Overlearning in the conditioning treatment of enuresis: A long-term follow-up study

V studies have reported high rates of relapse following the otherwise highly successful conditioning treatment of childhood enuresis nocturna (Young, 1969). Relapse would seem to be a hazard inherent in this form of treatment, and to be independent of patient variables (Young and Morgan, 1972a). Use of the technique of intermittent reinforcement schedules (Lovibond, 1964; Turner, Young and Rachman, 1970) and of CNS stimulant drugs (Young and Turner, 1965; Turner and Young, 1966) to counteract the problem of relapse have failed to achieve satisfactory results.

Young and Morgan (1972b) have demonstrated the success of overlearning therapy in reducing the relapse rate. This regime requires the child to maintain or regain his learned nocturnal bladder control, to a success criterion of 14 consecutive dry nights, while drinking up to 2 pints of liquid in the hour before retiring. The present paper reports the experience gained in the counteraction of relapse by the use of overlearning therapy over approximately 4 yr at the Vale Drive Clinic, at which enuresis is treated by conditioning techniques (Young, 1965; Morgan and Young, 1972).     

Electro-aversion therapy of chronic alcoholism

Twenty-six male patients with severe chronic alcoholism were treated with electro-aversion therapy according to two different designs. At follow-up after 12 months, 24 per cent had not had any relapse requiring admissions to hospital, 12 per cent were lost during the follow-up period, and 64 per cent had relapses. Before treatment all the patients had been admitted to hospital several times a year.

Aversion therapy without supplementary treatment is indicated mainly for patients who have intact social relationships and regular work. Treatment of advanced states of alcoholism requires supplementary treatment in the form of anxiety-relieving methods, psychosocial support and teaching the patient new and alternative habits.     

Maintaining disulfiram ingestion among outpatient alcoholics: a security-deposit contingency contracting procedure

Disulfiram is frequently prescribed to alcoholic patients as a deterrent to drinking. Although ingestion of ethanol by a disulfiram patient quickly results in an intense dysphonc reaction, the drug is not generally credited with significant value in alcoholism treatment (Mottin, 1973). It is suggested that most alcoholics simply stop taking the medication (Gerrein et al., 1973). and review articles conclude that motivation for abstinence is the crucial variable involved in successful disulfiram treatment (Ditman, 1966: Mottin, 1973).Motivation may be a characteristic of environmental contingencies rather than of individuals. If so, environmental contingencies should permit one to design into a disulfiram treatment progrim the requisite motivation to achieve therapeutic success. Contingency management procedures supporting disulfiram ingestion reported to date (Liebson et al., 1973: Haynes, 1973) have been of the sort to be imposed upon difficult populations rather than offered to general treatment applicants. Contingency contracting may represent a technique for supporting disulfiram ingestion appropriate to the broader general population of voluntary alcoholism treatment applicants. Contingency contract treatment (Homme, 1969; Stuart, 1971) is a procedure in which client and therapist mutually agree to establish an incentive for the client to achieve a behavioral goal. Contingency contracts can be viewed as a form of self-control therapy, and have been applied in a wide variety of problem areas, including school problems (Homme, 1969: Cantrell, et al., 1969). delinquency (Stuart, 1971),weight control (Mann, 1972). smoking reduction (Elliott and Tighe, 1968: Winett, 1973), drug abuse (Boudin, 1972), and alcoholism (Miller, 1972).Frequently contingency contracting involves the client's posting of a financial security deposit to serve as his incentive for achieving the agreed-upon therapeutic goal (Tighe and Elliot, 1968). This security deposit can be earned back consequent upon achieving specific goals, or sacrificed consequent upon failure. Controlled studies by Mann (1972) and by Winett (1973) have demonstrated this security-deposit procedure to be effective in enhancing weight loss and smoking reduction, respectively.We report here on our experience with application of the security deposit contracting procedure to maintaining routine disulfiram ingestion among outpatients in an alcoholism treatment program.     

Modification of excessive drinking by cue exposure

The value of an individual case study depends to a large extent on the nature of the predictions which are tested. If, for example, behaviour is modified by a method which flies in the face of current theory and practice, then it is worth reporting, and if detailed predictions about day-to-day changes are confirmed, so much the better. This individual case study was designed to test the possibility that excessive drinking behaviour can be modified by prolonged exposure to drinking cues.Our approach is based on the hypothesis that addictive behaviour is analogous to discriminated operants. We are also making the assumption that drinking, in the alcoholic, is frequently reinforced through the avoidance of unpleasant consequences (e.g. an escalation in anxiety, frustration or withdrawal symptoms) and that these avoidance responses are discriminated since they are triggered only by certain cues.Avoidance learning has been investigated in humans and animals for at least 50 years but in recent years strong evidence has accumulated which suggests a particular modification procedure. First, it has now been demonstrated that, in animals, a very effective extinction procedure involves exposure to the discriminative stimulus (i.e. cue) whilst blocking the avoidance response (Baum, 1969). Second, psychologists have considered obsessive-compulsive rituals to be analogous to avoidance responses (Hodgson and Rachman, 1972). Compulsive gas-tap checking, for example, avoids both catastrophic events and also unpleasant emotional states. During the last ten years an effective method of modifying obsessive-compulsive rituals has been developed which involves exposure to significant cues followed by response prevention which is either supervised (Meyer, 1966) or self-imposed (Rachman et al., 1971; Hodgson et al., 1972). The same method has also been successful in the modification of compulsive masturbation (Hodgson and Rachman, 1975).     

An operant treatment procedure for alcoholics

For many years total abstinence was regarded as the appropriate criterion for the successful treatment of alcoholism. It is suggested that given societal norms for social consumption of alcohol, plus the social reinforcers which maintain beverage alcohol ingestion, social drinking may serve as a realistic treatment goal. The efficacy of a social drinking criterion was clearly demonstrated by Bigelow et al. (1972). Chronic alcoholic in-patients were placed in a choice situation in which they earned the opportunity to participate in an ‘enriched’ environment contingent upon either moderate drinking or abstinence. Subjects overwhelmingly chose the moderate drinking alternative. Results also suggested that moderate drinking is more reinforcing than abstinence for alcoholics. Further support for the moderate drinking concept was rendered by Mills, Sobel and Schaeffer (1971) in a study which made electric shock contingent on gulping drinks, ordering straight alcoholic drinks and ordering and consuming more than three drinks. Time-out (Cohen et al., 1971), positive reinforcement (Cohen et al., 1971) and social contracting procedures (Miller, 1972) have been effectively employed to reduce drinking behavior from maladaptive to adaptive frequencies.

The present study attempts to extend treatment with a controlled drinking outcome to out-patient alcoholics     

Systematic desensitization, relaxation-training and suggestion in the treatment of test anxiety.

In investigations that have examined the component procedures in traditional desensitization treatment, desensitization was more effective than relaxation-training alone in several studies (Freeling and Shemberg, 1970: Davison, 1968; Rachman, 1968). while these treatments were equally effective in other studies (Benjamin, Mark and Huson, 1972: Aponte and Aponte, 1971; Johnson and Sechrest, 1968). One possible determinant of these inconsistent findings may be the presence of uncontrolled differences in therapeutic suggestion due to the fact that desensitization treatment typically includes a specific ‘rationale’ that explains the expected course and outcome of treatment while comparable authoritative guidelines for providing the rationale for relaxation treatment are not available.The present study compared the relative effectiveness of desensitization and relaxation-training in the treatment of test anxiety under conditions in which suggestion concerning the nature and outcome of treatment were essentially the same for both procedures. To examine systematically the role of suggestion in the treatment of test anxiety, instructions that were high and low in suggestion were given. Treatment outcomes were assessed in terms of changes in measures of anxiety and in performance on objective ability tests. A no-treatment group controlled for the effects of using the same pre- and post-treatment measures.     

Characteristics of the relapse situation of alcoholics treated with aversion conditioning

Recently, there has been considerable interest in applying the principles of learning theory and operant conditioning to the problems of alcoholism. One principle which may be of value is stimulus control. The principle of stimulus control would suggest that there should be some degree of similarity between the environmental circumstances in which alcoholics do their drinking and the situation where they take their first, post-treatment, drink. The principle of stimulus control also suggests that alcoholics treated with aversion therapy would tend to relapse under environmental conditions that were in some way different from their usual drinking environments.Whether we are able to observe a difference in drinking environments before and after treatment depends on whether we have selected the appropriate stimulus dimensions. The present author is in agreement with Lunde and Vogler (1970) who suggest that; types of liquor consumed; drinking associates; whether at home alone, with others or at a bar; are some of the important characteristics of an alcoholic's learning history. These stimulus conditions could be further simplified to location, type of beverage and social or non-social drinking.Since it is physically impossible to turn time backwards or to have observers follow patients everywhere they go, we must rely on self-reports of alcoholics about their drinking history. Although many clinicians have reservations about the veracity of alcoholics. Guze et al. (1963) report that 97 per cent of alcoholics in a prison population could be correctly diagnosed from their own self-report. Thus, it appears that at least when interviewed in the context of a research study where no contingencies are placed on their behavior, verbal or otherwise, self-report by alcoholics can indeed be reliable. The present study examined the relapse situation of alcoholics in terms of the location of the first drink episode, the social environment, and type of beverage consumed and compared this situation to the usual (most frequent) drinking situation prior to treatment.     

Collegiate COAs and Alcohol Abuse: Problem Drinking in Relation to Assessments of Parent and Grandparent Alcoholism

In a survey of college students (N = 860), significantly greater problem drinking was indicated by students who reported having a parent or grandparent diagnosed or treated for alcoholism. The highest rates of problem drinking were found among students who reported both an alcoholic parent and grandparent. Students who had experienced distress and family discord from parental alcohol abuse, though without a diagnosed alcoholic parent, also indicated greater problem drinking. The increased alcohol problems of students without a diagnosed alcoholic parent, however, were somewhat different from other children of alcoholics (COAs). Thus, different types of COAs must be considered in research, treatment, and prevention programs.     

The Use of Psychoeducation for a Patient with Hepatitis C and Psychiatric Illness in Preparation for Antiviral Therapy: A Case Report and Discussion

The standard of care treatment for chronic hepatitis C viral infection (HCV) is a combination of pegylated interferon alfa and ribavirin for 24-48?weeks according to the virus genotype. This therapy is known to have multiple neuropsychiatric side effects. A major concern when evaluating a patient for HCV treatment with a known history of a psychiatric disorder is the risk that the patient's psychiatric disorder will flare or become unmanageable. The possibility of precipitating depression, confusion, mania, psychosis, hallucinations, or suicidal ideation or attempt is frequently an obstacle to treatment. We present the case of a 50?year-old man with HCV and an extensive psychiatric history involving alcoholism, depression, and suicidality who participated in a psychoeducation group to help prepare him for treatment with pegylated interferon alfa/ribavirin therapy. Though the patient derived much benefit from the psychoeducation group, by the time of evaluation for HCV treatment two months after the group ended he had relapsed back into a depressive episode with suicidal thoughts. His acute psychiatric status made him unacceptable for pegylated interferon alfa/ribavirin therapy. Psychoeducation groups show promise for helping patients with chronic medical illness to be ready for and endure intensive medical treatment that has substantial psychiatric side effects. The challenge is to help patients overcome barriers to treatment, particularly psychosocial problems, because available treatments are increasingly effective.     

Combination pharmacotherapy in alcoholism: a novel treatment approach

Combination pharmacotherapy has proven effective in a number of psychiatric disorders, including depression and schizophrenia. However, compared with other affective disorders, few studies have explored the use of combination therapy in alcoholism, and the majority have been limited to animal models. There is evidence to support a role for combination therapy in alcoholism. For example, several neurochemical systems, including the dopaminergic, serotonergic, and opioidergic, appear to affect alcohol intake. Studies in several different types of alcohol-preferring rats have suggested that coadministration of agents to target more than one of these systems simultaneously may produce beneficial effects on alcohol intake, while avoiding problematic effects, such as alterations in food or water intake. Data from preliminary clinical studies have shown trends toward combination therapy reducing alcohol intake in humans. While such findings are encouraging, they must be explored further in larger, randomized, double-blind trials.     

Individualized Behavior Therapy for Alcoholics – Republished Article

A behavior therapy for alcoholism was designed based on the rationale that alcoholic drinking is a discriminated, operant response. Treatment emphasized determining setting events for each subject’s drinking and training equally effective alternative responses to those situations. Seventy male, hospitalized, Gamma alcoholics were assigned to a treatment goal of either nondrinking (N = 30) or controlled drinking (N = 40). Subjects of each group were then randomly assigned to either an experimental group receiving 17 behavioral treatment sessions or a control group receiving only conventional treatment. Treatment of experimental groups differed only in drinking behaviors allowed during sessions and electric shock avoidance schedules. Nondrinker experimental subjects shaped to abstinence, while controlled drinker experimental subjects practiced appropriate drinking behaviors with little shaping, a result attributed to instructions. Follow-up measuring drinking and other behaviors found that experimental subjects functioned significantly better after discharge than control subjects, regardless of treatment goal. Successful experimental subjects could apply treatment principles to setting events not considered during treatment, suggesting the occurrence of rule learning. Results are discussed as evidence that some “alcoholics” can acquire and maintain controlled drinking behaviors. Traditional treatment of alcoholics may be handicapped by unvalidated beliefs concerning the nature of the disorder.     

Alcoholism: etiologies proposed and therapeutic approaches tried

Alcohol, probably the most popular mood-altering drug, has frightening consequences when abused. Genetic factors and sociocultural influences contribute to alcoholic behavior. Study of endocrines, neurotransmitters, and neuropeptides may reveal biological markers to help identify those at risk for alcoholism. Drinking patterns are often based on the expectation of alcohol's mood-altering quality. The focus of treatment has expanded to include not only drinking behavior but also emotional, social, and vocational adjustment. Controlled drinking has proved effective for some, so that complete abstinence is no longer the sole goal of therapy. Behavioral, martial, group and individual, outpatient and inpatient therapy, and drugs as adjuncts, all help some alcoholics, but none is a cure for all. Answers still lag behind questions but researchers have registered some advances that challenge therapists to enlarge therapeutic approaches to fit the multifaceted picture of alcoholism.     

Fingarette on the disease concept of alcoholism

Herbert Fingarette [1] argues that alcoholism is not a disease and that the alleged alcoholic under certain circumstances has the power to control his or her drinking disorders. I shall analyze Fingarette's argument and show that his position rests on some logical and conceptual confusions. In analyzing Fingarette's argument for the self-control theory of drinking disorders I conclude that it is problematic for the following reasons: (1) his argument assumes that the identification of a single cause of alcoholism is a necessary condition of its being a disease; (2) unless it is already assumed (a priori) that persons with drinking disorders possess freedom and self-control to the extent that Fingarette assumes they do, then such persons are likely to suffer from apathy or defeatism regarding their condition; (3) even if Fingarette is correct in his criticism of certain health care programs for those with drinking disorders, it does not follow from this that certain theories about the possible causes of such disorders are false; (4) Fingarette's claim that those with drinking disorders are morally responsible for their actions that result from their disorders is problematic, that is, unless it can be shown that such persons act freely; and (5) Fingarette attempts to support the self-control theory of alcoholism by refuting a ‘straw man’ conception of the disease model of alcoholism.     

The effects of venlafaxine and cognitive behavioral therapy alone and combined in the treatment of co-morbid alcohol use-anxiety disorders

The effects of the antidepressant venlafaxine (VEN-225 mg daily) and transdiagnostic cognitive behavioral treatment (CBT) alone and in combination on alcohol intake in subjects with co-morbid alcohol use disorders (AUDs) and anxiety disorders were compared. Drinking outcomes and anxiety were assessed for 81 subjects treated for 11 weeks with one of 4 conditions: 1) VEN–CBT, 2) VEN-Progressive Muscle Relaxation therapy (PMR), 3) Placebo (PLC)-CBT and 4) a comparison group of PLC-PMR. For subjects who reported taking at least one dose of study medication, the Time × Group interaction was significant for percent days of heavy drinking and drinks consumed per day. For the measure of percent days heavy drinking, the paired comparison of PLC-CBT versus PLC-PMR group indicated that the PLC-CBT group had greater drinking reductions, whereas other groups were not superior to the comparison group. In Week 11, the proportion of subjects in the PLC-CBT group that had a 50% reduction from baseline in percent days heavy drinking was significantly greater than those in the comparison group. Of the 3 “active treatment” groups only the PLC-CBT group had significantly decreased heavy drinking when contrasted to the comparison group. This finding suggests that the transdiagnostic CBT approach of Barlow and colleagues may have value in the management of heavy drinking in individuals with co-morbid alcoholism and anxiety.     

Predictors of heavy drinking and drinking problems over the first 4 years of marriage.

This study investigated the factors predictive of heavy drinking and drinking problems over the early years of marriage, focusing on premarital drinking and the relatively stable individual risk and protective factors that were present prior to marriage and on social-interpersonal factors that may change or emerge over marriage. Newlywed couples were assessed at the time of marriage and at the 1st, 2nd, and 4th anniversaries with respect to frequency of heavy drinking and the extent of drinking problems and a variety of factors that have been found to be predictive of adult alcohol problems. The results indicated that antisocial characteristics, family history of alcoholism, negative affect, and alcohol expectancies were related to heavy drinking and alcohol problems at the time of marriage. Changes after marriage were predicted by the drinking of one's partner and of one's peers and by alcohol expectancies for social/physical pleasure for both men and women. In addition, the quality of the marriage was longitudinally protective from the experience of alcohol problems for both men and women, although it was not related to changes in heavy drinking.     

Ketamine Enhanced Psychotherapy: Preliminary Clinical Observations on Its Effectiveness in Treating Alcoholism

Ketamine is a dissociative anesthetic widely used by physicians in the United States and also a psychedelic drug that physicians can legally prescribe off-label within the United States for other therapeutic purposes. It has been used in Russia and elsewhere to successfully treat alcoholism and other psychological or psychiatric problems, but has not been researched for this purpose in the United States. Results of a series of clinical trials using ketamine for treating alcoholism in the United States are retrospectively reported, along with 2 case studies of how psychotherapy facilitated by this substance helped two individuals achieve abstinence through ketamine's transpersonal effects. Considering the massive problems caused by alcoholism, the need to begin formal research studies on ketamine psychotherapy for alcoholism is emphasized.     

Failure to find differences in drinking behavior as a function of familial risk for alcoholism: a replication

Groups of high-risk (alcoholic fathers), middle-risk (second-degree alcoholic relatives) and low-risk (no first- or second-degree alcoholic relatives) male college students were compared with respect to drinking behavior, sociodemographic variables, personality, cognitive functioning, and mental health and drug use problems in themselves and in family members. The groups differed significantly on only one of a number of sociodemographic variables. No significant group differences were revealed in drinking behavior, or alcohol-related symptoms or consequences. High-risk subjects reported significantly more childhood attentional and social problems than did low-risk subjects. No group differences were found with respect to other childhood problem behaviors, cognitive functioning, subject or family drug use, or mental health problems. The findings are discussed in terms of the questions they raise concerning the results of high-risk studies and the contribution of genetic factors to alcoholism.     

Correlates of intimate partner psychological aggression perpetration in a clinical sample of alcoholic men

This study longitudinally examined correlates of intimate partner psychological aggression in a sample of 178 men seeking treatment for alcoholism and their partners, building on a previous investigation examining correlates of intimate partner physical aggression (Taft et al., 2010). The men were largely Caucasian; average age was 41.0 years. Participants completed a battery of questionnaires that assessed distal and proximal predictors of psychological aggression perpetration. Distal factors, assessed at baseline, included initial alcohol problem severity, beliefs about alcohol, and antisocial personality characteristics. Proximal factors, assessed at baseline and at follow-ups 6 and 12 months later, included alcohol and drug use, relationship adjustment, and anger. Psychological aggression was assessed at all three time points. Findings showed that both groups of variables were associated with psychological aggression perpetration. Beliefs that drinking causes relationship problems and variables related to alcohol consumption exhibited the strongest associations with psychological aggression. The findings are consistent with theoretical models that emphasize both distal and proximal effects of drinking on intimate partner aggression. Implications for clinical interventions and directions for future research are discussed.     

Chemical aversion treatment of alcoholism: Lithium as the aversive agent

Animal work indicating flavour aversion produced by chemical aversion therapy (CAT) with lithium might be effective in the treatment of alcoholism led to this treatment being given to 25 patients. The abstinence rate six months later of 36% was significantly better than the 12% rate for an equivalent group of patients, treated with a disulfuram-like drinking deterrent, calcium carbimide. The rate for the CAT group improves to 47% if 8 patients are excluded who did not develop sickness reactions to lithium. CAT with lithium appears safe given proper medical precautions.     

A retrospective analysis of alcohol consumption on laboratory tasks as related to therapeutic outcome

The relationship between drinking on laboratory-analogue measures at the onset of inpatient alcoholism treatment and abstinence subsequent to treatment was examined. Twenty therapeutically successful and 20 unsuccessful chronic alcoholics were selected and did not differ on age, education, length of problem drinking, and length of follow-up. Retrospective analysis of responding on an operant drinking task and a ‘taste test’ assessment technique revealed significant differences between the groups, with successful patients drinking less than the unsuccessful ones. Implications for screening candidates for alcoholism treatment programs are discussed.