Family Therapy Treatment Outcomes

Joumal of Marital and Family Therapy
1995, Vol. 21, NO. 4, 475-509
FAMILY THERAPY TREATMENT OUTCOMES

FOR ALCOHOLISM
Martha E. Edwards Peter Steinglass

The Ackerman Institute for Family Therapy
We conducted a meta-analysis of 21 studies of family-involved therapy for alco-

holism, evaluating them for design adequacy, clinical significance, and effect size.
The review is divided into studies of family involvement in three phases of treat-
ment: ( a ) initiation of treatment, (b) primary treatmentlrehabilitation, and ( c )
aftercare. We conclude that family therapy is effective in motivating alcoholics to
enter treatment. Once the drinker enters treatment, family-involved treatment is
marginally more effective than individual alcoholism treatment. The data suggest
that three factors may mediate the effect of treatment: gender, investment in the
relationship, and perceived support from the spouse for abstinence. Modest ben-
efits have been obtained in family-involved relapse prevention programs. The
most recent studies are starting to address these issues by developing treatment
models specifically for women alcoholics and identifying factors that could be
used to match appropriate treatments to alcoholics and their families. These e f
forts are just beginning, however, and we make a number of recommendations to
support implementation of these and other efforts.
The costs of alcoholism-emotional, physical, economic-in our society are vast.

Approximately 18 million adult Americans experience problems associated with alcohol
abuse. The effects of this abuse are not only felt by the alcoholic but also have a significant
impact on family and friends through premature death, medical complications, neuropsy-
chological deficits, psychological distress, divorce, and unemployment (National Institute
on Alcohol Abuse and Alcoholism [NIAAA], 1987). Over 1 million people each year enter
treatment for alcoholism (Saxe, Dougherty, Estry, & Fine, 1983).
The research literature on family factors and alcoholism points not only to compelling
evidence of a familial predisposition regarding development of alcoholism, but also to the
significant role that family environmental factors play in influencing the differential course
of alcoholism in its chronic phase. An unbiased reading of this literature suggests that
active involvement of families, especially spouses, as an important component of a
comprehensive treatment approach would be a reasonable and prudent direction to take.
Yet for many years, this simply was not the case. Early trends in treatment approaches were
Martha E. Edwards, PhD, is a faculty member at the Ackerman Institute for Family Therapy, 149 E.
78th Street, New York, NY 10021.
Peter Steinglass, MD, is the Executive Director of the Ackerman Institute for Family Therapy, and
Clinical Professor of Psychiatry, Comell University Medical College, 149 E. 78th Street, New
York, NY 10021.
October 1995 JOURNAL OF MARITAL A N D FAMILY THERAPY 475
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comprehensive treatment approach would be a reasonable and prudent direction to take.
Yet for many years, this simply was not the case. Early trends in treatment approaches were
very much skewed toward a biomedical/behavioral treatment of the individual alcoholic
during initial phases and group therapy during rehabilitation phase, again for the individual
alcoholic.
During the 1960s and 1970s a number of alcoholism specialists began experimenting
with a variety of techniques for including family members in the treatment process, especially
during the assessment and initial engagement phases of treatment, Preliminary reviews of
these early efforts suggested that they were quite promising. For example, a Special Report
to the U.S. Congress on Alcohol and Health published over 20 years ago (Keller, 1974)
called family therapy “the most notable current advance in the area of psychotherapy [for
alcoholism]” (p. 164). And a comprehensive review of research carried out over the 25-
year period from 1950 to 1975 (Steinglass, 1976) tentatively confirmed this view, while at
the same time recommending more systematic studies of family interventions for alcohol
treatment.
Since then, conceptual and therapeutic advances in the family therapy field in general
have resulted in an increasingly wide variety of treatment models for working with couples
and families. Many of these models have at one time or another been applied to the treat-
ment of alcoholism, and in some instances the greater specification of treatment approaches
has facilitated more systematic research into treatment efficacy. Furthermore, reviews of
these treatments and their outcomes have been encouraging in concluding that family therapy
is not only successful in the treatment of alcoholism (McCrady, 1989; O’Farrell, 1992) but
also cost effective (Holder, Longabaugh, Miller, & Rubonis, 1991).
In this article, we will extend the findings of these reviews by including the most recent
studies and conducting a meta-analysis of the available evidence to answer the following
questions: (a) Is family-involved treatment effective? (b) Is family-involved treatment cost
effective? (c) What factors influence the effectiveness of family-involved treatment?
METHODS
Study Selection
Included in this review are what we believe to be the 21 most substantial reports of
treatment outcome studies to appear in the literature during the period from 1972 to 1993.
Three criteria were used to decide which studies to include. The first was that the study
evaluated the effectiveness of afarnily-involved treatment for alcoholism. The second was
that the study used at least a quasi-experimental design, comparing a treatment group with
a control group. Although most studies employed an experimental design in which subjects
were randomly assigned to the experimental treatment, we did not make random assign-
ment a criterion for inclusion in this review. Given the relatively small number of available
studies, we did not wish to be overly restrictive and leave out potentially informative inves-
tigations. The third criterion was the reporting of objective outcome data about subjects’
alcohol consumption and/or drinking-related problems after treatment.
The steps we used to identify available studies from which to select the ones for review
were: (a) searching the bibliographies of past reviews (Holder, 1991; McCrady, 1989; O’Far-
rell, 1992, 1993; Steinglass, 1976); (b) using the PsychLit data base and conducting a litera-
ture search on alcoholism treatment; (c) searching the bibliographies of all studies identi-
476 JOURNAL O F MARITAL A N D FAMILY THERAPY October 1995
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fied by the first two steps; and (d) contacting authors of unpublished or in press studies
listed and securing copies from the authors.
Grouping of Studies by Phase of Alcoholism Treatment

Prochaska and DiClemente (1983) identified three phases of treatment for addiction:
(a) initiation of treatment; (b) primary treatment/rehabilitation; and (c) aftercare. O’Farrell
(1993) used these phases to group descriptions of the major family-involved alcohol treat-
ment models. Since the issues in each of these phases are significantly different and likely
to affect treatment efficacy, we divided the review into studies focusing on the involvement
of the family in these three phases of treatment.
Clinical Signijkance
Throughout the review we will be referring to two types of significance in reporting
outcome data-statistical significance and clinical significance. In determining the latter,
one must both select a measure or measures of obvious face validity regarding treatment
impact and establish quantitative baseline criteria against which treatment impact is to be
evaluated (see Jacobson, Follette, & Revenstorf, 1984, for a discussion of these issues).
In studies of primary treatment and rehabilitation (Phase 11) and aftercare (Phase III),
the main target of treatment was a decrease in alcohol consumption. The specific alcohol
use criterion for determination of successful treatment has been a subject of some controversy
in the field. Although total abstinence was long considered the sole acceptable index of
successful treatment, as behavioral psychologists developed techniques for teaching less
severe alcoholics how to drink on a reduced, limited basis (Chick, Ritson, & Connaughton,
1988; Marlatt & Gordon, 1985; Miller & Baca, 1983; Miller & Caddy, 1977), controlled
drinking seemed to present itself as a reasonable alternative treatment goal.
Furthermore, since initial outcome studies seemed to provide evidence that controlled
drinking was a viable treatment outcome (Davies, 1962; Sobell & Sobell, 1976), some
clinicians argued for the acceptance of a broader set of drinking goals in alcohol treatment
(Pattison, 1976). However, controlled drinking as a treatment outcome remains controver-
sial. Reexaminations of the data used to buttress the controlled drinking position have
suggested that controlled drinking was a transient, not a long-standing outcome (Pendery,
Maltzman, &West, 1982). As Galanter (1993) reports, the consensus of practitioners in the
field, reflected in the established clinical programs throughout the United States, is that
abstinence should be the goal of treatment. Therefore, in evaluating and comparing the
outcomes across studies of family-involved treatments, we first examine the data on absti-
nence. In addition to the fact that it is recognized as the primary goal of treatment, it is also
the one measure common to all studies. Consequently, we use this measure to reflect the
clinical significance of the treatments as well.
As for the actual baseline criteria we used in evaluating clinical significance, we first
identified what level of abstinence one would expect if alcoholism was allowed to run its
natural course. Vaillant (1 983) estimates this figure to be 2% to 3% a year. This is compa-
rable to the 5% abstinence rate found for subjects on a waiting list for treatment (Kissin,
Platz, & Su, 1970). Second, we examined the outcomes of non-family-involved treatments
identified as successful and found abstinence rates of 54% after 1 year (Neubuerger et al.,
1982), 58% after 14 months (Saxon, Nace, & Cammarota, 1983), 29% who were complete-
ly abstinent and 26% with occasional slips over 4 years (Pettinati, Sugerman, DiDonato, &
Maurer, 1982), and 58% with no time period specified (Sheehan, Wieman, & Bechtel, 1981).
October 1995 JOURNAL OF MARITAL AND FAMILY THERAPY 477
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Therefore we set our clinical significance figure at 50% of the sample. Since the stud-
ies reported follow-up periods ranging from 6 months to 4 years, we do not specify a time
period in which this abstinence level must be maintained. This is the baseline for studies
that report abstinence in terms of the percentage of subjects abstinent. Other studies report
the percentage of abstinent days for each of the experimental groups. To calculate a corre-
sponding baseline for this form of data reporting, we looked at the studies that reported
abstinence rates in both forms (percentage of abstinent subjects and percentage of abstinent
days). We then extrapolated from these figures that the baseline for abstinent days that
corresponds to 50% abstinent subjects is 85% abstinent days.
This baseline applies to studies in Phases I1 and I11 where the goal is abstinence. It is
not applicable to studies in Phase I where the goal is for the alcoholic to enter treatment.
Using a similar strategy for identifying the course of untreated alcoholism, we noted that in
1988, 13 million Americans were diagnosed as alcoholics (Office of the President, 1989),
but only 1 million entered treatment (Saxe et al., 1983). The untreated rate of entry in
treatment is, therefore, approximately 8%. We did not have data that would help to identify
a baseline for clinical significance of a treated group. Therefore, we arbitrarily set the
baseline at 50%.
Methods for Meta-Analysis of the Studies

Integrating results across studies-the goal of meta-analysis-is not as easy as it might
at first appear. If one relies solely on the statistical tests performed in each study, important
trends in the data are likely to be missed. Therefore, we used a technique called meta-
analysis, which is a statistical analysis of the summary findings of multiple studies.
In other meta-analyses (see Shadish, Ragsdale, Glaser, & Montgomery, 1995, this is-
sue), the effect size of the difference between the experimental and control groups on a
particular measure is often obtained by calculating the difference between the means of the
two groups and dividing by the pooled standard deviation. However, in most alcoholism
treatment studies, in which outcomes are often expressed as frequency counts of the num-
ber of subjects in the sample who were abstinent, this formula is inadequate. Furthermore,
many of the studies we reviewed do not report the necessary data to calculate the effect size
using the above formula, even when frequency counts were not used to measure abstinence.
Therefore, we used a probit transformation (Glass, McGaw, & Smith, 1981) to calculate
effect size for our meta-analysis.
We did not calculate the effect size for all the outcome measures reported. In studies of
Phase I (initiation of treatment), we were primarily interested in whether the treatment
stimulated the alcoholic to enter a treatment program and whether it had an effect on drink-
ing. In studies of Phases I1 and 111, we were primarily interested in whether family-in-
volved treatment had an impact on the alcoholic’s drinking, in particular whether it resulted
in abstinence. Therefore, while the results from other outcome measures (e.g., marital/
family functioning, psychological functioning, occupational functioning) are reported in
the text, their effect sizes are not calculated.
Study Design Quality

In her review of alcohol treatment outcome studies, McCrady (1 989) cited 1 1 elements
of an optimally designed treatment outcome study (Emrick & Hanson, 1985): (a) random
assignment to experimental and control groups; (b) delivery of well-defined treatments
478 JOURNAL OF MARITAL A N D FAMILY THERAPY October 1995
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within each condition; (c) adequate description of subjects in the study; (d) use of objective,
reliable, valid measures of treatment outcome; (e) collection of data by persons not deliver-
ing the treatment; (f) measurement of outcome across major areas of life functioning; (g)
adequate length of follow-up, with 6 months as a minimum; (h) adequate rates of follow-
up, usually 80%or above; (i) use of collateral data sources to validate subjects’ self-reports;
(i) well-defined criteria of treatment success; and (k) appropriate statistical procedures to
analyze the results. We add a 12th element-that the therapy be done by a trained family
therapist (as opposed to an alcohol specialist). Table 1 summarizes the degree to which the
studies included in this review meet all of these criteria. (Five of the studies McCrady
reviewed are included in this review. We do not include the criterion of well-defined crite-
ria of treatment success in Table 1 because that was a criterion for including a study in our
review. Thus, all of the studies would meet this criterion.)
In the review of individual studies, we provide a brief description of the treatments
tested and describe key elements of the studies in order to highlight factors that appear to
influence the efficacy of the interventions. We then discuss the results from the study,
reporting results from not only the primary treatment outcomes measures but also other
measures used in the studies (e.g., measures of family, occupational, and psychological
functioning). To aid the reader in keeping all of this complex information straight, we
summarize critical information in Tables 2,3,4, and 5 , which provide information on both
clinical significance and effect size.
PHASE I: INITIATION OF TREATMENT
One of the first findings reported about involvement of family members in therapy was
that such inclusions significantly improved rates of engagement of the alcoholic patient in
ongoing rehabilitation. Given the importance of this issue for alcoholism treatment, it is
not surprising that clinicians have aggressively pursued new approaches to involve family
members early in the treatment process. Three such programs, designed to motivate an
alcoholic patient previously unwilling to stop drinking to enter treatment, have been sub-
jected to formal research assessment (see Table 2). Two of these approaches-the family
intervention and unilateral family therapy programs-are specifically designed to work
with nonalcoholic family members around the goal of engaging the alcoholic member in
therapy. The third program--community reinforcement training (CRT)-is more broad-
based in its objectives. We will discuss in turn each of these programs and the studies
carried out to test their effectiveness.
The Intervention Method

Let us start with perhaps the best known of these approaches, best known in part be-
cause it was used by First Lady Betty Ford’s family to compel her to enter treatment. It is
called the “intervention.” In this model, family members and friends of the alcoholic re-
ceive training (in four to five 2-hour sessions) to stage a formal confrontation of the alco-
holic. In the confrontation, family members describe their concerns about the alcoholic’s
drinking and its consequences.
In the only formal study of the intervention’s effectiveness, Liepman and his colleagues
(Liepman, Silvia, & Nirenberg, 1989)provided training to conduct the confrontation for 24
families, 7 of whom subsequently carried out a confrontation of their alcoholic members,
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478
P
00 Table 1
0
Design Characteristics of Treatment Outcome Studies
Adequate Objective Major life Minimum
Random Subject Defined Objective Data Col- Areas 6-month
Study Assign. Descrip. Treatment Measures lectors Assessed Follow-up
Corder, Corder, & No Yes Yes Yes Unclear No Yes

JOURNAL OF MARITAL A N D FAMILY THERAPY
Laidlaw, 1972
Cadogan, 1973 No Yes Yes Yes Unclear Yes No
Hunt & Azrin, 1973 No Yes Yes Yes Yes No Yes
Hedberg & Yes Yes Yes Yes Yes No Yes
Campbell, 1974
Azrin, 1976 Yes Yes Yes Yes Yes No Yes
McCrady, Paolino, Yes Yes Yes Yes Yes Yes Yes
Longabaugh, & Rosi,
1979, 1982
Azrin, Sisson, Yes Yes Yes Unclear Unclear Yes Yes
Meyers, & Godley,
1982
Ahles, Schlundt, Yes Yes Yes Yes Yes Yes Yes
Prue, & Rychtarik,
1983
Ossip-Klein, Yes Yes Yes Yes - il
No -
Van Landingham,
Prue, & Rychtarik,
1984
October 1995
O’Farrell, Cutter, Yes Yes Yes Yes Yes Yes Yes

Choquette, Floyd,
& Bayog, 1985, 1992
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Table 1 (continued)
October 1995
Adequate Objective Major life Minimum >

Random Subject Defined Objective Data Col- Areas 6-month S
Study Assign. Descrip. Treatment Measures lectors Assessed Follow-up F
McCrady, Noel, & Yes Yes Yes Yes Yes Yes Yes Y
Abrams, 1986
Sisson & Yes No Yes Yes Unclear No - -
Azrin, 1986
Stout, McCrady, Yes No Yes Yes Yes Yes Yes Y
JOURNAL OF MARITAL AND FAMILY THERAPY
Longabaugh, Noel,
& Beattie, 1987
Thomas, Santa, Yes Yes Yes Yes Unclear Yes Yes Y
Bronson, &
Oyserman, 1987
Zweben, Pearlman, Yes Yes Yes Yes Yes Yes Yes N
&Li, 1988
Liepman, Silvia, No Yes Yes Yes - - - -
& Nirenbeg, 1989
Thomas, Yoshioka, No Yes Yes Yes Yes Yes Yes Y
Ager, & Adams, 1993
Longabaugh, Yes Yes Yes Yes Unclear Yes Yes Y
Beattie, Noel, Stout,
& Malloy, 1993
O’Farrell, Yes Yes Yes Yes Unclear Yes Yes Y
Choquette, Cutter,
Brown, & McCourt,
I993
For studies of interventions to initiate treatment or prevent relapse, not relevant categories are designated with
Statistics were calculated from data reported.
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and 17 of whom chose not to pursue the issue further. Comparisons were then made of
these two groups (confronting versus nonconfronting) regarding (a) engagement in treat-
ment and (b) reasons why the 17 nonconfronters failed to cany through with an interven-
tion.
Results regarding treatment engagement proved quite dramatic. Of the families that
followed through with a confrontation, the alcoholics in six of the seven families (86%)
entered an alcohol detoxification or rehabilitation program as compared with the alcoholics
in three (I 7%) of the nonconfronting families. The confrontation not only yielded a statis-
tically significant difference, but the results were also clinically significant. Furthermore,
the confronted alcoholics were continuously abstinent for 11 months compared to only 2.8
months for the nonconfronted alcoholics.
Although the intervention is successful with some families, it appears as if the training
provided is insufficient to help the majority of families who are concerned about an alco-
holic member to intervene in the situation. It may be that making such a move is more
difficult for particular types of families. Analyses of the differences between the confront-
ing and nonconfronting groups yielded no significant differences in the gender of the alcohol-
ic, the number of members in the social networks involved in the counseling, the number of
prior treatments sought by network members or the alcoholic, the time span of treatment, or
number of hours of training provided. The difference that did emerge was that older alco-
holics were less likely to be confronted than younger alcoholics. The authors offered sev-
eral reasons for this difference, including: chronicity of the alcoholism in older persons
leading to a sense of hopelessness, intimidation in the face of confronting an older family
member, and the difficulty in disrupting entrenched family patterns.
Unilateral Family Therapy

A much more extensive model of treatment, which includes an intervention-like con-
frontation as an optional component of its treatment package, is unilateral family therapy
(UFT). The model is so named because therapists work exclusively with the nonalcoholic
cooperative spouse in helping the uncooperative alcoholic spouse enter treatment. Unilat-
eral therapy includes: an initial assessment, alcohol education, unilateral relationship
enhancement, disenabling, neutralizing old alcohol control behaviors, preparation for alcohol-
ic-directed interventions (e.g., confrontation, request, contracting), support for maintenance
of gains, relapse prevention training, and, if appropriate, help for the spouse in disengaging
from hidher alcoholic partner and the drinking problem and in dealing with emotional prob-
lems. Two studies tested the efficacy of this approach not only in motivating alcoholics to
enter treatment but also in reducing their drinking. In a pilot study, Thomas, Santa, Bronson,
and Oyserman (1 987) found that 61 % of the alcoholics whose spouses participated in the
UFT were classified as “improved” (entered treatment, reduced their drinking, or both),
whereas none of the alcoholics whose spouses did not participate in UFT were classified as
improved. These results are both statistically and clinically significant. Furthermore, they
saw a 53% reduction in drinking in alcoholics with UFT spouses as compared to a slight
increase in the drinking of alcoholics whose spouses did not receive treatment. UFT was
also associated with a decrease in the spouse’s life distress. Although there were no differ-
ences in the two groups on overall marital satisfaction, treatment was associated with an
increase in the spouses’ reports on the affection and sexual satisfaction in the marriage.
A larger scale study of UFT subsequently carried out by the same team (Thomas,
Yoshioka, Ager, & Adams, 1993) yielded stronger findings. In an abbreviated research
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October 1995
Table 2
Results from Studies of Interventions for Initiating Change (P
~~~~~~ ~ ~ ~~
Study Subjects Comparison Groups Outcome Measur

Liepman, Silvia, & 18 male & No assignment:
Nirenberg, 1989 6 female C: Confrontation Entered detodreh
alcoholics & ( n = 7) program
families NC: No confrontation Months continuou

( n = 17) abstinence
Thomas, Santa, Bronson, 25 spouses of Random assignment: Improvement (red
& Oyserman, 1987 24 male and UFT Unilateral family tion in drinking,
1 female therapy ( n = 15) entering treatmen
alcoholics C: Control ( n = 10) or both)
Reduction in drin
Thomas, Yoshioka, 69 spouses of UFT Unilateral family Entering treatmen

Ager, & Adams, I993 65 male and therapy (n = 55)
4 female C: Control ( n = 14) Reduction of drin
alcoholics
Sisson & Azrin, 1986 12 alcoholics CRT: Community Entering counseli
& concerned reinforcement training
family members ( n = 7) Reduction in drin
(9 spouses) TP: Traditional program
(\.-
n = -5I )
* = Difference is significant at p < .05 or less.
- = Can not compute.
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summary of this study, Thomas and Ager (1 993) reported that immediately after treatment,
alcoholic spouses of individuals in UFT entered treatment significantly more than alcohol-
ics whose spouses were not in the program. At the most recent follow-up period, however,
this difference remained clinically significant but was no longer statistically significant
(57% compared to 31%). The alcoholics whose spouses were in treatment also reduced
their drinking more (68% compared to 20%) than alcoholics whose spouses were not in
treatment. The authors linked entry into treatment to the changes spouses made while in the
UFT program: they significantly reduced their enabling and customary drink control be-
haviors more than did the control spouses. Participation in UFT was also related to a reduc-
tion in spouse psychopathology and life distress, and an increase in marital satisfaction.
These investigators thus demonstrated that it is possible to effect change in the family sys-
tem through interventions with only one member, a particularly salient finding in that it
suggests a potentially effective strategy for better engaging resistant alcoholic patients in
treatment.
Community Reinforcement Training

The final study reviewed in this section was carried out by Sisson and Azrin (1986); a
treatment model called community reinforcement training (CRT) was compared with a tra-
ditional program for spouses. The CRT for nondrinking cooperative spouses included:
how to reduce physical abuse, how to encourage sobriety (by reinforcing the alcoholic for
periods of sobriety and arranging negative consequences of drinking), and how to encour-
age treatment (by identifying and taking advantage of moments when the drinker is most
motivated to enter treatment). Both CRT and UFT are based on social learning principles
and have some similar components, but the event that actually triggers the entry into treat-
ment is quite different. In UFT, the nondrinking spouse requests the drinker to enter treat-
ment. In CRT, the nondrinking spouse waits until the drinker states a desire to quit drinking
(which typically occurs after an incident that has inconvenienced, embarrassed, shamed, or
hurt the drinker or other family members). At that time, the drinker and spouse attend a
conjoint counseling session (within 24 hours if possible). In the traditional program, the
spouses received education about alcoholism, referrals and help to get to Al-Anon meet-
ings, and supportive counseling.
In a pilot test of 12 women who were concerned about male family members’ drinking,
5 received treatment in a traditional program and 7 in the CRT program. None of the alco-
holics related to the 5 women in the traditional program came in for treatment, whereas 6 of
the 7 (86%) alcoholics related to women in the CRT entered treatment. During the time that
the women were in the training program, the alcoholics increased their abstinent days from
20% to 63%, as compared to the alcoholics whose family members were in the traditional
program whose drinking increased slightly. Thus, the training not only helped the drinkers
to get professional help but also contributed to a reduction in drinking even when they,
themselves, were not in treatment. (In treatment, the alcoholic and spouse participated in
conjoint sessions. The results from this part of the study are reported in the next section.)
Summary of Phase I Studies

Overall, the four studies reviewed above demonstrate the powerful effect that family
members have not only in motivating alcoholics to get treatment but also in altering drink-
ing behavior. This is confirmed by the average effect size for entering treatment (which
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does not include the outcome measure of reducing drinking levels) of 1.83-a statistically
significant finding. This figure means that the alcoholics whose spouses participated in
some intervention went into a treatment program at a rate almost 2 standard deviations
higher than alcoholics whose spouses did not participate in an intervention program. In that
sense, these studies offer compelling evidence that clinical reports of the positive influence
of family involvement in improving treatment engagement were on target. The clinical
significance of the treatments is equally powerful. Alcoholics whose family members were
involved in some form of treatment entered treatment at rates ranging from 57% to 86%
across the four studies as compared with rates ranging from 0% to 3 1% in the control
groups.
The weight of evidence in this regard seems so strong at this point as to support a
recommendation that family involvement, especially inclusion of nonalcoholic family mem-
bers in the assessment phase of treatment, be built in as a routine component of alcoholism
treatment programs. However, for family members to have this influence, active support of
the family and its deliberate inclusion in treatment planning appear to be necessary compo-
nents. Both the UFT and the CRT approaches help the family members change some of the
patterns of interaction around alcohol use and attempts at its control. Positive results in
family life may then make entering treatment more desirable for the alcoholics and/or put-
ting pressure on the alcoholic to enter treatment more feasible for the nonalcoholic family
members.
PHASE 11: PRIMARY TREATMENT/REHABILITATION
A vast array of family therapy treatment approaches to alcoholism have been described
in the literature of the past 30 years. Many of these approaches have been reported to be
efficacious, but in most instances these reports have either been anecdotal or come from
poorly designed studies. A more limited number of outcome studies have been carried out
examining treatment efficacy in designs that have included adequate comparison groups
and use of systematic outcome measures. We selected 15 studies as meeting our minimum
criteria for inclusion in this review.
The family therapy treatment models we examined can be roughly classified as falling
within two types: (a) family systems-oriented approaches, characterized by a focus on
interaction patterns and the regulation of internal and external environments; and (b) be-
haviorally oriented approaches, all of which are based on social learning theory and include
concepts such as reinforcement, reciprocity, and coercion. We will discuss each of these
types in turn.
Family Systems Treatment Models

Four studies were conducted to evaluate different family systems treatment models,
ranging from outpatient marital therapy, to conjoint hospitalization of husband and wife, to
group therapy for three or more families at a time (see Table 3).
The first report of a study using such a treatment approach was conducted by Corder
and his colleagues (Corder, Corder, & Laidlaw, 1972). They investigated whether includ-
ing a couple-focused segment in their otherwise traditional inpatient program would im-
prove results. The traditional program (Tp) consisted of 4 weeks of daily group-therapy
sessions, didactic lectures, and supportive recreational and occupational therapy. Spouses
October 1995 JOURNAL O F MARITAL A N D FAMILY THERAPY 485
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484
Table 3
Results from Studies of Family Systems Primary Treatment and Rehabil
Comparison Groups
Study Subjects wi Assignment Method Outcome Measure
JOURNAL OF MARITAL A N D FAMILY THERAPY
Corder, Corder, & 39 male Chronological 6-month follow-uo:

Laidlaw, I972 alcoholics assignment '70Subjects abstinent
and wives CT: Couples treatment ( n = 19)
TP: Traditional program ( n = 20)
Cadogan, I973 35 male and Chronological Posttreatment:
5 female assignment % Subjects abstinent
alcoholics and C T Couples treatment ( n = 20)
their spouses WL: Waiting list control ( n = 20)
McCrady, Paolino, 20 male and Random assignment: 6-month follow-uu:
Longabaugh, & Rosi. I3 female JA: Joint admission ( n = IS) % Subjects abstinent
1979 alcoholics CI: Couple involvement ( n = 8)
wlspouses I: Individual involvement ( n = 7)
McCrady, Moreau, 4-vear f o l l o w - ~ ~ :
& Paolino, 1982 % Subjects abstinent
( F ~ I I ~ w -to
u P1979 markedly improved
study)
Zweben, Pearlman, 96 male and Random assignment: 6-month follow-uo
& Li, 1988 38 female C T Conjoint therapy ( n = 70) %Abstinent days
alcoholics AC: Advice counseling ( n = 46)
18-month follow-up
% Abstinent days
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of half the alcoholics were invited to the hospital for the last 4 days of the program to
participate in the couples treatment (CT). The couples participated in two sessions of mul-
tiple couple therapy, discussions of transactional analysis game playing, AA or Al-Anon
meetings, and joint recreational activities. They also listened to lectures on medical and
psychological aspects of alcoholism and listened to representatives from aftercare programs.
At 6-month follow-up, CT subjects were more abstinent (58% subjects abstinent) than
the TP subjects (15% subjects abstinent). Thus, the CT intervention yielded both statisti-
cally and clinically significant results. They also attended follow-up treatments, partici-
pated in recreational activities, and were employed more than the TP group. There was no
difference in the separation or divorce rate of the two groups.
Cadogan and his colleagues (Cadogan, 1973) tested a longer program of family-in-
volved treatment with a different focus, concentrating on feeling expression and improve-
ments in communication and problem solving through discussion. After being discharged
from the hospital, alcoholics and their spouses attended weekly multiple couples therapy
for 3 to 6 months, and their 6-month posttreatment outcomes (drinking and marital func-
tioning) were compared to a waiting list group of couples. Significant differences were
found in abstinence rates at 6-month follow-up. Alcoholics who participated in couples
therapy with their spouses were more abstinent (45%)than the waiting list group (lo%), but
these results just missed being clinically significant. These investigators also measured pre
and post levels of marital communication and conflict but found no differences across treat-
ments at follow-up.
McCrady, Paolino, Longabaugh, and Rosi (1979) compared an individual treatment
with two types of couple treatments with inpatients in a private psychiatric hospital. In the
individual (I) treatment, only the patients attended group therapy. In the couples involve-
ment (CI) treatment, the patients and spouses attended multiple couples therapy group ses-
sions together, the patients attended group therapy by themselves, and the spouses attended
spouses group therapy by themselves. In the joint admission (JA) treatment, the spouses
lived on the ward and participated with the patients in all components of the CI program. In
addition, they attended all ward community meetings and the patient’s treatment team meet-
ings, and the patient and spouse participated together in all possible activities such as occu-
pational therapy and recreational activities. Because subjects entered the project at differ-
ent times but all groups terminated at the same time, the number of sessions attended across
subjects varied.
In the multiple couples groups, the couples discussed how alcohol had affected their
marriage, how each of the partners felt about it, how each of them had acted to bring about
the situations leading to alcohol abuse, and how they could alleviate these situations. They
also discussed problems of sex, finances, children, job, and leisure time in a problem-solv-
ing manner. In the patients’ groups, discussion centered around triggers to drinking and the
development of alternative coping strategies. In the spouses’ groups, the aim was to help
the participants focus on their own behavior and feelings and to detach themselves from the
patients’ drinking behavior.
At 6-month follow-up, subjects in both of the couple treatment groups (JA and CI)
were more abstinent (61% and 83%, respectively) than the subjects in the individual treat-
ment (43%). They had also improved significantly from pretreatment to follow-up in de-
creasing alcohol consumed. Although differences across treatments were not statistically
significant, the couple treatments did produce clinically significant abstinence rates. On
the psychological and marital measures, subjects in all three treatments significantly im-
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proved from pretreatment to follow-up, but there were no differences across treatments in
level of improvement.
In a 4-year follow-up of these subjects (McCrady, Moreau, & Paolino, 1982), there
were still no differences in outcomes across the three treatments. Specifically, there were
no differences across treatments in periods of abstinence, drinking improvement, negative
drinking consequences, subjective drinking improvement, marital status, employment sta-
tus, or rehospitalization. Furthermore, the abstinence rates had dropped below the 50%
baseline for clinical significance (33%for JA, 13%for CI, and 14% for I). Thus, the results
from these two reports demonstrate that both individual and couple treatments can be effec-
tive in reducing drinking and improving psychological, marital, and other types of func-
tioning. The couple treatments, however, do not appear to be superior to individual treat-
ment. Furthermore, effectiveness markedly diminishes several years after completion of
treatment.
In the fourth family systems treatment model study, Zweben, Pearlman, and Li (1988)
developed an outpatient couples treatment to address some of the issues raised by Steinglass,
Bennett, Wolin, and Reiss (1987) in their description and study of the alcoholic family. The
couple treatment (CT) examined the adaptive functioning alcohol might serve in the family
and the role it played in the family’s typical patterns of living. In eight conjoint sessions,
the therapist helped the couple assess typical patterns of interaction and problematic com-
munication, identify links between the drinking problem and interactional patterns, and
make suggestions for more effective problem solving and communication.
The control treatment was a single session of advice counseling (AC) that both the
alcoholic and spouse attended. The AC treatment was considered to be an acceptable alter-
native to a no-treatment control group. In this session, the therapist identified with the
couple significant issues related to drinking and the marital relationship, gave recommenda-
tions for improving these areas, and discussed relapse prevention strategies.
At 6-month follow-up, subjects in both groups had significantly increased the percent-
age of abstinent days as compared to pretreatment levels (36% to 52% for CT and 29% to
58% for AC). They had also decreased their percentage of heavy drinking days as com-
pared to pretreatment levels (44% to 16% for CT and 45% to 18% for AC). There were no
differences, however, between the two treatments in these outcomes. Similar results were
seen at the 18-month follow-up (5 1 % abstinent days for CT and 56% for AC). Thus, this
study failed to demonstrate clinical significance (for which the baseline was 85%) for the
measure of abstinent days.
Summary of Phase I1family systems treatment studies. To look at the overall results
from the studies of family systems treatment models, we first examined the average effect
size over a follow-up period of no more than 6 months. The difference between family-
involved treatment and the controls was .75, which was statistically significant. In these
four studies, two produced clinically significant abstinence rates and one just missed (45%
abstinent subjects). This means that, in the short run, family systems treatment yielded
higher rates of abstinence than did either individual treatment (three studies) or no treat-
ment (one study), and that these abstinence rates were generally clinically significant. How-
ever, these results did not hold up over time as the average effect size for follow-up periods
of either 18 months or 4 years was a nonsignificant .17. Possible reasons for the decay in
effect over time are discussed later.
488 JOURNAL OF MARITAL AND FAMILY THERAPY October 1995
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Family-Involved Behavioral Treatment Models
Six groups of investigators have conducted single studies or a series of studies of fam-
ily-involved behavioral treatment (see Table 4). The earliest of the groups was Hedberg
and Campbell (1 974), who tested four types of behavioral treatments, one of which in-
volved the alcoholic’s family. This study is noteworthy in two respects. First, therapy was
conducted with the entire nuclear family of the alcoholic rather than just the spouse. Sec-
ond, the subjects were permitted to select their own treatment goal-ither abstinence or
controlled drinking. Regardless of the goal chosen, the treatments were essentially the
same.
Subjects who had been referred for outpatient therapy were randomly assigned to one
of four behavioral treatments: electric shock treatment, covert sensitization, systematic
desensitization, or behavioral family counseling. The latter treatment consisted of conjoint
sessions that included behavioral contracts and training in communication, reinforcement,
assertiveness, and behavioral rehearsal. For all four treatments, 20 sessions were conducted
over 6 months, with 14 of these sessions in the first 8 weeks.
The authors did not conduct statistical tests to evaluate the relative effectiveness of the
four treatments. Nevertheless, their report of the frequencies of goal attainment in each of
the treatments enabled us to compute a chi-square (2= 9.12, n = 49, p = .03). When the
subjects who selected the goal of abstinence were examined separately, the chi-square was
no longer significant (x* = 7.05, n = 36, p = .08). An inspection of the distribution reveals
abstinence rates of 80% for the behavioral family counseling group, 60% for the systematic
desensitization group, 36% for the covert sensitization, and 0% (and many dropouts) in the
electric shock group. These results suggest that of the behavioral treatments available, two
appear to be more effective-behavioral family counseling and systematic desensitization.
A logical question is whether adding a family component to behavioral therapy is beneficial
or whether they yield essentially equivalent results. The other investigations of family-
involved behavioral therapy help to answer this question.
A second group of investigators conceptualized alcohol as a deterrent to other social
reinforcers. The therapeutic aim, therefore, was to increase the quality, frequency, and
variety of these social reinforcers so as to interfere with the drinking. They labeled their
intervention community reinforcement approach (CRA) and evaluated its efficacy in four
studies (Azrin, 1976; Azrin et al., 1982; Hunt & Azrin, 1973; Sisson &Azrin, 1986). This
approach was first tested with patients admitted to a state hospital for alcoholism (Hunt &
Azrin, 1973). Half the subjects participated in the traditional program (TP) only; the other
half participated in both the TP and CRA.
The traditional program (TP) included 25 one-hour didactic sessions with information
on Alcoholics Anonymous, statistics on drinking and the problems of alcoholics (behav-
ioral, physical, sexual), and ways of overcoming these problems.
The CRA consisted of four components that were used by the participants only if needed:
vocational counseling, conjoint maritavfamily counseling, social counseling (to help the
client develop and maintain a circle of friends), and reinforcer-access counseling (to in-
crease the client’s access to reinforcers such as radio, television, newspaper, telephone,
driving license). The degree to which patients took advantage of these services was not
uniform. Nine of the 16 patients were married. Unmarried patients participated in the
family counseling component with their parents or with synthetic families comprised of
friends and/or coworkers. The focus of the treatment was to increase the reinforcements for
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488
% Table 4
0
Results from Family-Involved Behavioral Primary Treatment and Rehab
Comparison Groups
Study Subjects w/ Assignment Method Outcome Measures
Hedberg & Campbell, 45 male and Random assionnient: 6-month follow-up

1974 4 female BFC: Behavioral family % Subjects abstinent

alcoholics counseling (n = 15)
SD: Systematic desensitization (n = 15)
CS: Covert sensitization ( n = 15)
ES: Electric shock ( n = 8)
Hunt & Azrin, 1973 I6 male alcoholics Matched pairshandom assionnient: 6-month follow-LID:
& their spouses, CRA: Community reinforcement % Abstinent days
parents, or approach (n = 8)
significant others TP: Traditional program (n = 8)
Azrin, 1976 38 male alcoholics Matched pairsirandom assionnient: 6-month follow-uD:

&their spouses, CRA: Community reinforcement %Abstinent days
parents, or approach (n = 19)
significant others TP: Traditional program ( n = 19)
Azrin, Sisson, Meyers, 36 male and Random assignment: 6-month follow-up:

& Godley, 1982 7 female alcoholics BTDA: Behavior therapy plus %5 Abstinent days
& spouses, parents, disulfirani assurance ( n = 14)
or significant DA: Disulfiram assurance (n = 15)
others TP: Traditional program (n = 14)
Sisson & Azrin. 1986 I2 male alcoholics Random assignment: 3-month follow-up:
& concerned CRT Community reinforcement %Abstinent days
family members approach (n = 7)
(9 spouses) T P Traditional program (n = 5)
*
October 1995
= Difference is significant at p < .05 or less.
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October 1995
9 Table 4 (continued)
q Comparison Groups
I
W Study Subjects w/ Assignment Method Outcome Measures

McCrady, Noel, 33 male and Random assiznment: 6-Month Follow-uo
& Abrams, 1986 12 female I9 ABMT - Alcohol behavioral %Abstinent subjects
drinkers wi marital therapy
nonalcoholic I2 AFSI - Alcohol-focused spouse
spouses involvement
14 MSI Minimal spouse involvement
~
Stout, McCrady, 229 married & Random assionment: 6-month follow-uo
2
5 Longabaugh, Noel, unmarried PO: Patient only % Days abstinent
& Beattie, 1987 sub-jects SE: Patient and social
5b environment (spouse, family, friends)
SOE: Patient, social, and occupational
? environments
[Only PO and SE comparisons
were reported]
5 O’Farrell, Cutter, 34 male Random assiznment: Posttreatment:
3
P
& Floyd, 1985 alcoholics BMT Behavioral marital therapy ( n = 10) % Days abstinent
b &wives ICT Interactional couples therapy (n = 12)
ST: Standard treatment (n = 12)
8
O’Farrell, Cutter, 6-month follow-up
Choquette, Floyd, & % Days abstinent
Bayog, 1992
24-month follow-ur,
% Days abstinent
Longabaugh, Beattie, 74 male and Urn randomization: 1 -year follow-uD:

Noel, Stout, & 33 female RCB: Relationship-enhanced % Days abstinent
Malloy, 1993 alcoholics & cognitive behavior therapy ( n = 65)
spouses ICB: Individual-focused extended
t2
489
cognitive behavior therapy ( n = 42)

- * = Difference is significant at p < .05 or less.
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both the alcoholic and family members and to make drinking incompatible with significant
relationships in their lives. After discharge from the hospital, all subjects were visited at
home by a counselor for approximately 10-15 sessions. Some of the family sessions were
carried out during these home visits.
At 6-month follow-up after discharge from the hospital, CRA subjects had better out-
comes than the TP subjects. CRA subjects had more days on which they were abstinent
(86% compared to 2 1%), more days employed, fewer days away from home, and fewer
days institutionalized. All of these differences were statistically significant and the differ-
ence in abstinence levels was also clinically significant.
The treatment was then modified by adding four components: (a) disulfiram (Ant-
abuse), (b) an early-warning notification system to alert the counselor that problems were
developing, (c) a neighborhood-friend-advisor to continue social support of the client after
professional counseling had been terminated, and (d) group counseling procedures to re-
duce the amount of counseling time per client. The revised CRA was then tested in a larger
study (Azrin, 1976). Not only were the previous results confirmed, but the superiority of
the CRA intervention in comparison with the TP regarding abstinence was even more strik-
ingly demonstrated.
Clients in the CRA program were abstinent 98% of the time as compared to 45% of the
time in the TP. The revised version of the CRA was also more efficient, requiring 30 hours
for the average client as compared to 50 in the original version. In a 2-year follow-up, the
abstinence of the CRAclients had been maintained at a level of over 90% of the time. Thus,
in addition to being statistically superior to a traditional program, the CRA was clinically
superior both in the short run and the long run.
The investigators suspected that the addition of disulfiram was the critical component
and conducted a third study to examine the role of family members in determining the
effectiveness of disulfiram (Azrin, Sisson, Meyers, & Godley, 1982). Outpatient clients
were randomly assigned to three treatment conditions and received five sessions in each. In
the first, the traditional program (TP), clients were given disulfiram and told it was their
responsibility to take it. Spouses accompanied the clients to the first session only. Sessions
covered basic alcoholism education, encouragement of abstinence, and sympathetic listen-
ing to the personal and social problems presented by the client. In the disulfiram assurance
(DA) treatment, clients were given the traditional program with two modifications: (a) the
significant other was encouraged to come to all sessions; and (b) specific training in adher-
ing to the disulfiram regimen was given. This training included taking the medication at
every session, role playing situations of nonadherence, and communication skill training
for the significant other.
The behavior therapy plus disulfiram assurance (BTDA) treatment consisted of the
components of the DA program plus instruction in refusing drinks, relaxation training, training
in dealing with difficult social situations, and advice on social and recreational activities. If
required, job counseling and/or marital reciprocity counseling was also provided. Eight of
the 14 clients in this treatment group chose to receive reciprocity marital counseling (to
increase mutually reinforcing behaviors) and 7 received job-finding assistance.
At 6-month follow-up, there were significant differences across treatments on all four
of the measures involving drinking behavior. The two conditions in which the spouse was
involved in the treatment (BTDA and DA) produced superior outcomes to the traditional
treatment (TP) in that subjects took disulfiram more, were more abstinent (97% abstinent
days for BTDA, 74% for DA, and 45% for TP), drank less alcohol, and had fewer days on
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which they were intoxicated. Furthermore, both of the family treatments yielded clinically
superior results as compared to the TP. There were no differences across treatments in
outcomes related to employment, institutionalization, and absence from home.
An important treatment by marital status interaction was observed. For married couples,
the DA program was sufficient to produce almost complete abstinence. Thus, involving the
spouse in the disulfiram compliance procedures as well as providing communication skills
training appear to be the significant components of treatment success; marital reciprocity
did not seem to add any additional benefit. For the single clients, however, the DA proce-
dure had little effect, but the addition of the behavior therapy program produced nearly
complete abstinence.
The fourth study of CRA (Sisson & Azrin, 1986) also supported the efficacy of involv-
ing spouses in treatment. The intervention began with training for the spouse of the alco-
holic resistant to treatment. This phase of treatment was called community reinforcement
training (CRT). (This part of the study was described in more detail in the previous section
on initiating treatment.) During the time that only the spouses were involved in treatment,
the alcoholics significantly increased the number of abstinent days from an average per
month of 19% to 63%. Then when both alcoholic and spouse were in conjoint treatment,
abstinence was further increased to 93% as compared to a rate of 13% in the TP. The spouse
treatment was enough to influence the drinker to make some improvements and the addi-
tion of conjoint therapy resulted in continued major clinical gains. It is also important to
recognize that these gains were made with drinkers who initially refused treatment.
The work of Azrin and his colleagues clearly provides support for the importance of
including the spouse in treatment. But the ways in which they can be most effectively
included have not yet been verified. Initially it looked as if participating in a reciprocity
marital counseling intervention made the difference. But the 1982 study suggests that it is
the support provided by the spouse, made concrete by the spouse’s participation in the
disulfiram contract, and bolstered by communication skills training. Furthermore, the CRA
includes interventions other than marital therapy (e.g., job counseling, social counseling).
Thus, the degree to which marital counseling is necessary, as opposed to interventions de-
signed to improve the general social milieu of the alcoholic, needs to be addressed.
The third group of investigators examining the effectiveness of behavioral treatments
compared various types of couple treatments (McCrady, Noel, & Abrams, 1986). Subjects
were recruited to participate in outpatient treatment. They were assigned to one of three
experimental conditions using an urn randomization model to equalize age and occupa-
tional status across the conditions. In the minimal spouse involvement (MSI) treatment, the
spouse was present for understanding and support, but all interventions were directed to-
ward the alcoholic. These included self-monitoring of drinking and urges, cognitive
restructuring, drink refusal training, assertiveness training, and relaxation training.
In the alcohol-focused spouse involvement (AFSI) treatment, all the interventions used
in the MSI were included but the spouse was also taught to reinforce abstinence, decrease
behaviors that cued drinking andor protected the drinker from consequences of drinking,
increase skills to express feelings about alcohol-related situations or behaviors assertively,
respond in drink refusal situations, and use relaxation skills. Role playing and covert re-
hearsal were used extensively with the spouses. In the alcohol behavioral marital therapy
(ABMT) treatment, all skills taught in the MSI and AFSI were included, as well as marital
interventions including: “love days,” planning and implementing shared activities, communi-
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cation training, and problem-solving training. All three groups received 15 sessions of
therapy.
Significant improvements in the subjects’ pretreatment level of functioning and func-
tioning at 6-month follow-up were observed in drinking behavior, marital satisfaction, and
psychological, social, and occupational functioning. None of these improvements in absti-
nence or in other areas of functioning, however, was related to the type of treatment re-
ceived. Specifically, pretreatment and 6-month follow-up percentages of abstinent days
were 26% to 88% for MSI, 36% to 75% for AFSI, and 25% to 80% for ABMT. The percent-
age of subjects who were abstinent at 6-month follow-up was also reported; none reached
clinical significance (37% for ABMT, 42% for AFSI, and 36% for MSI).
These results suggest that involving spouses in the treatment is important since all
subjects improved in many ways over time. However, as in the investigations of the CRA,
just what this involvement needs to be is not clear since the level of involvement seemed
not to make a difference in the treatment outcomes.
In the CRA model, the clients were offered interventions in the areas of marriage and
family, friendships, employment, and other social reinforcers. A combination of these ap-
peared to be influential in improving treatment. A fourth group of investigators (Stout,
McCrady, Longabaugh, Noel, & Beattie, 1987) looked more closely at this question; they
replicated some of McCrady et al.’s work and extended it into the occupational milieu.
Both married and unmarried subjects were included in the study. They were assigned
randomly to three outpatient treatment conditions, each involving up to 20 therapy ses-
sions. The therapy in each condition followed a social learning orientation and focused on
a functional analysis of drinking behavior. In the first condition, the patients came alone to
the therapy sessions (patient only-PO condition). In the second condition, members of the
patient’s immediate social environment (spouse, family, friends) were involved in the therapy
(the social environment-SE condition). The third treatment condition includes not only
persons from the patient’s immediate social environment but also persons from the patient’s
occupational environment (the social and occupational environment - SOE condition).
In the presentation of this study, Stout et al. report only on the results from the PO and
SE conditions. At 6-month follow-up, both groups achieved clinically significant abstinent
rates (91 % for PO and 87% for SE), but the family-involved treatment was no more effec-
tive than the individual treatment. There was, however, a difference in the linear time
trends, calculated by the slope of the line made by plotting 3-month follow-up data over the
6-month treatment interval and 6-month follow-up interval. The time trends for the two
conditions were significantly different; the slope of the line for the PO condition was nega-
tive while the slope of the line for the SE condition was positive. This means that there was
a downward trend for the abstinence level of subjects who participated alone in treatment.
The subjects who participated with their spouses initially had lower levels of abstinence
than the PO group, but after approximately 6 months of treatment, the abstinence levels
began to rise.
These findings may provide some support for the long-term benefits of family-involved
treatment, but just identifying trends in the levels of abstinence is not enough evidence.
The clinically significant issue is whether the subjects stop drinking or reduce their drink-
ing to tolerant levels. Thus, we must suspend judgment until additional follow-up data are
analyzed and these clinically relevant outcomes can be assessed.
A fifth set of investigators compared behavioral marital therapy and a more systemic
marital therapy to a standard individual treatment program (O’Farrell, Cutter, & Floyd,
494 JOURNAL O F MARITAL A N D FAMILY THERAPY October 1995
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1985). They randomly assigned subjects and their spouses to three treatment groups that
were begun after discharge from an inpatient rehabilitation or detoxification program. The
standard treatment (ST) consisted of four weekly individual alcoholism counseling ses-
sions in the first month of clinic contact and monthly sessions thereafter for as long as the
patient desired. The sessions provided supportive counseling that encouraged the use of
disulfiram, participation in AA, and abstinence from alcohol.
The other two groups engaged couples in treatments, both of which were focused on
reducing drinking; decreasing conflict about drinking; and increasing positive interactions,
effective communication, and resolution of problems and conflicts between spouses. In
both treatments, each couple met with the therapist for two conjoint sessions and then par-
ticipated in 10 weekly multiple couples groups. The interactional couples therapy (ICT)
groups emphasized mutual support, sharing of feelings, problem solving through discus-
sion, and providing verbal insight into each couple’s relationship. The behavioral marital
therapy (BMT) groups used behavioral rehearsal and weekly homework assignments to
help couples negotiate and carry out an Antabuse contract, increase positive activities and
caring behaviors, increase communication skills, and increase problem-solving skills.
At posttreatment, all three treatment groups had increased their abstinence. The per-
centages of pretreatment and posttreatment abstinent days were 43% and 99% for BMT,
46% and 83% for ICT, and 21 % and 91 % for ST. The BMT and ST treatments resulted in
both statistically significant and clinically significant increases in abstinence. Of the seven
measures of marital functioning, the BMT group improved on four (marital satisfaction,
areas of change, marital stability, and positive interaction), and the ICT group improved on
two (areas of change and positive interaction). The ST group did not improve their marital
functioning at all. When the three treatments were compared to one another, couples who
received either of the two marital treatments improved their marital functioning more than
did couples receiving the standard treatment (marital satisfaction,marital stability, and posi-
tive interaction). BMT was superior to ICT in improving the marital satisfaction of the
couples but no other aspect of their marital functioning.
Although all three treatments produced a decrease in drinking behavior, only the sub-
jects in the marital therapies improved their marital functioning. Do these improvements
provide a protective and prophylactic effect that will help the alcoholics remain alcohol-
free over a long period of time? O’Farrell and his colleagues did a follow-up study to
answer that question (O’Farrell, Cutter, Choquette, Floyd, & Bayog, 1992). At 6-month
follow-up, the percentage of abstinent days had decreased somewhat for subjects in the
BMT and ST treatments (83% for BMT, 86% for ICT, and 72% for ST). It is important to
note that the biggest drop occurred in the subjects who had not participated with their fami-
lies in treatment. Furthermore, the ICT treatment yielded clinically significant results. The
differences across treatments, however, were not statistically significant. At 2-year follow-
up, the subjects’ levels of abstinence had decreased further, especially those in the ST group
(7 1% for BMT, 8 1% for ICT, and 63% for ST). The treatment gains that were evident at 6-
month follow-up did not hold up over time.
The gains that subjects had made in marital satisfaction at posttreatment also did not
hold up at 2-year follow-up. This was especially true for the alcoholic husbands. With the
wives, however, a different pattern emerged. In a secondary analysis, it became clear that
wives who were very dissatisfied with their marriages (pretreatment marital satisfaction
score less than 67) did not respond to BMT. However, wives who were more satisfied did
better in the BMT group than in the ST group. Thus, participants’ initial feelings about
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their marriages may influence how effective the treatment will be. If marital satisfaction is
extremely low, perhaps it feels too hopeless and there is little commitment to the therapy.
The effect of a client’s feelings about his or her marriage on treatment efficacy is taken up
next in a study by Longabaugh and his colleagues.
These investigators reasoned that the degree of investment that an individual had in his
or her marital relationship would mediate the benefits of spouse involvement in treatment
(Longabaugh, Beattie, Noel, Stout, & Malloy, 1993). If individuals d o not particularly care
about the relationship, or are very discouraged in it, marital therapy is unlikely to help
reduce drinking and may not even improve the relationship. In addition to the alcoholics’
level of investment in their relationships, the investigators also assessed the level of support
for abstinence the alcoholics perceived from family members.
Subjects were randomly assigned to two types of treatment, both of which were done in
an outpatient setting for a maximum of 20 sessions. One mode of treatment was individual-
focused cognitive behavioral therapy (ICB) that was usually done in a group, but if subjects
preferred they could have individual sessions. The focus of therapy was the identification
of antecedents and consequences of drinking and then modification of these associations
through cognitive-behavioral restructuring. The second mode of treatment was relation-
ship-enhanced cognitive behavioral therapy (RCB). In this mode, subjects participated in
six sessions of individual or group therapy devoted to the functional analysis described
above. Remaining sessions were focused on the relationship with a significant other and, if
pertinent, to work. Four to eight sessions were devoted to couples therapy, focusing on (a)
techniques to help the relationship reinforce abstinence and deal with slips; (b) enhancing
reinforcers in the relationship; and (c) problem-solving skills. Two didactic sessions were
offered to the partners on “alcohol abuse and how to help.”
The results verified the investigators’ initial hypotheses about the mediating effects of
support and relationship investment, although not in every way they predicted. At 1-year
follow-up, without considering investment or support, both treatments produced clinically
significant results (88% abstinent days for RCP and 91% for ICB). There were no differ-
ences across treatments in their effectiveness. Without regard to treatment, however, the
interaction of investment and support was significantly related to the percentage of days
abstinent. Individuals who were highly invested in their relationships and perceived a high
level of support from their significant others were abstinent 94% days in the fourth quarter
of the 1-year follow-up period. Those with a high investment and perceived low support did
the worst and were abstinent only 82% during the same period. Subjects who were not
invested in their relationships did quite well, regardless of the level of support for absti-
nence they perceived from their spouses. Of this low invested group, the ones who per-
ceived a low level of support were abstinent 94% of the time, and the ones who perceived a
high level of support were abstinent 91 % of the time. Here we see the apparent effects of
the relationship on outcome.
Neither the two-way interaction of investment and treatment nor the three-way interac-
tion of investment, support, and treatment yielded significant results. However, the interac-
tion of support and treatment did result in significant relationships. For those subjects who
perceived high support from their partners, the individual and couple treatments were equally
effective in producing abstinence (92% for RCB and 93% for ICB). For those subjects who
perceived a low level of support from their partners, however, the individual treatment
yielded outcomes superior to the couple treatment (84% for RCB and 90% for ICB). These
results are important to consider. Both the individual and couple treatments were effective
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and we can now begin to tease out the conditions under which one treatment is more effec-
tive than another. This suggests the need for a careful assessment of the alcoholic and his or
her family before treatment begins, followed by a selection of the most appropriate treat-
ment.
Summary of Phase II family-involved behavioral treatment and rehabilitation. These
studies of family-involved behavioral treatment show a mixed picture of its effectiveness.
Overall, the mean effect size was a significant 3 6 . In the straightforward studies by Hedberg
and Campbell, Stout, and O’Farrell et al., family treatment did not prove to be better than
individual treatment. The CRA, however, consistently yielded more clinically significant
effects than a traditional individual treatment model. However, not all the CRA partici-
pants were married, and they may have received additional components of treatment that
included vocational counseling, social counseling, and reinforcer-access counseling. When
these four studies are excluded from the analysis of the family-involved behavioral treat-
ments, the effect size is still a significant .58. Thus, by itself, family treatment is an impor-
tant influence on the social milieu of the alcoholic which helps to reduce drinking.
McCrady and her colleagues attempted to identify more precisely the optimal role of
the spouse in treatment, but they did not find any significant differences among treatments
with varying levels of spouse involvement. The work of Longabaugh et al., however, is
illuminating since it highlights the issues of the alcoholic’s investment in the relationship
and his or her perception of the spouse’s support for treatment. These findings, combined
with those from studies of the CRA, suggest that it may be necessary first to identify just
what improvements patients would value most in order to provide the most effective treat-
ment. These improvements are likely to include some, but not all, of the following areas:
marriage, parent-child relationships and child psychosocial functioning, friendships, employ-
ment, and one’s own psychosocial functioning. This would help clinicians assess what
modalities of treatment may be most appropriate for particular alcoholics and their families.
This issue is discussed later under the topics of family assessment and treatment matching.
PHASE 111: AFTERCARE
Aftercare (often called maintenance or relapse prevention in the addictions literature)

is an important aspect of many types of alcohol treatment. Alcoholic patients, upon comple-
tion of the acute phases of the most comprehensive treatment programs (detoxification and
initial restabilization), often need additional intervention, support, and education to help
them maintain the gains they have made. Traditional treatment programs usually rely heavily
on group therapy and participation in Alcoholics Anonymous to provide these services.
Family members, if included in this phase at all, are typically encouraged to participate in
separate programs, for example, Al-Anon groups. Less common is the continuing direct
involvement of families in the aftercare phase of treatment. But in the few instances in
which such involvement was tried and results of a systematic evaluation of the impact of
family member presence was reported in the literature, findings have been supportive of the
importance of family involvement in promoting both attendance in aftercare and absti-
nence. In this section, we will briefly review the findings of these studies (see Table 5 ) .
Ossip-Klein and her colleagues (Ossip-Klein, Van Landingham, Prue, & Rychtarik,
1984) studied the impact of a simple family-involved intervention on increasing attendance
at aftercare. Aftercare sessions consisted primarily of individual, problem-oriented coun-
seling; significant others were encouraged to attend with the alcoholic. There were eight
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496
Table 5
Results from Studies of Relapse Prevention (Phase 111
Comparison Groups
Study Subjects w/ Assignment Method Outcome Measure
5 Ossip-Klein, 50 male Random assignment: Post-aftercare

Van Landingam, Prue, participants in CC: Calendar/contract (6 months posttrea
$% & Rychtarik, 1984 a 28-day
inpatient
condition (n = 25)
C: Control (no calendar
Aftercare attendan
% treatment or prompt) (n = 25)
b
% program
5 Ahles, Schlundt, 36 participants 1-vear follow-up
2 Prue, & Rychtarik, 1983 who responded
to follow-up
(from treatment)
YO Subjects abstine
$ inquiries
2 Post-aftercare
% O’Farrell, Choquette, 59 male Random assignment:
?
.i
Cutter, Brown, & alcoholics & BMTRP: Behavioral marital (1 2 months posttre
therapy plus relapse prevention % Days abstinent
h
s McCourt, 1993 nonalcoholic
wives (n = 30)
k BMTO: Behavioral marital
2 therapy only ( n = 29)

- = Can not compute.
October 1995
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sessions (four in the first 2 months and one monthly thereafter) over the 6 months following
discharge.
Inpatients being discharged from a 28-day treatment program were assigned to two
groups. The experimental group received the contractkalendar (CC) intervention that had
two features. One feature was an attendance contract, negotiated between the patient and
significant other (typically spouse, parent, or sibling). If the patient went to an aftercare
appointment, the significant other would provide an incentive (e.g., special meal, special
recreational activity) within 1 week of each kept appointment. The second feature was a
calendar with the aftercare appointments circled in red that the patient agreed to put in a
prominent place. The control group received standard aftercare scheduling procedures and
encouragements to attend.
At 6 months after discharge, attendance at aftercare was assessed. The group who
received the contract/calendar intervention attended significantly more sessions than did
the control group (53% compared to 28%). At 12 months, a follow-up study was conducted
to assess participants’ level of functioning (Ahles, Schlundt, Prue, & Rychtarik, 1983).
They were able to contact 36 of the patients (18 in each group). The subjects in the CC
group were significantly more abstinent than the control group (61 % of the subjects com-
pared to 21 %). They also had more functioning days (when they drank less than 2 ounces
of alcohol) and did better in employment than did the subjects in the control group. Thus
these authors found that a minimal intervention involving family members who support
attendance at aftercare sessions was helpful not only in increasing attendance levels, but
also in achieving clinically significant abstinence levels. Would increasing the intensity of
the intervention improve the results?
O’Farrell and his colleagues (O’Farrell, Choquette, Cutter, Brown, & McCourt, 1993)
answered this question in their study of an aftercare program consisting of a couples relapse
prevention intervention, given after a series of behavioral marital therapy sessions. The
BMT program was conducted over a 4- to 5-month period. There were six to eight weekly
pregroup sessions conducted conjointly with each couple, followed by weekly multiple
couples BMT sessions, as described above in the O’Farrell et al. (1985) study. After this
treatment, couples were randomly assigned to the behavioral marital therapy plus relapse
prevention (BMTRP) or the behavioral marital therapy only (BMTO) groups. The relapse
prevention program consisted of 15 sessions spread out over a year, with gradually decreas-
ing frequency. The foci of these sessions were to encourage the couple to keep up the
Antabuse contract for at least 6 months, to attend AA or Al-Anon meetings, to resolve
remaining marital issues, and to develop and practice a relapse prevention plan.
At the end of the RP program, the BMTRP subjects had achieved more abstinent days
(94%) than the BMTO group (82%), but these differences were not statistically significant.
The RP intervention did, however, produce clinically significant results in that the absti-
nence levels were greater than the 85% baseline. With regard to marital satisfaction, pre-
treatment to follow-up comparisons showed an increase in husbands’ marital satisfaction in
both treatments and an increase in wives’ marital satisfaction in the BMTRP condition only
(increase in BMTO was marginal, p = .05). In comparison of the treatments at follow-up,
the wives in the BMTRP group had higher levels of marital satisfaction than the wives in
the BMTO group. There was only a marginal difference (p = .05) between husbands’ mari-
tal satisfaction in the two groups.
The relapse prevention intervention focused on the use of the Antabuse contract and
the continuation of marital behaviors taught in the BMT phase of treatment (positive activi-
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ties, communication skills, and problem-solving skills). These aspects of marital life ap-
pear to be related to the alcoholic’s drinking since both the marital behaviors and the use of
the Antabuse contract were correlated with abstinence ( r = .47, p < .001; r = .23, p < .05,
respectively). These findings are important since they suggest just how family-involved
treatment affects abstinence. The couple actually changes the way they behave with one
another-perhaps in addition to their participation demonstrating support for abstinence.
Summary of P hase III studies. The average effect size for the outcome measure of
abstinence was a significant .94. Furthermore, the difference between the family- and non-
family-involved treatments was clinically significant. Thus, although these results come
from just three reports of two outcome studies, they support the importance of the family in
maintaining gains made in primary treatment and in preventing relapse.
DISCUSSION
In this paper we reviewed findings from 21 studies investigating the efficacy of family
therapy as a treatment for alcoholism and found evidence to support the potential useful-
ness of including family members at all three phases of alcoholism treatment-initiation of
treatment, primary treatmenthehabilitation, and aftercare. At the same time, we also noted
that the overall picture was more complex than it was straightforward. That is, no single
type of family therapy approach was clearly superior to all others, and secondary factors
such as gender of the identified alcoholic, commitment to andor satisfaction with the mar-
riage, and spousal support for abstinence all seemed to influence outcome findings. Let us
therefore return to and answer the three questions we posed at the beginning of this article:
(a) Is family-involved treatment for alcoholism effective? (b) Is family-involved treatment
cost effective? (c) What factors influence the effectiveness of these types of treatments?
Is Family-Involved Treatment Effective?

Initiation of treatment. In this phase of treatment, the findings seem unequivocal. Fam-
ily-involved treatments are very effective in helping to motivate alcoholics to enter treat-
ment. Furthermore, they are somewhat helpful in reducing drinking, sometimes even be-
fore treatment for the alcoholic family member has begun. What appears to happen in
treatment is that the spouses switch the focus from merely stopping their partners’ drinking
to making positive changes in the relationship and in their own lives. Spouses learn to
reduce enabling behaviors and give up trying to control the drinker’s behavior. Instead,
they positively reinforce nondrinking behavior and plan and implement positive nondrinking
joint activities with their partners. Presumably, the alcoholic family member observes other
family members taking responsibility for themselves, thus making it harder to continue the
same patterns of drinking.
These treatments, however, are initiated by concerned spouses who are motivated to
make changes. Conditions are likely to be different for a spouse who is offered family
therapy as part of his or her spouse’s alcohol treatment program; here motivation for change
is likely to be lower. Thus, one factor in determining the appropriateness of family-in-
volved treatment is the spouse’s motivation for change and his or her potential supportiveness
of the treatment.
Primary treatmentlrehabi2itation. With regard to the effectiveness of family therapy in
the primary treatment of alcoholism, results to date seem less clear cut. For example, if
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drinking behavior alone is used as the outcome variable, family therapy shows impressive
results in the short run but more ambiguous results long term. That is, the average effect
sizes in tests of both the family systems and family behavior treatment models taken at
follow-up periods of 6 months or less were statistically significant. Furthermore, in 8 of 13
comparisons, family treatment yielded clinically significant results as compared to indi-
vidual treatment (n = 12) or no treatment ( n = I). (This is important to underscore because
it is clear from the available evidence that these family therapy approaches, which aim at
more broad-based impacts on psychosocial functioning, are able to do so without sacrific-
ing efficacy regarding impact on frequency and amount of alcohol consumption.)
On the other hand, however, when follow-up periods are greater than 1 year, treatment
gains dissipate. Not only is family treatment no longer superior to individual treatment, but
it also is no longer clinically significant in its own right (nor is individual therapy, for that
matter). However, it is also important to underscore that in none of the studies we exam-
ined was a carefully designed aftercare program included as a component of the treatment
model. Thus faulting the ability of family therapy to produce long-term results is probably
too harsh a judgment for us to make at this juncture.
Regarding other aspects of functioning (other than drinking behavior alone), results
also seem ambiguous at this stage of our knowledge. Four groups of investigators (Cadogan,
1973; McCrady et al., 1979, 1982,1986; O’Farrell et al., 1985, 1992) examined the impact
of family treatment not only on drinking behavior but also on marital functioning. Of these
four, three found that marital functioning improved over time (from pretreatment to follow-
up) in both family and individual treatments. Only one of these groups (O’Farrell et al.)
found that marital functioning was improved significantly more with couple treatment than
with individual treatment.
Thus, although the ambitious agenda established by most family therapists to influence
positively not only drinking behavior but also family functioning and family satisfaction
seems to be more or less met in most of the studies evaluated, the superiority of couples/
family therapy over individual therapy in this regard is far from established. Furthermore,
it also appears that the impact of couples/family therapy is apparently associated with (or
mediated by) a series of secondary factors, especially spousal characteristics and gender of
the alcoholic individual. These will be discussed later.
Aftercare. The data about effectiveness of aftercare programs is at this point the least
satisfactory. The evidence from both the effect size and the clinical significance data sug-
gests that both simple and elaborate family-involved interventions help to maintain treat-
ment gains in the short run. Right now, however, we have no treatments that have been
demonstrated to be effective for more than 2 years. Furthermore, methodological problems
abound in the few studies we currently have available, and hence all findings are largely at
the impressionistic stage. In particular, we have almost no systematic data about the long-
term preventive impact of the most commonly implemented aftercare program for fami-
lies-Al- Anon.
Is Family-Involved Treatment Cost Effective?

The cost effectiveness of available treatments-both in absolute and comparative
terms-is acritical issue for clinicians and policy makers alike. However, to date very little
attention has been paid to this issue in the alcoholism treatment literature. In fact, only one
of the studies we reviewed explicitly included data on treatment costs as part of its findings.
October 1995 JOURNAL OF MARITAL AND FAMILY THERAPY 50 1
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Azrin (1976) demonstrated that the cost effectiveness of the CRA was increased by chang-
ing the unit of treatment from the individual (person or family) to a multiple unit (group
therapy or multiple couple/family) because staff contact hours per client were reduced from
50 to 30. This illustrates one method of evaluating the cost effectiveness of treatment, that
is, calculating the direct costs of treatment in terms of expenditures for facilities, staff time,
and staff salaries.
A second way to evaluate cost effectiveness is to examine the more indirect costs,
incurred by both alcoholics and their families, associated with no treatment and the benefits
associated with treatment. Family-involved treatment is likely to reduce costs to society
and individuals regarding law enforcement ( e g , alcohol-involved traffic accidents, public
intoxication), social services, medical care, and psychological care. It may also increase
benefits by increasing money earned and taxes paid.
Because there is such potential for multiple outcomes in family-involved treatment-
often called the multiplier effect-it is critical when evaluating cost effectiveness to con-
sider a variety of indices that relate to the alcoholic, to other family members, and to society
in general. Unfortunately, this was not done in the studies reviewed, and thus we cannot
draw conclusions about this important aspect of treatment outcome.
What Factors Influence the Effectiveness of Family-Involved Treatment?

As we have already pointed out, our review suggests two major conclusions to be
drawn from the alcoholism treatment outcome literature: (a) family therapy approaches are
effective treatments for alcoholism (the results of our meta-analyses); but (b) its impact is
differentially felt depending on at least three additional factors-gender of the alcoholic,
investment in the relationship, and support for abstinence from the family.
Gender issues. Gender of the alcoholic family member appears to be related to the
degree to which family or couple treatment is superior to other types of treatment. In the
studies of primary treatmenthehabilitation (not initiation of treatment or relapse preven-
tion), 8 of the 12 studies in which family treatment was statistically superior to control
treatment in reducing drinking had female subjects as a percentage of the total that ranged
from 0 to 13%, with an overall percentage of 6%. The four studies in which family treat-
ment was not statistically superior to the control treatment had female subjects as a percent-
age of the total that ranged from 28% to 40%, with an overall percentage of 30%. Wiens
and Menustik (1 983) found that women who participated in treatment with their spouses
did not fare as well as men who participated with their spouses. In the studies with a
preponderance of male alcoholics, marital or family therapy may be more likely to yield
positive results; family treatment for female alcoholics may lose its edge over individual
treatment.
Investment in the relationship. A second factor is the degree to which family members,
especially married partners, are invested in their relationships with one another. O’Farrell
et al. (1992) found that when marital satisfaction was too low, couples treatment was not as
effective as individual treatment. Longabaugh et al. (1993) discovered that investment in
the relationship also affected the degree to which couples treatment was effective. Perhaps
related dynamics were going on in the three studies of the CRT program in which subjects
could decide what types of services they wished to use and some chose marital counseling,
others chose job-assistance counseling, and still others chose neither. These results point to
the necessity for a careful assessment and match to treatment. Family treatment may not be
appropriate for all subjects, and we are just beginning to understand the factors that need to
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be considered in selecting this form of treatment for patients.
Family commitment to abstinence. Longabaugh et al. (1 993) found family support of
the alcoholic's abstinence to be an influential factor in treatment. In work that also bears on
this issue, Steinglass et al. ( 1 987) have described factors within families that can present
obstacles to successful detoxification as an initial step in therapy, In particular, he posits
that situations in which alcohol-related behaviors have become embedded in family rou-
tines, rituals, and problem-solving strategies make it more difficult for families to negotiate
the transition from active drinking through detoxification. However, when the role of alco-
hol in family life is first explored with the whole family as a precursor to attempting detoxi-
fication of the alcoholic family member, the above obstacles dissipate, and the family be-
comes an ally in the treatment process (see Rohrbaugh, Shoham, Spungen, & Steinglass, in
press, for a detailed description of one such treatment protocol using this approach.) Virtu-
ally none of the treatments in the studies reviewed in this paper take the above issues into
consideration in either assessment or therapy model.
Other Issues That Influence Treatment Outcome and Its Evaluation

At the same time that we are able to make some initial statements about family therapy
as a useful treatment for alcoholism, any conclusions about either its efficacy or factors
contributing to its differential degree of success must be tempered by a number of qualify-
ing statements. Furthermore, there are a number of issues that have yet to be addressed
adequately by researchers.
Study design. There are still relatively few competently designed treatment outcome
studies in this area. Although we were able to identify 21 studies carried out during the
period 1972-1993 that met our minimum inclusion standards, comparisons across studies
remain compromised by (a) who was included in the therapy; (b) the gender of the alcohol-
ics treated; (c) where the treatment was conducted (e.g., inpatient, outpatient); (d) the treat-
ment context (e.g., single couple or family, multiple couple or family); (e) the number and
type of control treatments to which the family-involved treatment was compared; (9 the
number of sessions of treatment; (g) the uniformity of number of sessions across treatments
and subjects; (h) the outcome measures employed (e.g., drinking behavior, marital satisfac-
tion, marital interactions); and (i) the way outcomes were measured (e.g., days abstinent,
amount of alcohol consumed, reduction in drinking from pretreatment to posttreatment).
Some of these differences made it difficult to compare results across studies. Other differ-
ences made it possible to identify factors that appear to influence significantly the efficacy
of treatment.
One of the most serious design inadequacies is the lack of adequate longitudinal data.
This latter issue is particularly important given the chronic nature of alcoholism and de-
bates in the literature about how the natural course of alcoholism influences decisions about
treatment goals (e.g., the debate about whether controlled drinking is a viable outcome
goal). Furthermore, there have been no replications of studies in which family/marital
therapy was clearly superior to individual treatments. Although all of these issues are com-
mon to most psychotherapy outcome research, they must nevertheless be mentioned at this
point.
Lack of agreement on measures of treatment outcome. Family therapists, in treating
alcoholism, aim at both individual level and family/marital level outcomes. At the indi-
vidual level, family therapists endorse the almost universal view that a change in drinking
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(amount, pattern) and an improvement in the patient’s psychosocial functioning are core
indices of successful treatment. But family therapists also believe that family-involved
treatment is more effective, in the long run, because of the multiplier effect it has in creating
changes in the marital and family functioning of the family. This has a recursive effect that
tends to support the improvements at the individual level (both for the alcoholic and for
spouses and children). Hence the importance of also including an assessment of marital
satisfaction and family functioning in the outcome measurement package. But thus far
there is little concordance among investigators in how they approach these assessments.
(We agree with Shadish et al., 1995, in their proposal to develop a standardized set of
outcome measures that researchers could use to improve comparability across studies.)
Effect of types of alcoholism on treatment. None of the published studies has utilized
current notions about typologies of alcoholism as a strategy for assigning patients to differ-
ent types of treatment. Alcoholism researchers have expressed considerable interest in this
topic over the past two decades, and a number of typologies have been proposed that have
attempted to delineate subtypes of alcoholism that have strong clinical relevance. For ex-
ample, a typology proposed by Cloninger and his colleagues (Cloninger, 1987) suggests
two different forms of alcoholism presumably related to different genetic predispositions.
One type is characterized by early onset of excessive drinking and other substance abuse,
impulsivity and risk taking in adolescence, and antisocial behavior, plus histories of alco-
holism and criminality in biological parents. The second type is characterized by later and
more insidious onset of alcoholism, steady-state rather than binge drinking, little evidence
of sociopathy, and more mixed histories of substance abuse in biological parents.
Another typology proposed by Jacob, Dunn, and Leonard (1 983) is based on detailed
observations of current drinking patterns. Distinctions are made between episodic drinkers
whose drinking often occurs outside the home and is associated with impulsivity and poor
interpersonal relationships, and steady-state (daily or weekend) drinkers who drink often at
home and tend not to have associated symptoms of physical violence and impulsivity. This
typology was also useful in predicting levels of negative impact of drinking on marital
relationships and family satisfaction (Jacob & Leonard, 1988). Given the sharp distinctions
between alcoholism subtypes being drawn in these various typologies, it is surely reason-
able to assume that the different subtypes might require different treatment strategies.
Lack of attention to family assessment. Family therapy research into alcoholism has
not taken advantage of advances in family assessment techniques from the expanding fam-
ily research literature. For example, none of the studies we reviewed in this paper con-
ducted a sophisticated assessment of family interaction patterns, problem-solving styles,
and so forth, in attempting to tease out differential responses of patients and their families to
the treatment program being tested. Furthermore, there is now an extensive body of re-
search on differences in family interactive styles in the presence versus absence of alcohol
(Jacob & Leonard, 1988; Liepman et al., 1989; Steinglass, 1989). The consensus of many
of these researchers is that an ability to understand these differences is invaluable in devel-
oping and carrying through treatment strategies with families. In fact, some techniques are
now available to assess directly what has been called intoxicated interactional behavior
(Liepman et al., 1989) but these techniques have not yet been incorporated into treatments
being formally assessed in outcome studies.
Furthermore, the work of O’Farrell et al. (1985, 1992) and Longabaugh et al. (1993)
suggest that, at the very least, one should assess the level of marital satisfaction and/or
504 JOURNAL O F MARITAL AND FAMILY THERAPY October 1995
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commitment to the relationship and the level of support for treatment goals key family
members are likely to give to the alcoholic. The spouse’s drinking behavior was measured
in only a handful of studies. Their drinking, and attitude toward abstinence, is likely to have
a significant impact on the alcoholic’s recovery and should be included in the standard
assessment battery.
Co-morbidity. Alcoholism is not a condition that typically occurs in isolation. Helzer
and Pryzbeck ( 1 988) report that 44% of male alcoholics and 65% of female alcoholics have
a lifetime diagnosis of an additional psychiatric disorder. Only three of the studies re-
viewed included screenings for and excluded subjects with major mood disorders, schizo-
phrenia, or neurological deficits. Only one study screened for the abuse of other drugs in
either the alcoholic or the spouse. None screened for the presence of personality disorders.
Although excluding subjects with dual diagnoses is one way to increase the level of
experimental control, it inhibits learning about whether the treatments tested are effective
for the typical alcoholic who is very likely to exhibit other types of disorders. As a result,
some treatments are being tested under somewhat sterile research conditions, devoid of the
characteristics that are likely to be present in average clinical situations. This severely
restricts the generalizations that we can make from research outcome studies to what treat-
ments would be effective in the field. Therefore, it will be necessary to both screen for and
include subjects with different configurations of illnesses or behavior patterns.
Effect ofgender on treatment eflcacy. Treatment models for alcoholism have gener-
ally been developed and tested for male alcoholics and do not appear to be as effective with
female alcoholics. This may especially be the case when family-involved treatment is be-
ing tested. At the very least, we would caution that findings from existing studies not be
assumed to be valid as the basis for designing alcoholism treatment programs for women.
Treatment matching. Is family-involved treatment appropriate for every alcoholic in-
dividual? This question was addressed in a few of the investigations reviewed above, nota-
bly the studies of the CRA and Longabaugh et ale’s (1993) study on behavioral marital
therapy. In the CRA, patients had the freedom to choose marital therapy if they thought it
would be helpful. They were not, however, given any assistance in making an informed
decision. Longabaugh et al. found that the commitment to the relationship and support for
treatment had a significant impact on treatment outcomes. It appears that attempting to
involve the family in therapy may backfire without sufficient commitment and support.
This, however, raises the issue of doing an adequate assessment to identify those families
for which family-involved treatment would be helpful.
Also important in treatment matching are the issues of typologies of alcoholism, co-
morbidity, and gender. First, the assessments must be sophisticated enough to tap the pat-
tern of alcoholism (typology) and the presence of other disorders. Second, we need to make
sure that the treatments we have are appropriate for the patients we have in treatment. This
includes not only alcoholism typologies and co-morbidity but also gender.
Some researchers in this area are well aware of the need to move to a new generation of
studies that incorporate these issues in their designs. For example, a study currently being
carried out by Beutler et al. (in press) at the University of California, Santa Barbara, not
only examines the relative efficacy of a systemic couples therapy versus an individual be-
havioral therapy for problem drinking but also includes a sophisticated individual-level and
family-level assessment battery that will afford the researchers an opportunity to examine
patient to treatment match/mismatch questions. Furthermore, both the systemic couples
October 1995 JOURNAL O F MARITAL AND FAMILY THERAPY 505
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therapy and individual behavioral therapy have been designed by highly experienced thera-
pists committed to their respective treatment approaches and have been detailed in treat-
ment manuals as part of the research process (Rohrbaugh et al., in press). In another area,
Wetchler and his colleagues (Wetchler, McCollum, Nelson, Trepper, & Lewis, 1993) are
addressing the issue of gender in their development of and research on a systemic couples
therapy designed specifically for substance-abusing women and their spouses.
Multirnodal treatments. We have shown that family-involved treatment may be a nec-
essary part of the therapeutic package, especially for particular alcoholics and their fami-
lies, but we have yet to verify whether it is sufficient as a treatment by itself. Initial im-
provements in both drinking and marital satisfaction have been documented, but these de-
cay over 2 years or more. How can these treatments be improved? One recommendation is
suggested by the success that models such as UFT and CRT had in working with the
nondrinking spouse. We propose a model that incorporates work with the drinker and spouse
individually (addressing behavioral, cognitive, and affective issues) as well as a couples or
family treatment component. Existing models deal with the behavioral and cognitive com-
ponents of alcoholism very well but virtually ignore the affective dynamics-both internal
to the individuals and expressed in the interaction among family members. This is likely to
involve a longer period of treatment and more contact hours, but perhaps longer lasting
results could be achieved.
Although each of the above issues must be noted as a limitation in the existing litera-
ture on family therapy for alcoholism, it is also the case that work is currently being done to
address many of these issues. As findings from such studies begin to appear in the litera-
ture, we will clearly be in a much stronger position to examine further the very promising
initial findings that have been described in this review.
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Joumal of Marital and Family Therapy

1995, Vol. 21, NO. 4, 475-509

FAMILY THERAPY TREATMENT OUTCOMES

Martha E. Edwards Peter Steinglass

We conducted a meta-analysis of 21 studies of family-involved therapy for alco-

The costs of alcoholism-emotional, physical, economic-in our society are vast.

October 1995 JOURNAL OF MARITAL A N D FAMILY THERAPY 475

476 JOURNAL O F MARITAL A N D FAMILY THERAPY October 1995

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Grouping of Studies by Phase of Alcoholism Treatment

October 1995 JOURNAL OF MARITAL AND FAMILY THERAPY 477

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Methods for Meta-Analysis of the Studies

Study Design Quality

478 JOURNAL OF MARITAL A N D FAMILY THERAPY October 1995

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PHASE I: INITIATION OF TREATMENT

The Intervention Method

October 1995 JOURNAL OF MARITAL AND FAMILY THERAPY 479

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Corder, Corder, & No Yes Yes Yes Unclear No Yes

O’Farrell, Cutter, Yes Yes Yes Yes Yes Yes Yes

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Adequate Objective Major life Minimum >

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Unilateral Family Therapy

482 JOURNAL OF MARITAL A N D FAMILY THERAPY October 1995

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Study Subjects Comparison Groups Outcome Measur

families NC: No confrontation Months continuou

Thomas, Yoshioka, 69 spouses of UFT Unilateral family Entering treatmen

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Community Reinforcement Training

Summary of Phase I Studies

484 JOURNAL OF MARITAL A N D FAMILY THERAPY October 1995

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PHASE 11: PRIMARY TREATMENT/REHABILITATION

Family Systems Treatment Models

October 1995 JOURNAL O F MARITAL A N D FAMILY THERAPY 485

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Corder, Corder, & 39 male Chronological 6-month follow-uo:

* = Difference is significant at p < .05 or less.

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488 JOURNAL OF MARITAL AND FAMILY THERAPY October 1995

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October 1995 JOURNAL OF MARITAL AND FAMILY THERAPY 489

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Hedberg & Campbell, 45 male and Random assionnient: 6-month follow-up

1974 4 female BFC: Behavioral family % Subjects abstinent

Azrin, 1976 38 male alcoholics Matched pairsirandom assionnient: 6-month follow-uD:

Azrin, Sisson, Meyers, 36 male and Random assignment: 6-month follow-up:

= Difference is significant at p < .05 or less.

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W Study Subjects w/ Assignment Method Outcome Measures

Stout, McCrady, 229 married & Random assionment: 6-month follow-uo

Longabaugh, Beattie, 74 male and Urn randomization: 1 -year follow-uD:

cognitive behavior therapy ( n = 42)

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492 JOURNAL OF MARITAL A N D FAMILY THERAPY October 1995

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October 1995 JOURNAL OF MARITAL AND FAMILY THERAPY 493