The IATP pilot study was intended to explore whether a treatment could be devised that would train adaptive coping skills to alcoholic patients more effectively than current manual-based coping skills treatments. It was hypothesized that IATP, with its highly idiographic approach to skills assessment and training, would yield more use of coping skills and better posttreatment outcomes than would a well-constructed, but less individualized, approach. To an important extent these hypotheses were borne out. PDA outcome was significantly (if modestly) better at posttreatment in IATP than in PCBT, although IATP yielded equivalent PDH and DrInC scores. IATP yielded nearly twice the abstinence rate as PCBT. If the follow-up had continued it is possible that the discrepancy between PCBT and IATP in abstinence might have increased over time, as has been demonstrated in other clinical trials (24
The use of experience sampling allowed us to carefully assess not only drinking episodes, but also the coping responses employed (or not) in response to high risk situations. As hoped, IATP yielded significantly greater increases in the use of a variety of coping skills than did PCBT. Additionally, the increased coping was significantly associated with both posttreatment PDA, and with posttreatment drinking recorded on a momentary basis.
As indicated by the logistic regression analysis, participants who used an adaptive coping response when they were tempted were much less likely to drink at those moments. Indeed, each coping response reported resulted in a 30% reduction in the risk of drinking at that moment. Likewise, those who were in the IATP condition were less likely to drink. The interaction of treatment × coping was not significant in that analysis, but this was not surprising. We would not expect coping to be more effective just because a person is assigned to IATP. The function of IATP was to enhance coping, which in turn should reduce drinking.
One aspect of the coping response results is interesting. The IATP treatment appeared most successful at eliciting greater use of behavioral coping, or problem-focused strategies. Thus IATP patients responded with significantly greater increases in the use of avoidance, distraction and drink refusal than did the PCBT patients. The one cognitive or emotion-focused strategy that emerged for IATP was “waiting out the urge.” Both “waiting out the urge” and the use of behavioral coping were specifically covered in IATP as responses to the pretreatment ES assessments. Although these skills were also covered in the PCBT protocol, the nature of IATP, with its focus on addressing individualized strengths and deficits, allowed for greater time spent on tailoring the training of specific skills that would be most useful to the patient in his or her own environment.
The PCBT condition used here is an example of the kind of structured relapse prevention treatment used in many community and research settings. The highly individualized structure of the IATP program made it much different from PCBT. It is not clear, therefore, whether differences in coping and outcome variables were a function of differences in therapy structure, content, or both.
There are some limitations to this study. Because of the pre-post design, the drinking recorded at posttreatment occurred during the treatment period. It is not known how these two treatments would have compared at more distant follow-up periods. Also, the failure to blind research assistants to treatment assignment must be considered a weakness, as is the fact that therapist adherence ratings were made by the therapy supervisor. Another issue is possible reactivity to the ES protocol; the idea that frequent prompts to answer questions about alcohol-related urges and behavior might have altered these urges and behavior. Reactive effects, if they occurred, do not threaten internal validity because all subjects participated in the same ES protocol. The greater threat is to the external validity of the study. However, there is evidence in the literature that experience sampling does not affect the relapse rate of treated alcoholics (25
), or prevent substance use or other behaviors, such as overeating in dieters (27
Another problem with any treatment based on analyzing high risk situations, is the difficulty many people have recognizing cravings or urges to drink. Our own research (15
) has indicated that treated alcoholics are frequently unwilling to acknowledge, or unable to identify, cravings for alcohol. Therefore the results presented regarding temptation situations must be viewed with some caution. The IATP treatment in the present study, however, was based not only on drinking urges, but also recurring situations that were associated with drinking during the pretreatment period.
Because of limitations in the technology employed when the study started, open-ended coping questions were not used. Instead, subjects responded to a checklist that may have restricted or directed participants' recall of how they reacted to a potential high-risk situation. Two aspects of the data suggest that the restriction-of-choice problem may not have been severe. First, the data are distributed in a way that is consistent with how we believe patients respond in real life. For example, there was relatively resort to “pleasant thoughts.” Likewise, the rate of endorsing “refused a drink” was low; there are relatively few instances in most participants' days in which they are actually offered a drink. Second, participants did record their drinking episodes, and, more important, recorded when they did ”nothing” to avoid drinking. The present dataset, then, is at least valid on its face. Our upcoming work will allow free responses to characterize coping efforts.
A final limitation is that the IATP condition was only superior to PCBT in one of four outcomes. This is not a very serious limitation, however. The control condition used here was, intentionally, extremely strong. The intent of the present study was to determine if a treatment such as IATP could be implemented and if it would work as planned.
Despite the limitations of this study, we find the results to be quite encouraging. IATP did work as planned. IATP resulted in fewer temptation episodes at posttreatment than did PCBT, and when temptations were recorded IATP patients were less likely to drink and more likely to employ adaptive coping efforts to deal with them. Additional work will be undertaken to improve delivery of IATP and in-vivo assessment of coping.
Consistent with the hypotheses, IATP resulted in increased coping and reduced days of drinking at posttreatment. Additionally, a test of meditational effects of coping on PDA outcome approached significance. Nevertheless, the results of this study must be interpreted with caution. It is not clear whether reduced drinking at posttreatment reflected coping changes that occurred as a function of treatment (as hypothesized), or whether coping responses were enhanced due to changes in drinking. It will require another study with additional follow-ups and interim coping assessments to establish a causal chain. It is possible, even likely, that coping and drinking influence each other over time, in a dynamic relationship. We are optimistic that the methodology employed here, for training coping skills and evaluating their effects on drinking, lead to a better understanding of the dynamics of coping and recovery.