reducing attrition from conjoint therapy with alcoholic couples

Drug and Alcohol Dependence, 11 (1983) 321331 Elsevier Scientific Publishers Ireland Ltd.

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REDUCING ATTRITION FROM CONJOINT THERAPY WITH ALCOHOLIC COUPLES*

ALLEN ZWEBEN, SHELLY PEABLMAN and SELINA LI

Addiction Research Foundation, Clinical Institute, 33 Russell Street, Toronto, Ontario, M5S 2Sl (Canada)

(Received January lOth, 1983)

SUMMARY

Premature termination of treatment by the client has been a pervasive problem in the alcohol treatment field. This drop-out problem is compounded in conjoint therapy for alcoholic couples since most clients typically do not view the drinking problem from a systemic, interactional perspective. Within a short-term communication-interaction based conjoint therapy program offered to couples with an alcohol problem on an outpatient basis, specific mechanisms were developed to deal with client-initiated attrition from treatment. These procedures involve the systematic involvement of the spouse in all aspects of intake, assessment and treatment; the use of role induction in a pretherapy interview; and formal contracting during the beginning phase of therapy. Preliminary results suggest that these efforts may be effective in retaining more socially stable alcoholic clients. For the more transient, less socially stable group of individuals with alcohol-related difficulties, the above mechanisms may not be sufficient to forestall unplanned terminations. It is suggested that the latter group may require help to reduce stresses related to concrete concerns prior to receiving conjoint therapy for their alcohol problem.

Key words: Alcoholism - Continuance - Treatment -Marriage

‘An earlier version of this paper was presented as part of a symposium on ‘Spouse-Involved Treatment for Alcohol Abuse’ at the Sixteenth Annual Convention of the Association for the Advancement of Behavior Therapy, Los Angeles, November 1982. Abbreviations: MSS, Marital Systems Study; SSI, Social Stability Index.

0 1983 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland

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SPOUSE-INVOLVED TREATMENT AND ATTRITION

Concern with premature termination of treatment on the part of the client has been and continues to be pervasive in the alcohol treatment field. Different studies have found that the majority of clients engaged in the treatment of alcohol-related difficulties on an outpatient basis do not complete their prescribed course of therapy 11,21. This tends to reinforce an attitu%e of pessimism among staff treating these clients and at the same time raises questions about the efficacy of outpatient therapy as the principal mode of treatment for this population 131.

This drop-out problem is compounded in conducting systems-oriented approaches. From a systems perspective, alcohol dependence is concep- tualized as an interactional or transactional problem, as opposed to the more traditional psychodynamic perspective. Thus, alcohol abuse is viewed as being related to disturbed, distressed or dysfunctional family relationships rather than as a manifestation of unresolved intrapsychic conflicts within the individual alcoholic. The family rather than the individual alcoholic is the client and changes in the family’s typical patterns of relating, resolving problems, dealing with intimacy, dividing authority and maintaining a sense of equilibrium are seen as necessary in order to affect and maintain changes in the alcohol-related difficulties.

Within this context of distressed family relationships, the marital relationship has been a particular area of interest and concern, both in terms of understanding the persistence of alcohol abuse and in terms of affecting change. Various studies have shown that alcohol may be an important adaptive or stabilizing force for the marital dyad 141. In addition, other studies have identified the powerful though at times very subtle role that the spouse plays in supporting or sabotaging the alcoholic’s involvement and progress in treatment C-51. Clearly, the spouse not only is affected by, but actively and directly affects the course of the alcohol abuse. The spouse’s involvement in treatment is seen as necessary to ensure that the alcohol problems are dealt with from an interactional perspective, while at the same time, helping the couple to develop a collaborative, mutually sup- portive attitude towards therapy and change.

A major difficulty in carrying out this approach is that couples typically do not view the drinking problem from a systemic, interactional perspective. Very few couples approach treatment committed to the notion that the current crisis confronting them is based on problems which are interactional in origin, even in situations where marital tensions are readily identified and acknowledged. Where the presenting problem is alcohol abuse, a problem which has been traditionally viewed in individually-oriented psychodynamic and moralistic terms, the initial expectations and assumptions of the client concerning the etiology and course of treatment of the problem may clearly be incompatible with the proposed systems-based therapeutic intervention. In such situations, there is likely to be a significant clash of

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perspectives between client and therapist concerning treatment, creating confusion, apprehension and uncertainty on the part of the client and ultimately resulting in premature termination of therapy. This lack of consensus between therapist and client concerning matters to be dealt with during the course of treatment has been emphasized in the work of Lennard and Bernstein IS], Levitt 171, Frank 181 and Zweben and Li 191 in explaining premature defection from therapy.

Procedures to reduce attrition Within the Marital Systems Study (MSS), a treatment research project

currently underway in the Clinical Institute of the Addiction Research Foundation in Toronto, Canada, specific mechanisms have been developed to deal with this concern about client-initiated attrition from treatment. In this project, short-term (8 sessions) communication-interaction based conjoint outpatient therapy is being compared with a single session of advice for couples where alcohol abuse has been identified as the primary problem. Although the examination of the impact of these procedures was not a focus of the study, we believe that these procedures have become an important element in assisting the client to understand and comply with the require- ments of the project and thereby complete the treatment contract. These procedures involve the systematic involvement of the spouse in all aspects of intake, assessment and treatment; the use of role induction in a pretherapy interview; and systematic contracting during the beginning phase of therapy to ensure that the client and spouse are familiar with the rationale, direction and nature of the proposed treatment being offered.

The involvement of the spouse begins with the initial telephone contact at which time she/he is requested to accompany the ‘identified patient’ to the intake interview. During the initial interview, the reasons for involving the spouse are discussed directly and openly. The major theme presented to the couple is that in order to ensure that the spouse’s interest in and concern for the drinking partner can best be used to facilitate change, we need to know how the drinking effects and is effected by the marital interaction. Both this theme and the active role of the spouse continue throughout the assessment stage. The spouse becomes a principal source of data during the assessment, as well as serving to validate much of the information derived directly from the drinking partner. In addition, much of the focus of the assessment process itself is directed towards assessing the intrinsic quality of the marital relationship, as well as the impact that alcohol has on marital dynamics. In fact, within the MSS the assessment battery focuses almost equally on drinking behavior and consequences on the one hand and marital dynamics and happiness on the other.

After completing the assessment and prior to the first therapy session, there is a brief role induction interview, in which a concerted, systematic effort is made to provide further information to the couple concerning the outpatient conjoint treatment program in which they will be participating.

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This special pretherapy session is conducted by a member of the study team and is essentially educational rather than purely therapeutic in orientation. The session attempts to elicit confirmation from the couple concerning the existence of an alcohol problem, to build upon a sense of hope and positive expectancies they may have concerning their ability to alter that problem and, most importantly, to provide a concrete and cogent rationale for the proposed intervention in which the non-alcoholic spouse will be an active and involved participant. The interview typically begins with a discussion about why both spouses are being seen and continues with a detailed account of the structure and content of the therapy sessions. Concerns the couple may have about the apparent diversion to ‘marital systems therapy’ are discussed openly and frankly, with reassurance being offered to them that the conjoint therapy is entirely consistent with their over-riding concern with the problematic use of alcohol. Logistical issues relating to such matters as the timing and frequency of interviews and the expectation that both spouses attend each session are discussed. Lingering questions or apprehensions on the part of the couple are dealt with openly, with reassurance and specific information being provided by the individual conducting the orientation session. Finally, some of the common reactions to therapy, e.g. impatience concerning the pace of change, periodic questioning of the utility of the enterprise and concern about the direction of an interview, are legitimized with the suggestion being offered that there may be a need to discuss these matters with the particular therapist during the course of treatment.

The process of explicitly linking the alcohol problem with interactional dynamics continues during the contracting phase of the actual therapy. In this initial stage, the rationale and potential benefits of the treatment being offered are reviewed. Specific treatment goals derived from the assessment findings are explored with the aim of identifying and gaining a consensus about the problems to be dealt with during the course of therapy. Questions are invited and resistance and ambivalence on the part of one or both spouses are explored in order to clarify misperceptions or resolve dis- agreements about the goals and strategies of the intervention. Considerable support and encouragement may be necessary for couples to reveal their ongoing concerns or frustrations about the approach being taken. To maintain compatibility among the participants concerning the expectations of therapy, the therapist may need to recontract in subsequent sessions.

By introducing such mechanisms as role induction and contracting during this critical period when motivation and commitment to therapy are being developed, we hoped to engage and sustain a higher proportion of couples in the treatment program. It is interesting to note that approximately 80% of the unplanned terminations in the study occurred prior to the fourth treatment appointment, thereby adding further importance to this initial period in terms of generating patient compliance with the treatment regimen.

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FOCUS OF THE INQUIRY

To determine the impact of the above procedures on continuance, clients assigned to outpatient conjoint therapy were compared with married clients engaged in individual outpatient therapy. The individual outpatient therapy, for the most part, was also offered on the basis of a brief (8 session) contract based treatment approach. The latter group was matched in accordance with the eligibility criteria utilized in the MSS. In the individual therapy group, however, spouses were not required to participate in assessment and treatment. Criteria for inclusion in the study were: (1) Alcohol abuse was the primary presenting problem. (2) The client was married or involved in a common-law relationship and was living with his/her partner at the time of admission. (3) The client had no major medical problems requiring inpatient care. (4) The couple scored 8 or above on the Clarke-Wais vocabulary test.

Ninety-six clients admitted to individual therapy in the Clinical Institute between April 1978-April 1981 and 49 MSS clients admitted to the Clinical Institute between February 1981-August 1982 comprised the study sample.

RESULTS

An examination of the data revealed that clients seen together with their spouses in assessment and treatment within the MSS were more likely to enter, continue in, and complete outpatient therapy than married clients engaged in individual outpatient therapy, i.e., where spouses were not required to participate in assessment and treatment. Fifty-one percent of the MSS group completed the short-term course of conjoint therapy as opposed to 17.7% of the individual therapy group. Moreover, only 6.1% of the MSS group failed to show for their initial treatment appointment, in contrast to 29.2% of the individual therapy group (x2 = 24.26, 3 d.f., P < 0.001) (Table I).

Similar findings have emerged from other studies dealing with the drop- out problem. Zax et al. [lo] discovered that alcoholics tended to remain in treatment longer when family members or ‘significant others’ played an active role in the referral process. In that study, the nature of the referral source, e.g., a family member or an individual having an intimate relationship with the identified patient in contrast to a staff member in an ‘im- personal institution’, was associated with continuance (defined in this study as completing more than the median number of appointments, 12.5). Gerard and Saenger [21, in their evaluation of outpatient treatment settings for alcoholics, found that spouse involvement in the treatment of alcoholism was related to the length of stay in a program. In their study, however, spouse participation was limited, for the most part, to providing information at assessment.

TO determine whether differences in retention rates between the in-

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TABLE I

CONTINUANCE RATES OF MSS AND INDIVIDUAL THERAPY SAMPLES

x2 = 24.26 with 3 d.f., P < 0.001.

Marital systems Individual

% W) % W)

Complete treatment 51.0 (25) 17.7 (17) Drop-out 4 appointments 10.2 (5) 25.0 (24)

Drop-out l-3 appointments 32.7 (16) 28.1 (27) No show 6.1 (3) 29.2 (28)

Total 100.0 (49) 100.0 (96)

dividual therapy and MSS groups could be attributed to selection factors, the demographic and background characteristics of the two groups were compared in Table II. Of the seventeen variables examined, significant between group differences were found in two descriptors, namely, social stability and occupational status. The fact that a disproportionate number of individual therapy clients were unemployed, a category included in both the Social Stability Index (SSI) and occupational status, explains why significant between group differences were found in both of these variables. Given this overlap, only the SSI was employed as a test factor in subsequent analyses.

The SSI is a measure of social integration. The degree to which a client is integrated into a social network in contrast to maintaining a transient life style is determined by this scale. It is computed by adding up scores from seven items: (i) present accommodation, (ii) family contact, (iii) pos- sibility of returning to live with family, (iv) regular employment, (v) job at present, (vi) job changes and (vii) legal status. The reliability estimate of the Index (coefficient alpha) is reported to be 0.62 [ll]. It has been found to be a reliable predictor of treatment outcome and is routinely administered to clients at the Clinical Institute [ll].

As there was a disparity between the MSS and individual therapy groups with respect to the SSI, a further analysis was performed stratifying the two groups on the above test factor. In order to conduct this analysis, MSS and individual therapy clients were ranked as ‘high’ or ‘low’ on the SSI depending upon whether their respective scores were above or below the sample mean (the mean and median were approximately the same for this sample). These results are presented in Table III.

It can be observed that differences between the MSS and individual therapy clients with regard to completion rates were more marked for the high stable (i.e., high SSI) group but were reduced or nonsignificant in the

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TABLE II

BACKGROUND CHARACTERISTICS OF MSS AND INDlVIDUAL THERAPY SAMPLES

Marital systems (N = 49)

Individual (N=96)

Age sex (8)

Male Female

Marital status (%) Married Common-law

Number of children

Years of education Patient

spouse Patient’s occupation” (8)

Unemployed Labourer, clerical, sales Manager, professional, etc. Housewife, student, etc.

Spouse’s occupation (%)

Unemployed Labourer, clerical, sales Manager, professional, etc. Housewife, student, etc.

Annual income (in thousand) Legal problem (%) Social stabilityb

Consider alcohol a problem (%) Yes Sometimes No

Consider self alcoholic (%) Previous treatment (%) Referral type (%)

Mandatory Voluntary -self Voluntary -friend, etc.

Treatment goal (%) Control stop No addiction problem

Number of drinking days 3 Months prior to admission

MAST score

axz = 13.73 with 3 d.f., P < 0.01 W143) = 2.90, P < 0.01.

39.82 10.0 37.859.2

73.5 72.9 26.5 27.1

83.7 70.8 16.3 29.2 2.0 t 1.5 1.8t 1.8

11.12 2.2 11.5 t 2.9

11.7k2.5 12.0 t 2.3

18.4 29.8 34.7 47.9 24.5 18.1 22.4 4.2

0 4.2 58.1 56.3 18.6 21.9 23.3 17.6 16.3 2 12.7 13.1+9.8 16.3 30.5 12.6 + 1.6 11.5-t 2.5

73.5 83.3 16.3 14.6 10.2 2.1 72.1 77.7 24.5 35.4

4.1 4.2 32.7 46.3 63.2 49.5

46.8 46.4 51.1 51.6 2.1 0

31.7k20.4 23.3k7.5

33.2 r20.9 25.1+9.8

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TABLE III

RELATIONSHIP BETWEEN TREATMENT AND CONTINUANCE CONTROLLING F’OR

SOCIAL STABILITY

Continuance (S) Marital systems Individual

Low stable” Complete treatment Drop-out No show

N (42)

50.0 23.8 40.0 52.4 10.0 23.8

N’ High stubleb (39) Complete treatment 51.3 Dropout 43.6 No show 5.1

‘x2 = 2.90 with 2 d.f., N.S. bx2 = 20.30 with 2 d.f., P < 0.001.

N 64) 13.0 53.7 33.3

low stable (i.e., low SSI) group. Among the high stable clients, 51% of the MSS group completed conjoint therapy in contrast to only 13% of the individual therapy group (x2 = 20.30, 2 d.f., P < 0.0001); whereas among the low stable clients, 50% of the MSS group in comparison to 23.8% of the individual therapy group completed their prescribed treatment (x2 = 2.9, 2 d.f., N.S.).

It should also be noted that there has been a gradual overall increase in the percentage of couples completing conjoint therapy in the MSS as the study has progressed. Figure 1 compares four groups of clients admitted to the study at different stages during the course of the study. The groups were divided into 5-month periods, except for the last group which covers only a 3-month period of time. Within the initial 5 months of the study, only 42% of the clients completed conjoint therapy, whereas in the last 3 months 83% completed treatment. The completion rates of the second and third periods were 44% and 65%, respectively (x2 = 8.97, 3 d.f., P < 0.05). Since there were no significant differences in the characteristics of the couples in the four groups, such improvement could not be attributed to different patient characteristics among the groups admitted at various stages of the study.

One could speculate that improvement in the implementation of the procedures described above may partially account for the enhanced completion rates. Another possible factor accounting for this trend may be the improved quality of the actual treatment being provided. As the therapists attain greater experience and comfort in implementing this treatment modality in a systematic, consistent fashion with an alcoholic population, the likelihood of attrition from treatment may be reduced.

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Fig. 1. Completion ratea of patienta admitted to conjoint therapy at four periods of the study.

DISCUSSION

Given the facts that the two study groups were not randomly selected for the purpose of this inquiry and that there are a limited number of cases in some of the cells, these results should be viewed with caution. Nonetheless, these tentative findings seem to suggest that employing special procedures for engaging spouses in the treatment process may be useful in terms of retaining in treatment those clients who are deemed to be more stable, e.g., those clients who are maintaining contact with their families and/or who are regularly employed. In contrast, such an intervention strategy seems to have less impact on facilitating compliance among a more transient population with alcohol-related problems.

The findings emerging from the present investigation could have important implications in utilizing a systems-oriented approach with less socially stable, married, alcohol abusing clients. The latter group includes individuals whose lives are severely disrupted by unemployment, legal and

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financial problems and who may be gradually withdrawing from everyday family events. Efforts aimed at dealing with or resolving fundamental marital/family dynamics in this population may be thwarted or futile so long as these immediate concerns continue to prevail. It may first be necessary to attend to these immediate issues before offering them the oppor- tunity to participate in systems-oriented conjoint therapy, as conducted in the present study. Such an approach may initially involve assisting these clients in gaining access to a variety of services related to their everyday circumstances, such as job counselling, child care services, and welfare assistance, while at the same time offering specific help for their substance abuse problem, e.g., antabuse therapy or detoxification. This is the approach supported by Chafetz et al. 131 and Blane and Meyers 1121 who demon- strated that attempts to engage this group of alcoholics in a therapeutic relationship are usually more successful after these immediate problems are alleviated.

Because of the post hoc nature of this inquiry, data dealing with a variety of factors influencing continuance were not available. Such con- tingencies as the perceived costs/benefits of the proposed intervention on the part of the client, the credibility and the quality of the treatments being offered and the nature of client-therapist interaction could conceivably influence help-seeking behaviour. None of these factors were systematically examined and, as a consequence, the scope of the present investigation was limited.

It would be important in future research, to gather data on the above factors in order to further the knowledge base in this problem area. In such research, it would also be instructive to separate out and determine the relative contributions of the different components of the service delivery strategy employed in the present study, namely (a) spouse participation in assessment and treatment (b) role induction and (cl contracting, in promot- ing adherence to the therapeutic regimen. This would yield a better understanding about designing and implementing specific cost-effective strategies to reduce drop-out from conjoint treatment with alcoholic couples.

To conclude, in order to determine the efficacy of systems-oriented conjoint therapy, certain procedures were utilized to maintain the couple’s involvement with the research program. For instance, role induction and the use of contracting were employed to enhance a couple’s understanding and acceptance of this interactional approach. Preliminary results suggest that these efforts may be somewhat effective in retaining those clients identified as high stable, married alcoholics. Among those considered to be low stable or more transient alcohol abusers, the above mentioned mechanisms may not be sufficient to forestall unplanned terminations. With regard to the latter group, it is suggested that attempts be made to reduce stresses associated with immediate or concrete concerns prior to instituting conjoint therapy, in order to gain the client’s commitment to the intervention being offered.

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REFERENCES

1 F. Baekland and L. LundwaIl, Psychol. Bull., 82 (1975) 738.

2 D.L. Gerard and G. Saenger, Outpatient Treatment of Alcoholism: A Study Its Determinant, Brookside Monographs for ARF, 1966.

3 M. Chafetz et al., J. Nerv. Ment. Dis., 134 (1962) 395. 4 P. Steinglass, Family Pmt., 15 (1976) 97.

5 D.E. Meeks and D. Kelly, Q.J. Stud. Alcohol, 31 (1970) 399. 6 H.L. Lennard and A. Bernstein, Psychother., (4) 1 (1967) 1. 7 E.E. Levitt, Psychother., (3) 4 (1966) 163. 8 J.D. Frank, Persuasion and Healing, John Hopkins Press, Baltimore, 1973. 9 A. Zweben and S. Li, Am. J. Drug Alcohol Abuse, 8 (1981) 171.

10 M. Zax, R. Marsey and C. Biggs, Q.J. Stud. Alcohol, 22 (1961) 98. 11 H.A. Skinner, Res. Adv. Alcohol Drug Problems, 6 (1981) 319. 12 H.T. Blane and W.R. Meyers, Q.J. Stud. Alcohol, 24 (1963) 503.

of Outcome and

reducing attrition from conjoint therapy with alcoholic couples

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