cn S-l 4-1 <D cd > CD U o 4-1 o cc! 4-4 CO •rl 4-1 Cd CD U O 4-1 CJ (0 u o 4-1 o cd 4-1 CD rH CD rH 4-1 •rl U 4-1 cd CO cd cd cd rJ <x CD a a i-l o ,4-1 o nJ 4-4 CD •rl 4-1 id CD CJ 3 M O 4-1 a cd 4-1 CD •rl 4-1 >s cd !-i CO cu a > 3 my work l i f e i s my s o c i a l l i f e i s my home .... l i f e i s my l i f e i n g e n e r a l i s Have you attended A . A . s i n c e l e a v i n g VLES? 1. Yes 2. No (a) I f y e s , how o f t e n on the average do you attend.? 1. once per month 2. tw ice per month 3 . once per week 4. t w i c e per week 5. more than tw ice per week Have you seen a c o u n s e l l o r s i n c e l e a v i n g VLES? 1. Yes 2. No (a) I f y e s , approx imate ly how many t imes? t imes Was Antabuse p a r t of your going home p lan? CIRCLE ONE. 1. Yes 2. No (a) I f y e s , how long d i d you take i t ? 1. one week or l e s s 2. 1-2 weeks 3 . 2 weeks-1 month 4. 1-3 months 5. 4 - 6 months 6. 6 months-1 year 7. 2 years or more. (b) Are you s t i l l t a k i n g Antabuse? 1. Yes 2. No 3. Off and One Have you consumed any a l c o h o l s i n c e l e a v i n g VLES? 1. Yes 2. No How many of the l a s t 90 days have you been t o t a l l y dry? # of days. 45 14. Dur ing the l a s t 3 months how much a l c o h o l d i d you u s u a l l y consume on an average d r i n k i n g day? INDICATE BOTH THE AMOUNT AND TYPE OF BEVERAGE. 15. Compared to when you f i r s t came to VLES, do you now d r i n k . . . much more about the l e s s much more same l e s s 16. S ince l e a v i n g VLES has your use of a l c o h o l been: a ve ry a major somewhat of a s l i g h t no problem severe problem a problem problem at a l l problem 46 17. When at VLES, did your husband/wife attend the spouse program? 1. Yes 2. No 18. (a) If yes, how h e l p f u l to you personally was the fa c t that he/ she attended? very unhelpful p a r t l y unhelpful/ h e l p f u l very unhelpful p a r t l y h e l p f u l h e l p f u l 18. (b) If yes, how h e l p f u l do you think the spouse program was to your wife/husband? very unhelpful p a r t l y unhelpful/ h e l p f u l very unhelpful p a r t l y h e l p f u l h e l p f u l 47 APPENDIX 2 P r e t e s t and Ad jus ted P o s t t e s t Group Means: M u l t i v a r i a t e A n a l y s i s of V a r i a n c e and Analyses of Covar iance V a r i a b l e No Spouse 1 Day 5 Day MS P e r s o n a l O r i e n t a t i o n Inventory Sca le 1 P r e t e s t P o s t t e s t Sca le 2 P r e t e s t P o s t t e s t Sca le 3 P r e t e s t P o s t t e s t Sca le 4 P r e t e s t P o s t t e s t 12.87 16.55 71.69 88.44 16.75 20.16 17.69 22.05 12.78 13.47 16.20 16.69 1.42 .18 73.67 73.35 84.08 88.31 120.91 1.34 18.39 18.29 20.56 20.68 1.43 .25 17.17 18.18 20.61 21.77 10.61 .89 Sca le 5 P r e t e s t P o s t t e s t 12.81 13.67 13.97 16.62 16.38 17.16 3 .95 .56 Sca le 6 P r e t e s t P o s t t e s t 9.19 10.22 9.73 12.79 12.90 13.26 1.49 .22 Sca le 7 P r e t e s t P o s t t e s t 9 .00 9 .61 9.38 11.88 12.28 12.34 1.23 . 2 0 Sca le 8 P r e t e s t P o s t t e s t 14.19 17.04 12.78 14.38 13.38 16.48 35.17 3 .34* Sca le 9 P r e t e s t P o s t t e s t 9.75 12.08 10.94 12.27 11.12 11.67 2.31 1.12 . . . cont inued 48 APPENDIX 2 cont inued V a r i a b l e No Spouse 1 Day 5 Day MS F Sca le 10 P r e t e s t 5.19 6 .22 6 .20 P o s t t e s t 6 .74 7.14 7.04 . 7 1 .42 Sca le 11 P r e t e s t 13.44 14.78 13.68 P o s t t e s t 17.89 16.80 17.86 7.29 .89 S c a l e 12 P r e t e s t 15.31 15.39 15.56 P o s t t e s t 20 .30 18.69 20.25 16.50 1.81 £. < -05 Note. F_ v a l u e f o r MANOVA on p r e t e s t scores i s .88 49 APPENDIX 3 P r e t e s t , F o l l o w - U p , and Change Score.Group Means and Standard D e v i a t i o n s : Ana lyses of Va r iance V a r i a b l e No Spouse 1 Day 5 Day MS F M a r i t a l S a t i s f a c t i o n P r e t e s t 3 .35 (1.14) 2.59 (0.91) 3 .10 (1 .06) 3 .22 2 .97* Fo l low-Up 2.65 2.27 2.17 Change - . 7 0 (1.49) - . 3 2 (1.46) - . 9 3 (1.33) 2 .31 1.14 Work L i f e S a t i s f a c t i o n P r e t e s t 2 .00 (0.86) 2 .09 (0.61) 2.32 (0 .86) 0.67 1.08 Fo l low-Up 2 .10 2.09 1.96 Change 0.10 (1.55) 0 .00 (1 .57) - . 3 6 (0.99) 1.43 0.47 S o c i a l L i f e S a t i s f a c t i o n P r e t e s t 3 .70 (1.08) 3.27 (1.03) 3 . 6 0 (0.99) 1.10 1.03 Fo l low-Up 2.25 2.05 2.17 Change - 1 . 4 5 (1.19) - 1 . 2 2 (1 .34) - 1 . 4 3 (1.28) 0.34 0 .81 Home L i f e S a t i s f a c t i o n P r e t e s t 3 .05 (1 .05) 2.72 (0 .93) 3 .10 (1.03) 0.97 0.96 Fo l low-Up 2.45 1.81 2.07 Change - . 6 0 (1 .27) - . 9 1 (1 .44) - 1 . 0 3 (1 .26) 1.13 0.64 Number Days A b s t i n e n t i n P r e t e s t L a s t 90 Days 41.05 31.23 (31.02) (28.90) 38.76 (20.62) 657.88 0.93 Fo l low-Up 77.85 85.18 74.07 Change 36 .80 (34.92) 53.95 (28.57) 35.31 (21.74) 2347.20 2 .93* cont inued 50 APPENDIX 3 cont inued V a r i a b l e No Spouse 1 Day 5 Day MS Amount of A l c o h o l Consumed on D r i n k i n g Day P r e t e s t 19.70 13.65 14.20 223.48 2 . 8 1 * . (6 .89) (12.01) (7.85) Fo l low-Up 5 .10 3 .30 3 .80 Change - 1 4 . 6 0 - 1 0 . 3 5 - 1 0 . 4 0 120.59 0.87 (11.72) (13.79) (10.33) * £ < .10 Note : Scores on s a t i s f a c t i o n r a t i n g s range from 1 (very s a t i s -f a c t o r y ) to 5 (very u n s a t i s f a c t o r y ) Note: Standard d e v i a t i o n s are shown i n parentheses on t h i s and subsequent t a b l e s . 51 APPENDIX 4 Group Means and Standard D e v i a t i o n s f o r F i r s t P r i n c i p a l Component Scores on M a r i t a l , Work, S o c i a l , Home, and L i f e S a t i s f a c t i o n R a t i n g s : A n a l y s i s of V a r i a n c e V a r i a b l e No Spouse 1 Day 5 Day MS F Mean 51.85 48.68 49.59 55.97 .54 (10.07) (10.63) , (9 .78) Note . Higher scores i n d i c a t e g r e a t e r s a t i s f a c t i o n . 52 APPENDIX 5 Ana lyses of Va r iance of P r o p o r t i o n s : Frequency Data of Persons Unemployed, Separated or D i v o r c e d , Attended AA, Consumed A l c o h o l s i n c e Treatment, A b s t i n e n t i n L a s t 90 Days, and C o n t r o l l e d D r i n k i n g i n Las t 90 Days as a F u n c t i o n of Group Percentage V a r i a b l e No Spouse 1 Day 5 Day x 2 Number Unemployed 14.3 13.6 0.0 4.273 Separated or D ivorced 14.3 17.4 7.4 1.343 Attended AA s i n c e Treatment 5 5 . 0 68 .2 69 .2 1.129 Consumed A l c o h o l s i n c e Treatment 71.4 .'•52.2 79.3 4.476 A b s t i n e n t i n Las t 90 Days 61 .9 5 9 . 1 35.7 4.496 C o n t r o l l e d D r i n k i n g i n Las t 90 Days 5 . 0 9 . 1 35.7 9 .062* *£ < .01 Note. Percentages are based on those c l i e n t s tha t were contacted or f o r which f a c t u a l i n f o r m a t i o n was a v a i l a b l e (not the t o t a l sample f o r each group) . 53 APPENDIX 6 Fo l low-Up Group Means and Standard D e v i a t i o n s : M u l t i v a r i a t e A n a l y s i s of Va r iance V a r i a b l e No Spouse 1 Day . 5 Day Change i n F i n a n c i a l 2 .70 2.54 2.68 S ta tus (0 .92) (1 .06) (0 .61) Number of Days Absent 1.20 0.55 1.96 from Work i n Las t 90 Days (2.12) (1.26) (6 .20) Rat ing of S a t i s f a c t i o n 2.25 2.09 2.25 w i t h L i f e i n Genera l (1.20) (1.11). (0.93) Number of Times Seen a 4 .25 6.04 7.32 Counselor (8.75) (9.49) (10.42) Length of Time on Antabuse 3 .50 2.73 2.78 (2.44) (2.45) ; (2.28). Now Dr ink More or Less 4 .70 4.86 4.86 (0.73) (0.64) (0 .59) Note . F v a l u e f o r MANOVA i s .41 APPENDIX 7 Fo l low-Up Group Means and Standard D e v i a t i o n s : H o t e l l i n g s T 2 V a r i a b l e 1 Day 5 Day R a t i n g of How H e l p f u l Spouse Program was to 4 .10 4.14 C l i e n t (1.05) (1.41) Rat ing of How H e l p f u l Spouse Program was to 3 .73 4 .14 Spouse (1.24) (1 .43) Note. Scores range from 1 (very u n h e l p f u l ) to 5 (very h e l p f u l ) . _F v a l u e f o r H o t e l l i n g s T 2 i s 1.14 55 APPENDIX 8 D r i n k i n g Index: Number of A b s t i n e n t Days i n the 90 Days P r i o r to Follow-Up/Amount of A l c o h o l Consumed on an Average - D r i n k i n g Day No Spouse Involvement Group N = 20 n=13 V 90 t 80 I 70 60 Number of Days A b s t i n e n t 50 40 30 20 10 0 5 10 15 20 25 30 35 40 45 50 55 60 65 Amount A l c o h o l Consumed/Day (ounces) cont inued 56 APPENDIX 8 cont inued One-Day Spouse Involvement Group N = 22 n=13 Number of Days A b s t i n e n t 90 80 70 60 50 40 30 20 10 - 1 '" < 1 « — ' — • « » . » 1 t » > i 0 5 10 15 20 25 30 35 40 45 50 55 60 65 Amount A l c o h o l Consumed/Day (ounces) cont inued APPENDIX 8 cont inued F i ve -Day Spouse Involvement Group N. = 28 n=10 9c> 80 70 60 j-Number of Days 50 A b s t i n e n t 40 30 20 10 0 5 10 15 20 25 30 35 40 45 50 55 60 65 Amount A l c o h o l Consumed/Day (ounces) ' 

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