Introduction

S

pecialized interventions are often required to arrest drinking; to alleviate the physiological, psychological, and social consequences of alcoholism; and to help patients maintain long-term sobriety. These interventions are delivered either singly or in various combinations and in diverse treatment settings (primarily inpatient and outpatient treatment programs); the duration and intensity of treatment services ranges from full-time multifaceted inpatient programs lasting several weeks, to weekly counseling sessions over a defined time period, to less formal aftercare meetings over an indefinite time period.

According to the 1991 National Drug and Alcoholism Treatment Unit Survey (NDATUS) (National Institute on Drug Abuse/National Institute on Alcohol Abuse and Alcoholism in press),1 more than one-half million persons were in treatment in 8,161 alcoholism treatment units on September 30, 1991. Fewer than 2 percent of the patients were in inpatient and outpatient detoxification, 11 percent were in inpatient rehabilitation, and 87 percent were in outpatient rehabilitation; the ratio of male to female patients was three to one. Approximately 83 percent of

the patients were age 21 through 54 years; the heaviest concentrations of patients were in the age groups 25 through 34 years (35 percent) and 35 through 44 years (24 percent); 11 percent were younger than 21 years of age, and 5 percent were 55 or older. Of the 516,631 patients for whom ethnicity was known, approximately 67 percent were Caucasian, 17 percent were African American, and 12 percent were Hispanic; an additional 4 percent represented other ethnic groups, such as Native Americans, Asian Americans, and Pacific Islanders.

Specialized interventions are often required to arrest drinking; to alleviate the physiological, psychological, and social consequences of alcoholism; and to help patients maintain long-term sobriety.

To help clinicians and treatment providers meet the needs of this large, diverse patient population, treatment research is conducted in several domains: patient factors and their relationship to ameliorating alcoholism, treatment

factors and their relationship to ameliorating alcoholism, and the efficiency with which treatment services reach persons in need of such services. This chapter describes major diagnostic systems for recognizing patient factors that indicate the presence or absence of alcohol abuse or alcoholism and for differentiating one disorder from another; it also describes ongoing efforts to refine these diagnostic systems on the basis of systematic research. In addition, the chapter reports new findings on patient assessment-the determination of personal and disease characteristics as an aid to formal diagnosis, treatment planning, and treatment outcome measurement. Some of the issues associated with patient assessment, including the validity (the ability to measure that which is supposed to be measured) of patient self-reports of drinking and the utility of laboratory tests of alcohol consumption, are also important to screening, which is the subject of Chapter 13, Screening and Brief Intervention.

Because the etiology and mechanisms of alcohol abuse and alcoholism are incompletely understood, clinicians base the diagnosis of these disorders on the recognition of clearly observable phenomena and clusters of characteristics that are common to different people in different environments at different times.

This chapter also reports recent findings on the effectiveness of specific therapeutic approaches, including both single pharmacological and psychological-behavioral interventions and broad-spectrum treatment program components (such as aftercare and marital-family therapy) that comprise multiple interventions. Findings on other treatment factors believed to influence results, including therapist characteristics and treatment setting, are also considered. In addition, the chapter examines findings from methodologically sophisticated treatment outcome studies, including controlled clinical trials that compared the relative effectiveness of various treatments

for separate populations of alcohol-abusing workers.2

Finally, the chapter reviews the results of investigations of the efficiency with which alcoholism treatment services reach specific populations, with special attention to traditionally underserved groups and those in need of specialized services. Progress derived from studies of patienttreatment matching, a strategy that evaluates the interactions of various patient characteristics with various interventions, is reported as well. Findings from cost-benefit analyses of alcoholism treatment are presented in Chapter 11, Economic Issues in Alcohol Use and Abuse.

Patient Factors: Diagnosis

and Diagnostic Instruments

The first step in determining which interventions are best for which patients is accurate diagnosis. Because the etiology and mechanisms of alcohol abuse and alcoholism are incompletely understood, clinicians base the diagnosis of these disorders on the recognition of clearly observable phenomena and clusters of characteristics that are common to different people in different environments at different times (Beresford in press).

Two major diagnostic systems classify the variables that distinguish alcohol use disorders: the International Classification of Diseases, Tenth Revision (ICD-10), published by the World Health Organization (WHO) (1992) and the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R), published by the American Psychiatric Association (APA) (1987). Like its predecessors, ICD-10 was developed to provide a list of all injuries and diseases, including alcohol use disorders, for compiling morbidity and mortality statistics throughout the world. Unlike ICD-10, DSM-III-R is a classification of mental-but not physical-disorders and is used primarily in the United States.

ICD and DSM are not static but are revised periodically to improve their validity, reliability (the ability to yield consistent results), and utility for planning treatment and measuring treatment outcome. Revisions of both ICD-9 and DSM-III-R have been under way since publication of the Seventh Special Report, and the two diagnostic