British Journal of Addiction, 73 (1978) 35-38. Longman. Printed in Great Britain.

Minimal, Moderate and Long-termTreatment for Alcoholism

Reginald G. Smart and Gaye GrayAddiction Research Foundation, 33 Russell Street, Toronto, Canada

Serious quesLions have been raised about how length of treatment for alcoholismrelates to improvement. Some studies (e.g. Gerard and Saenger, 1966) have found thatthose who stay longer in treatment show more improvement but a number (e.g.Aharan et al. 1967; GiUies et al., 1974) have found no difference. In a recent reviewEmrieh (1975) compared outcomes from several studies of alcoholics given notreatment or minimal treatment (i.e., five or fewer interviews) and 'more thanminimal' treatment. He found that abstinence rates were not related to length oftreatment. However, it was noted that 'these results must be taken with somereservation since very few minimal and no-treatment data were involved and patientcharacteristics were not controlled'. Also, it is probably out of keeping with chnicaljudgement that length of treatment and improvement are unrelated. It would beimportant to know whether length of treatment is a factor in recovery regardless ofpatient characteristics. It may be that patients who drop out of treatment early are lesswell motivated or have less severe symptoms. The present paper reports an outcomestudy in which three groups of alcoholics were matched on intake characteristics suchas age, sex, alcoholic symptoms, motivation for treatment but differed in amounts oftreatment. The essential design ofthe study is quasi-experimental in that the 3 groupswere matched for variety of characteristics rather than being randomly assigned. Thematching was done after the follow-up study was completed and not during intake.

Data for this study were drawn from a large follow-up study of alcoholics treated at10 outpatient and two inpatient clinics in Ontario (Gillies et ai, 1974). In that study1,388 alcoholics were interviewed at intake and 70 % were foUowed-up one year later.Intake characteristics included demographic variables (age, sex, marital status, etc.)alcohol consumption in the previous year and scores on 13 dimensions - physicalhealth, drug use, social stability, marital stability, drinking assessment, problems dueto drinking, attitudes to abstinence, motivation for treatment, resources in terms ofrelationships, isolation from relationships, resources in terms of interests and activities,isolation from such interests and activities, and a measure of patient satisfaction withself in the year before intake.

All of the scales had high internal consistency in that each of the items correlatedwith the total scores on the Alcoholic Involvement Scale, a 35 item scale withconsiderable internal validity, test-retest reliability and internal consistency (Gillies etal., 1975). Relatively few differences were found among improvement groups for any ofthe scales. The most important variables were age, alcoholic involvement, physicalhealth, social stability, attitudes to abstinence and motivation for treatment. In the

36 R. G. Smart and G. Gray

present study groups with different lengths of treatment were matched on all thesevariables, before assessing outcomes.

MethodData from 793 alcoholics treated at five of the 10 outpatient clinics and followed-up

for one year after treatment were considered for this study. These patients were dividedinto three lengths of treatment groups:

(i) minimal treatment: one outpatient contact only(ii) moderate treatment: up to six months, a period arbitrarily chosen to include70 % of those given more than minimal treatment(iii) long-term treatment: more than six months treatment.The scales on which the matching was done (in addition to age) were:

(i) Alcoholic Involvement Scale - 35 items with scores of 0 to 140, designed toreflect changes which were considered by experts to be symptomatic of developingor fully developed alcoholism problem (including quantity and frequency ofdrinking, dependence on alcohol, alcoholic symptoms such as blackouts, bendersetc.). See Gillies et al. (1975) for a complete description of the validity andreliability of this scale.

(ii) Physical Health - 5 items concerned with the alcoholic's general health in thepast year in terms of health related events (e.g. visits to a physician orhospitalization) and the patient's assessment of his own health.

(iii) Motivation for Treatment — 6 items to discover what changes in drinkingbehaviour and what treatment measures the patient would be willing to undergo toascertain whether he is strongly motivated to deal with his alcohol problem.

(iv) Social Stability - 10 items designed to measure adequacy of functioning in theareas of work, finances, changes in job and accommodation and relationships withthe law.

(v) Attitudes to Abstinence - 6 items aimed at discovering whether the patientholds opinions that would seem to promote or inhibit his accepting abstinence, e.g.,whether he should change his drinking, whether he could cope with not drinkingand whether his drinking is determined by circumstances he cannot control.

As a starting point the characteristics of the minimal treatment group at intakewere assessed: the variables examined were age, alcoholic involvement-scores, physicalhealth, motivation for treatment, social stability, and attitudes to abstinence. The totalnumber of patients {n = 66) in the minimal treatment group were used. The other twotreatment groups were constructed so that all three had the same range of scores andsimilar means for the six matching variables. This was done by deleting cases at theextremes for each variable until the mean and range on each variable were the same asfor the minimal group. The results of this matching can be seen in Table 1 The sampleused in this study included only 510 of the original 793 since during the matching

Minimal(1 contact)

39.965.936.697.718.28

72.5066

Moderate(Up to 6 months)

38.905.406.636.626.92

71.10133

Long Term(> 6 months)

39.805.657.097.086.93

74.80311

Treatment for Alcoholism 37

Table 1 Characteristics at intake of the minimal treatment, moderate treatment, and long-termtreatment groups

Treatment Groups

Age (range 20-59)Physical health (range 0-12)Social stability (range 0—29)Attitudes to abstinence (range 2-14)Motivation for treatment (range 2-16)Alcohol involvement (range 30—118)

Total cases

process alcoholics not fitting the characteristics of the minimal group were dropped.The total sample of 510 includes 66 in the minimally treated group, 133 in themoderate treatment group, and 311 in the long term group.

Treatment outcomes were measured in terms of abstinence and changes in scoreson the Alcoholic Involvement Scale after a one year follow-up, i.e.:

(i) abstinent; no drinking in the past year(ii) much improved - a large decrease in alcoholic involvement scores - abovemedian for the total group(iii) some improvement — small decrease in alcoholic involvement scores — belowthe median for the total group(iv) no improvement — no change or an increase in alcoholic involvement scores.

ResultsIt can be seen from Table 2 that few patients were abstinent as follow-up (11 %) but

that most were improved or much improved (67 %). The variation in rates for thedifferent treatment groups is considerable. Very few (3 %) of the minimally treatedgroup were abstinent at follow-up. However, three times as many given moderatetreatment and more than five times as many given long term treatment were abstinent.

Table 2 Number and per cent in minimal treatment, moderate treatment and long-termtreatment groups with positive and negative outcomes

Much Somewhat NoImproved improved improvement Abstinent Totals

Minimal treatmentModerate treatmentLong-term treatment

Total

1812041

179

(27%)(39%)(31 %)(35%)

299441

164

(44%)(30%)(31%)(32%)

176330

110

(26%)(20%)(23%)(20%)

2342157

(3%)(11%)(16%)(11%)

66311133510

= 14.84, 6 d f, /) <0.05, All Groups= 7.25, 2 d f, /) <0.05, Abstinent vs. Non-abstinent= 0.93, 2 d f, non-sign, Total improvement (less abstinent) vs. Not improved= 0.80, 2 d f, non-sign. Total improvement (including abstinent) vs. Not improved

38 R. G. Smart and G. Gray

This difference is statistically significant (/^ — 7.25, p <0.05). When the totalimproved are compared with the total not improved the differences are not statisticallysignificant whether the abstinent are included or not. Only 2 % more were improved inthe minimally treated than the moderately treated group. There is no significantdifference between the minimally treated and the long term treatment groups although9 % more were improved in the minimally treated groups.

DiscussionThe results obtained from this matched group, quasi-experimental study support

the view that keeping alcoholics in treatment generates more successfijl outcomes interms of abstinence. The value of long term treatment would seem to be in creating thecdnditions for abstinence, with only insignificant effects on overall improvement rates.However, it should be noted that random assignment of patients to treatment groupswas not done and that a classical experiment study has not been attempted here. Such astudy would be very difficult to do since it would have to overcome the tendency ofalcoholics to accept different amounts of treatment. The present study attempts tosurmount these difficulties by matching the treatment groups on factors related tooutcome.

The results here are similar to those found in some earlier studies but different fromothers. Several studies of treatment length and outcome, for example, Emrich's study(1975) found that abstinence rates were not higher for those given minimal than morethan minimal treatment. However, the definition employed by Emrich involvedminimal treatment as 5 or fewer interviews whereas the present definition involves onlyone contact. Also, it was pointed out in Emrich's review (1975) that control overpatient characteristics was not attempted nor has it been attempted in other studies oftreatment length and outcome. The present study where alcoholics were matched atintake for age, physical health, social stability, attitudes to abstinence, motivation fortreatment, and alcohol involvement does indicate the value of long term treatment inpromoting abstinence. The results strongly suggest that the failure to find such an effectmay be due to the differing symptoms, motivations, and attitudes of patients typicallydropping out of treatment and staying in treatment. Where such characteristics aresimilar at intake long term treatment seems more successful in terms of abstinence.

ReferencesAHARAN, C. H . , et al. (1967). Clinical indications of motivations in alcoholic patients. Quarterly Journal of Studies on

Alcohot, 28, 486^92.EMRICH, D . D . (1975). A review of psychologically oriented treatment of alcoholism. II: The relative effectiveness of

different treatment approaches and the effectiveness of treatment vs. no treatment. Journal of Studies on Alcohol, 36,88-108.

GERARD, D . L. and SAENGER, G. (1966). Outpatient Treatment of Alcoholism. University of Toronto Press, Toronto.GILLIES, M , et al. (1974). Outcomes in treated alcoholics: patient Mtid treatment characteristics in a one year follow-up

study. Journal of Alcoholism, 9, 125-134.GILLIES, M . et a/. (1975). The Alcoholic Involvement Scale: a method of measuring change in alcoholics. Journal of

Alcoholism, 10, 142-147.