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Objectives: Two-year alcohol use trajectories were documented among residents in a project-based Housing First program. Project-based Housing First provides immediate, low-barrier, nonabstinence-based, permanent supportive housing to chronically homeless individuals within a single housing project. The study aim was to address concerns that nonabstinence-based housing may enable alcohol use., Methods: A 2-year, within-subjects analysis was conducted among 95 chronically homeless individuals with alcohol problems who were allocated to project-based Housing First. Alcohol variables were assessed through self-report. Data on intervention exposure were extracted from agency records., Results: Multilevel growth models indicated significant within-subjects decreases across alcohol use outcomes over the study period. Intervention exposure, represented by months spent in housing, consistently predicted additional decreases in alcohol use outcomes., Conclusions: Findings did not support the enabling hypothesis. Although the project-based Housing First program did not require abstinence or treatment attendance, participants decreased their alcohol use and alcohol-related problems as a function of time and intervention exposure.

Objectives: Increasing evidence suggests that deficits in mindfulness (awareness, attentiveness, and acceptance of the present moment) play a role in a range of disorders involving behavioral dysregulation. This paper adds to that literature by describing a transdiagnostic psychotherapy (Mindfulness & Modification Therapy; MMT) developed to target behavioral dysregulation., Design: An open-treatment pilot-trial investigated the feasibility, acceptability, and pre-post effects of MMT targeting women (N = 14) court-referred for alcohol abuse/dependence and aggression., Results: Pre-post comparisons revealed significant decreases in alcohol use, drug use, and aggression. In addition, the retention rate was 93%., Conclusion: Preliminary evidence suggests that MMT is a feasible and acceptable treatment that decreases dysregulated behaviors such as substance use and aggression, while also potentially increasing retention., (© 2011 Wiley Periodicals, Inc.)

Objective: The present study examined the relationship between alcohol use and positive psychology's character virtues1 in a college student sample. Each of the virtues of wisdom, courage, humanity, justice, temperance, and transcendence were examined as protective factors and moderators of drinking consequences., Participants: This sample included 425 undergraduate students at a large Northwest University (69% female; 52% Caucasian, 34% Asian)., Methods: Participants completed paper and pencil questionnaires during October and November 2006 in exchange for extra credit in psychology classes., Results: Higher temperance scores were associated with abstinence, lower risk drinking, and fewer consequences among heavy drinkers; both increased justice and transcendence were independently associated with abstinence only; and wisdom, courage, and humanity were not associated with any outcomes., Conclusions: The associations between virtues and college student drinking support a collaboration between addictive behaviors and positive psychology to address college student drinking and minimize consequences.

Context: Chronically homeless individuals with severe alcohol problems often have multiple medical and psychiatric problems and use costly health and criminal justice services at high rates., Objective: To evaluate association of a "Housing First" intervention for chronically homeless individuals with severe alcohol problems with health care use and costs., Design, Setting, and Participants: Quasi-experimental design comparing 95 housed participants (with drinking permitted) with 39 wait-list control participants enrolled between November 2005 and March 2007 in Seattle, Washington., Main Outcome Measures: Use and cost of services (jail bookings, days incarcerated, shelter and sobering center use, hospital-based medical services, publicly funded alcohol and drug detoxification and treatment, emergency medical services, and Medicaid-funded services) for Housing First participants relative to wait-list controls., Results: Housing First participants had total costs of $8,175,922 in the year prior to the study, or median costs of $4066 per person per month (interquartile range [IQR], $2067-$8264). Median monthly costs decreased to $1492 (IQR, $337-$5709) and $958 (IQR, $98-$3200) after 6 and 12 months in housing, respectively. Poisson generalized estimating equation regressions using propensity score adjustments showed total cost rate reduction of 53% for housed participants relative to wait-list controls (rate ratio, 0.47; 95% confidence interval, 0.25-0.88) over the first 6 months. Total cost offsets for Housing First participants relative to controls averaged $2449 per person per month after accounting for housing program costs., Conclusions: In this population of chronically homeless individuals with high service use and costs, a Housing First program was associated with a relative decrease in costs after 6 months. These benefits increased to the extent that participants were retained in housing longer.

Addiction is characterized by dyscontrol - substance use despite intentions to restrain. Using a sample of at-risk drinkers, the present study examined whether an implicit measure of alcohol motivation (the Implicit Association Test [IAT]; Greenwald, A.G., McGhee, D.E., & Schwartz, J.L.K. (1998). Measuring individual differences in implicit cognition: the Implicit Association Test. Journal of Personality and Social Psychology, 74, 1464-1480) would predict dyscontrol of alcohol use. Participants completed an IAT and, to elicit motivation to restrain alcohol use, were instructed that greater consumption in a taste test would impair performance on a later task for which they could win a prize. All participants viewed aversive slides and then completed a thought-listing task. Participants either exerted self-control by suppressing negative affect and thoughts regarding the slides or did not exert self-control. Post-manipulation, the groups did not differ in mood, urge to drink or motivation to restrain consumption. During the subsequent taste test, participants whose self-control resources were depleted consumed more alcohol than did those in the control group. Additionally, the IAT, but not an explicit measure of alcohol motivation, more strongly predicted alcohol use when self-control resources were depleted. The results indicate that the IAT may have utility in predicting dyscontrolled alcohol use.

Aim: The People Awakening (PA) study explored an Alaska Native (AN) understanding of the recovery process from alcohol abuse and consequent sobriety., Design: PA utilized a cross-sectional, qualitative research design and community-based participatory research methods., Setting and Participants: The study included a state-wide convenience sample of 57 participants representing all five major AN groups: Aleut/Alutiiq, Athabascan, Inupiaq, Yup'ik/Cup'ik and Tlingit/Haida/Tsimshian. Participants were nominated and self-identified as being alcohol-abstinent at least five years following a period of problem drinking., Measurements: Open-ended and semistructured interviews gathered extensive personal life histories. A team of university and community co-researchers analyzed narratives using grounded theory and consensual data analysis techniques., Findings: A heuristic model of AN recovery derived from our participants' experiences describes recovery as a development process understood through five interrelated sequences: (i) the person entered into a reflective process of continually thinking over the consequences of his/her alcohol abuse; (ii) that led to periods of experimenting with sobriety, typically, but not always, followed by repeated cycling through return to drinking, thinking it over, and experimenting with sobriety; culminating in (iii) a turning point, marked by the final decision to become sober. Subsequently, participants engaged in (iv) Stage 1 sobriety, active coping with craving and urges to drink followed for some participants, but not all, by (v) Stage 2 sobriety, moving beyond coping to what one participant characterized as 'living life as it was meant to be lived., Conclusions: The PA heuristic model points to important cultural elements in AN conceptualizations of recovery.

Objective: The current pilot study examined the preliminary efficacy of a brief intervention (BI) for at-risk drinking in an employee assistance program., Method: Clients (N = 107) entering the employee assistance program (EAP) for mental health services were screened and met criteria for at-risk drinking. EAP therapists were randomly assigned to deliver either the BI plus EAP services as usual (SAU) or SAU only. Participants in the final analyses consisted of 44 BI + SAU (30 women, 14 men) and 30 SAU (21 women, 9 men) EAP clients who completed a 3-month follow-up., Results: Results suggested that participants in the BI + SAU group had significant reductions in peak blood alcohol concentration, peak quantity, and alcohol-related consequences compared with the SAU group. Men in the BI + SAU group had greater reductions in alcohol-related problems compared with men in the SAU group. Groups did not differ by number of total EAP sessions attended or rates of presenting problem resolution., Conclusions: Results provide preliminary evidence to support the integration of alcohol screening and BI as a low-cost method of intervening with clients with at-risk drinking in the context of co-occurring presenting problems.

The most widely cited road block to successful treatment outcomes for psychological and substance use disorders has been described as the return to the previous behavior, or "relapse." The operational definition of "relapse" varies from study to study and between clinicians, but in general the term is used to indicate the return to previous levels of symptomatic behavior. One explanation for the variation in the operationalization of relapse is the wide variety of behaviors for which the term is applied, including (but not limited to): depression, substance abuse, schizophrenia, mania, sexual offending, risky sexual behavior, dieting, and the anxiety disorders. A second explanation for the multitude of definitions for relapse is the inherent complexity in the process of behavior change. In this paper we present the most recent treatment outcome research evaluating relapse rates, with a special focus on the substance use disorders. Following this review of the literature we present an argument for the operationalization of relapse as a dynamic process, which can be empirically characterized using dynamical systems theory. We support this argument by presenting results from the analysis of alcohol treatment outcomes using catastrophe modeling techniques. These results demonstrate the utility of catastrophe theory in modeling the alcohol relapse process. The implications of these analyses for the treatment of alcohol use disorders, as well as a discussion of future research incorporating nonlinear dynamical systems theory is provided.

The present study evaluated whether Posttraumatic Stress Disorder (PTSD) symptom severity was associated with participation and treatment outcomes comparing a Vipassana meditation course to treatment as usual in an incarcerated sample. This study utilizes secondary data. The original study demonstrated that Vipassana meditation is associated with reductions in substance use. The present study found that PTSD symptom severity did not differ significantly between those who did and did not volunteer to take the course. Participation in the Vipassana course was associated with significantly greater reductions in substance use than treatment as usual, regardless of PTSD symptom severity levels. These results suggest that Vipassana meditation is worthy of further study for those with comorbid PTSD and substance use problems.

Alcohol lapses are the modal outcome following treatment for alcohol use disorders, yet many alcohol researchers have encountered limited success in the prediction and prevention of relapse. One hypothesis is that lapses are unpredictable, but another possibility is the complexity of the relapse process is not captured by traditional statistical methods. Data from Project Matching Alcohol Treatments to Client Heterogeneity (Project MATCH), a multisite alcohol treatment study, were reanalyzed with 2 statistical methodologies: catastrophe and 2-part growth mixture modeling. Drawing on previous investigations of self-efficacy as a dynamic predictor of relapse, the current study revisits the self-efficacy matching hypothesis, which was not statistically supported in Project MATCH. Results from both the catastrophe and growth mixture analyses demonstrated a dynamic relationship between self-efficacy and drinking outcomes. The growth mixture analyses provided evidence in support of the original matching hypothesis: Individuals with lower self-efficacy who received cognitive behavior therapy drank far less frequently than did those with low self-efficacy who received motivational therapy. These results highlight the dynamical nature of the relapse process and the importance of the use of methodologies that accommodate this complexity when evaluating treatment outcomes.

Little is known about what type of drinking related consequences may enhance motivation to change or may hinder behavior change over time. In order to examine this research question, 120 adult participants abusing alcohol were administered the Drinker Inventory of Consequences-Recent (DrInC-R), the Brief Readiness to Change Questionnaire (BRTC), and the Steady Pattern Chart (SP). Subscale scores from the DrInC-R and the BRTC; and alcohol consumption as assessed by the SP at baseline and three month follow-up were retained for data analyses. Greater intrapersonal DrInC-R consequences scores significantly predicted greater contemplation stage scores (R2=.37, p<.001), and lower precontemplation stage scores (R2=.32, p<.001), and DrInC-R impulse control and interpersonal consequences scores significantly predicted alcohol consumption at three month follow-up after controlling for baseline consumption (R2=.50, p<.001). Increased awareness of intrapersonal drinking related consequences may motivate change, whereas numbers of impulse control and interpersonal consequences may predict changes in drinking behavior over the short-term.

Relapse prevention, based on the cognitive-behavioral model of relapse, has become an adjunct to the treatment of numerous psychological problems, including (but not limited to) substance abuse, depression, sexual offending, and schizophrenia. This article provides an overview of the efficacy and effectiveness of relapse prevention in the treatment of addictive disorders, an update on recent empirical support for the elements of the cognitive-behavioral model of relapse, and a review of the criticisms of relapse prevention. In response to the criticisms, a reconceptualized cognitive-behavioral model of relapse that focuses on the dynamic interactions between multiple risk factors and situational determinants is proposed. Empirical support for this reconceptualization of relapse, the future of relapse prevention, and the limitations of the new model are discussed.

Objective: Native-American adolescents are reported to be at high risk for drug and alcohol use and related negative consequences. A brief screening instrument that is culturally and developmentally appropriate can aid clinicians who work with Native youth in determining whether more extensive assessment of substance use is necessary. The CRAFFT has been shown to be a valid and reliable screen among general adolescent outpatient clinic samples., Method: Data were collected as part of the Journeys of the Circle project, a collaborative effort between the Seattle Indian Health Board (SIHB) and the University of Washington's Addictive Behaviors Research Center. Psychometric properties of the CRAFFT were examined in 70 American-Indian and Alaska-Native youths ages 13 to 19 recruited from public schools and SIHBs outpatient clinics., Results: The CRAFFT demonstrated good internal consistency (alpha = 0.81). A score of 2 or higher on the CRAFFT was found to be optimal for capturing youths with high alcohol-related problems (sensitivity, 0.95; specificity, 0.86), frequent alcohol use (sensitivity, 1.00; specificity, 0.72) and frequent marijuana use (sensitivity, 1.00; specificity, 0.75). A cut-point of 3 was appropriate for identifying adolescents with frequent other drug use (sensitivity, 0.86; specificity, 0.76)., Conclusions: The CRAFFT may be a valid instrument for identifying Native youths at risk for alcohol and other drug problems. This brief screen can be effective in helping providers determine the need for further assessment and treatment or prevention services for Native-American adolescents.

Cognitions about drinking, such as positive expectancies and self-efficacy, have been found to profoundly influence drinking behavior. Although the relationship of self-efficacy and positive expectancies with drinking consumption has been established, the relationship of self-efficacy and alcohol expectancies with the number of reported drinking related consequences has not been examined. One hundred thirteen participants who met criteria for alcohol abuse or dependence were administered the Situational Confidence Questionnaire, the Alcohol Expectancies Questionnaire, the Drinker Inventory of Consequences-Recent, and the Losses of Significance Self-report Questionnaire-Revised. As predicted, lower self-efficacy and greater positive alcohol expectancies predicted greater recent drinking consequences beyond those accounted for by alcohol consumption alone. Greater numbers of positive alcohol expectancies also predicted greater numbers of recent important alcohol related losses. Correcting errant assumptions about alcohol expectancies and strategies designed to increase self-efficacy may reduce harmful drinking consequences even if a client is unwilling to reduce consumption.

Harm reduction approaches to alcohol problems have endured a controversial history in both the research literature and the popular media. Although several studies have demonstrated that controlled drinking is possible and that moderation-based treatments may be preferred over abstinence-only approaches, the public and institutional views of alcohol treatment still support zero-tolerance. After describing the problems with zero-tolerance and the benefits of moderate drinking, the research literature describing prevention and intervention approaches consistent with a harm reduction philosophy are presented. Literature is reviewed on universal prevention programs for young adolescents, selective and indicated prevention for college students, moderation-based self-help approaches, prevention and interventions in primary care settings, pharmacological treatments, and psychosocial approaches with moderation goals. Overall, empirical studies have demonstrated that harm reduction approaches to alcohol problems are at least as effective as abstinence-oriented approaches at reducing alcohol consumption and alcohol-related consequences. Based on these findings, we discuss the importance of individualizing alcohol prevention and intervention to accommodate the preferences and needs of the targeted person or population. In recognizing the multifaceted nature of behavior change, harm reduction efforts seek to meet the individual where he or she is at and assist that person in the direction of positive behavior change, whether that change involves abstinence, moderate drinking, or the reduction of alcohol-related harm. The limitations of harm reduction and recommendations for future research are discussed.

This study compared Web-based assessment techniques with traditional paper-based methods of commonly used measures of alcohol use. Test-retest reliabilities were obtained, and tests of validity were conducted. A total of 255 participants were randomly assigned to 1 of 3 conditions: paper-based (P&P), Web-based (Web), or Web-based with interruption (Web-I). Follow-up assessments 1 week later indicated reliabilities ranging from .59 to .93 within all measures and across all assessment methods. Significantly high test-retest reliability coefficients support the use of these measures for research and clinical applications. Furthermore, no significant differences were found between assessment techniques, suggesting that Web-based methods are a suitable alternative to more traditional methods. This cost-efficient alternative has the advantage of minimizing data collection and entry errors while increasing survey accessibility.

Executive cognitive functions (ECFs) seem important for motivating change and self-regulation of problem drinking. Evidence for executive cognitive deficits have been found among heavy-drinking college students. Although college students who abuse alcohol often experience a variety of negative consequences related to their drinking behavior, executive cognitive dysfunction may interfere with recognizing consequences and responding skillfully to avoid future harm. Fifty college students with drinking problems completed assessments of ECFs. Greater negative drinking consequences and short-term memory function significantly predicted greater awareness of drinking problems. ECF may be an important factor for motivation to change drinking behavior among college students.

Fraternity, sorority, and residence hall residents were compared on drinking rates and patterns, drinking-related problems, family history of alcohol problems, alcohol outcome expectancies, and high school drinking patterns. Results indicated residence in a fraternity was related to more frequent alcohol consumption and greater negative consequences even after accounting for family history, expectancies, and high school drinking rates. Family history of alcohol problems was only related to negative consequences for men. Only high school drinking rates were related to amount of alcohol consumed per occasion, for both men and women. Fraternity residence was found to be related to more negative consequences even after accounting for current drinking habits. However, sorority residence was found to moderate the relationship between current drinking and negative consequences. Both high and low drinkers in sororities indicated similar rates of alcohol-related negative consequences, whereas high frequency female drinkers in the residence hall sample reported significantly more problems.

While overall alcohol consumption and alcohol-related automobile deaths have declined, rates of alcohol dependence, liver cirrhosis, and alcohol-related problems remain high among adults, and binge drinking continues as a major health risk for high school and college students. Some individual-level downstream interventions have been evaluated with sufficient rigor to recommend widespread dissemination, and widened availability of new pharmacotherapies could further increase effectiveness. Midstream population-based programs, such as screening and brief interventions in hospitals and managed care organizations, may have greater public health impact than tertiary treatment because of early identification and low cost. Upstream programs and policies that place limits on alcohol availability (e.g., higher legal purchasing age) have the greatest potential to reduce morbidity and mortality at the least cost to society.

Relapse prevention (RP) is an important component of alcoholism treatment. The RP model proposed by Marlatt and Gordon suggests that both immediate determinants (e.g., high-risk situations, coping skills, outcome expectancies, and the abstinence violation effect) and covert antecedents (e.g., lifestyle factors and urges and cravings) can contribute to relapse. The RP model also incorporates numerous specific and global intervention strategies that allow therapist and client to address each step of the relapse process. Specific interventions include identifying specific high-risk situations for each client and enhancing the client's skills for coping with those situations, increasing the client's self-efficacy, eliminating myths regarding alcohol's effects, managing lapses, and restructuring the client's perceptions of the relapse process. Global strategies comprise balancing the client's lifestyle and helping him or her develop positive addictions, employing stimulus control techniques and urge-management techniques, and developing relapse road maps. Several studies have provided theoretical and practical support for the RP model.

In this commentary on the Relapse Replication and Extension Project, several points are addressed. First, the selection of the pretreatment "baseline relapse" as the key predictor variable for post-treatment relapse in the predictive and construct validity studies is questioned. It is doubtful whether retrospective accounts of drinking episodes after 4 days of abstinence qualify as relapse episodes for the following reasons: clients may not have been committed to abstinence (e.g. weekend binge drinkers); treatment may have included coping skill training for pretreatment high-risk situations (i.e. treatment intervention is viewed as a "nuisance variable"). By assuming that a client's retrospective report of a poorly defined pretreatment "relapse" is predictive of the type of relapse episode experienced during the post-treatment follow-up assessment is to commit an error of "taxidermy" in evaluating the reliability and validity of the taxonomy; i.e. the tendency for researchers to "stuff and permanently mount" distal baseline episodes as static predictor variables, thereby depriving them of their dynamic and fluid role as proximal determinants in the relapse process. The difference between researchers who assess distal trait predictors of relapse and clinicians who focus more on proximal state predictors in conducting relapse prevention therapy is discussed and illustrated by means of a case study. Finally, the metaphor of relapse as "falling off the wagon" is described as an example of a systems approach to relapse prevention.

The purpose of this paper is to provide an historical overview of the development of the taxonomy of high-risk situations for relapse in patients receiving abstinence-based treatment for alcoholism. Research conducted during the 1970s on determinants of relapse is briefly reviewed, beginning with a preliminary analysis of relapse patterns in alcoholics treated with aversion therapy. Theoretical foundations underlying the development of the taxonomy are then discussed with an emphasis on social-learning theory and its implications for cognitive-behavioral interventions for relapse prevention. Findings supporting the efficacy of coping-skills training for high-risk relapse situations, based on a prospective treatment outcome study for inpatient alcoholics, are also presented in support of the clinical validity of the relapse model. The paper concludes with a description of the refined and extended taxonomy of high-risk situations and the associated cognitive-behavioral model of relapse described in the Marlatt & Gordon (1985) text on relapse prevention.

Development, content, and evaluation of the Alcohol Skills Training Program (ASTP) is described. Patterned after strategies for relapse prevention, the ASTP is a cognitive behavioral approach to the secondary prevention of alcohol problems. Format and context of the six group sessions are detailed, and process considerations are discussed. Results are summarized for two controlled investigations of the ASTP with young adult drinkers. The psychoeducational approach of the ASTP is recommended as an effective means for changing drinking patterns among young adults who are at risk for alcohol-related problems.

Behavioral approaches have made significant contributions to understanding the etiology and treatment of alcohol dependence. The present chapter provides a brief overview of changes that have occurred within this perspective over the past decade. Significant changes at a theoretical level have included a move toward mediational cognitive-behavioral models of etiology and maintenance, integrative multivariate models, and an empirical, developmental model based on the natural history of the drinking and alcohol problems. Significant changes in clinical practice have included an expanded role of assessment within the context of a biopsychosocial model of alcoholism, an increased focus on secondary prevention and brief intervention with less-alcohol-impaired individuals, a focus on "harm reduction" as a goal of such interventions, the development of a stepped-care approach to treatment with a reliance on patient-treatment matching, an increased emphasis on the maintenance of therapeutic gain and relapse prevention, and the incorporation of behavioral and cognitive principles into self-help programs.

This study tested 3 forms of alcohol risk reduction programming for young adults. Volunteers were randomly assigned to receive a 6-week class and discussion group, a 6-unit self-help manual, or a single 1-hr feedback and advice session with professional staff. Results reveal significant reductions in self-reported drinking at the end of the intervention phase and maintenance of drinking changes throughout a 2-year follow-up period. Comparable drinking reductions were rated across treatments; however, noncompliance with the self-help reading program suggested limited utility. Treatment response was related to subject age, as subjects showed increased drinking during the year they reached legal drinking status. The efficacy of brief motivational interventions and client matching in prevention programs is discussed.

This study evaluated secondary prevention approaches for young adults (N = 36, mean age 23 years) at risk for alcohol problems. Subjects were randomly assigned to cognitive-behavioral alcohol skills training, a didactic alcohol information program, or assessment only. The skills program included training in blood alcohol level estimation, limit setting, and relapse prevention skills. All subjects maintained daily drinking records during the 8-week intervention and for 1 week at each follow-up. Repeated measures MANOVA found a significant reduction over 1-year follow-up in self-reported alcohol consumption for the total sample. For all drinking measures, the directional findings consistently favored skills training. Despite overall reductions, most subjects continued to report occasional heavy drinking.

Treatment of alcohol problems typically focuses on the cessation of drinking. Although cessation is necessary and important to achieving sobriety, this article suggests that maintenance of sobriety is a crucial, but oft ignored, component of effective treatment. Alcohol relapse is discussed in the context of aftercare treatment employing a relapse prevention approach. Within this model, relapse is not automatically defined as a treatment failure but as an opportunity for intervention and the interruption of the relapse process. Determinants and predictors of relapse are discussed, and assessment and intervention strategies provided. A case study illustrates the components of the relapse process and the interventions employed to maintain continued sobriety.

The primary goal of the present article is to compare expectancy models with competing attitude models of alcohol use. First, several methodological issues in expectancy research were addressed, to more adequately compare the theoretical models. Study 1 examined the effect of possible self-report biases on associations among expectancy constructs and alcohol use. In Studies 2 and 3, the basic distinction between general factors of positive and negative alcohol expectancies was investigated in both cross-sectional and prospective models. Alternative predictions that were based on competing expectancy and attitude theories were evaluated primarily in Study 3. Results from these studies supported the validity of the expectancy constructs and the proposed distinctions among expectancy and attitude constructs-in terms of strong discriminant validity, absence of self-report bias, and differential prediction of alcohol use. Furthermore, the findings favored certain expectancy models over alternative attitude models of alcohol use, reaffirming the usefulness of the expectancy framework.

A brief description of the controversy surrounding moderation goals for individuals with alcohol problems is provided. Although the controversy is as yet unresolved, particularly for severely dependent individuals, evidence for the utility and appropriateness of offering goal choices (including moderation goals) to less dependent problem drinkers is discussed. In addition, secondary prevention of alcohol problems with high-risk drinkers often utilizes moderation goals; these individuals are unlikely to fit the traditional alcoholic pattern, but are at risk for a variety of intoxication-related problems. Relapse prevention, an example of a tertiary prevention program to facilitate abstinence in the treatment of addiction, may also be applied to secondary prevention (moderation) goals. Following a description of the relapse prevention approach and its use with moderation goals, two studies applying this approach to secondary prevention are discussed, and summaries of the results are presented.

Cue exposure techniques have been increasingly applied in the treatment of addictive behaviors. The role of cue exposure in a comprehensive approach to relapse prevention is considered from several theoretical perspectives. Issues discussed include the optimal definition of both cue and response variables in cue exposure, the relation between exposure to drug-taking cues and elicitation of outcome expectancies, and the combination of extinction-based cue exposure methods and skill training in relapse prevention programs. Whether cue exposure effects are mediated by extinction of appetitive craving responses and/or by the modification of efficacy and outcome expectancies is discussed.

Behavioral approaches to understanding the etiology of alcoholism represent a divergence from traditional biomedical and psychodynamic models. The behavioral perspective subsumes a number of diverse conceptual models that share a common emphasis on the interplay between environmental forces and the response of the organism (S-R model). Yet these models--classical conditioning, drive reduction, and operant conditioning--offer different procedural paradigms and explanatory mechanisms. Through consistent application of the scientific method, certain behavioral principles from these models have survived empirical validation and continue to enrich our understanding of alcoholism. This chapter reviews these models and their attendant empirical findings, from both animal and human research, as they pertain to the etiology of alcoholism. The cognitive-behavioral approach, a recent product of this evolutionary development, focuses on cognitive processes that mediate stimulus-response relationships. The cognitive-behavioral model provides a comprehensive account of both the acquisition and maintenance of problem drinking and is discussed in some detail.

Verbal report procedures, such as interviews, tests and questionnaires, have become the dominant method to obtain clinical data on alcohol abuse and its modification through treatment. The extent to which this method provides reliable and valid information for research purposes, and how its accuracy and usefulness can be enhanced, is examined. A review of methodological studies in the alcohol literature shows that although the information obtained from alcoholics and heavy drinkers tends to be reliable and valid, there can be considerable variability in accuracy, depending on the sensitivity of the information sought, the specificity of the validation criteria, the personal characteristics of the respondents and the demand characteristics of the task. It is suggested that the question of whether verbal report procedures are valid or invalid is less important than the issue of how they can be improved to the point that confidence can be placed in their findings. To facilitate this process, methodological techniques likely to enhance validity are reviewed.