Project MATCH: What It Was and What It Found

Stanton Peele

General Statement: Project MATCH was an extremely expensive intervention in which a volunteer, selected group of alcohol dependent patients had a small number of outpatient sessions with a highly trained and monitored staff, and reduced their drinking substantially and maintained reduced drinking over a year.

Summary. About 1500 alcoholics were volunteer subjects in a study designed to administer 12 sessions of three major forms of outpatient alcoholism treatment (12-step, coping skills, and four sessions of motivational enhancement). Subjects attended on average two-thirds of the scheduled sessions. Nonetheless, they significantly reduced their drinking amounts and frequency of drinking from 25 days to 6 days/month a year following treatment. A third of a purely outpatient treatment group drank without bingeing (>33%), compared with a fifth (<20%) who abstained throughout the one-year follow-up. Thus, fairly low levels of high-quality outpatient treatment succeeded in greatly reduced drinking among alcohol-dependent subjects for a substantial follow-up period.

A. The Basic Project. Project MATCH was organized by the National Institute on Alcohol Abuse and Alcoholism to assess the impact of three different types of treatment (Coping Skills, Motivational Enhancement, and Twelve-Step) for alcoholic subjects (averaging 6-7 alcohol dependence symptoms on enrollment) with special reference to patient characteristics that might predict better outcomes for each treatment for different types of alcoholics. Treatment was on an outpatient basis (for a purely outpatient group and an aftercare to hospital treatment group). Subjects were treated for 3 months and outcomes were measured at three-month points until a year after treatment. The two primary outcome measures were percent days abstinent and drinks per drinking day.

B. Project Staff and Resources. Science News reported that Project MATCH cost $27 million and took 8 years to complete. The Project MATCH Research Group consisted of two NIAAA coordinators, fifteen Clinical Research Unit staff, four Coordinating Center staff, eight Collaborating Investigators, and a five-person Data Monitoring Board. These 35 individuals all had doctorates or medical degrees. There were 20 Collaborating Facilities, listing 26 staff (although in a few cases these staff were also listed as researchers). Eighty psychotherapists delivered the treatment at 30 locations. This totals to approximately 130 clinical professionals involved in the treatment, administration, and analysis. The study started with 1,726 subjects (952 outpatient; 774 aftercare; 1307 men; 419 women).

C. Client Characteristics. Clients were assessed for alcohol abuse/alcohol dependence according to DSM-III-R, but were excluded if they had concurrent drug dependencies. Almost all subjects (95% in outpatient, 98% in aftercare) measured alcohol dependent according to DSM. Initially, 4,481 potential subjects were screened for possible participation in the study. At initial screening, 459 potential subjects declined to participate because of inconvenience or the amount of time required. Other potential subjects were declared ineligible for "failure to complete the assessment battery; residential instability; legal or probation problems, etc.," but no figure is given for how many were ineligible. Thus, subjects were volunteers with better than average prognosticators (e.g., residential stability). Fifty-seven subjects were referred to outside treatment during the course of the study. Subjects on average completed two-thirds of their sessions.

D. Treatment Delivery. Treatment was delivered individually on an outpatient basis in 12 weekly sessions, except for motivational enhancement, which took four sessions. Treatment protocols and standards for therapist certification were developed, all sessions were videotaped, and 25% of all therapy sessions were monitored by supervisors for quality control. The care and quality control of Project MATCH therapy differs so substantially from standard treatment provided for alcoholism patients in the U.S. that the two bear almost no relationship.

E. Client Measures. Treatment lasted 12 weeks; follow-up assessments were at 3, 6, 9, 12, and 15 months. Ten primary client characteristics were measured and reported (e.g., conceptual level, motivation, psychiatric severity, gender). Additional secondary characteristics not yet reported were also measured, including DSM diagnostic categories, self-efficacy, alcohol dependence and seven other traits and "several higher order and global matching hypotheses." Missing drinking data caused 8% of aftercare subjects and 7% of outpatient subjects to be dropped. Six additional outcome measures were reported, with widely varying subject numbers. For one outcome, only 284 (out of 952) outpatient subjects were reported.

F. Drinking Results. Subjects substantially reduced drinking intensity and frequency of drinking across all treatments, but relatively few did not drink at all. About 20 percent of the outpatient group and slightly over a third (35%) of the aftercare group abstained throughout the year follow-up. At 9-month and 12-month follow-up, no type of treatment achieved a majority abstinent for that three-month period. However, only 40% of aftercare and 46% of outpatient subjects drank heavily for three straight days during the year follow-up. In other words, a third of outpatient alcoholics drank without bingeing, compared with a fifth who abstained totally. The JSA Project MATCH report did not actually show that, according to Science News: "before treatment, volunteers drank on 25 days out of 30 days, a number that fell to 6 days of drinking per month by the end of the follow-up."

G. Treatment and Interaction Effects. No significant main treatment effects were found for drinking. There were no significant differences in drinking days in any month among the treatment groups. Sixteen hypothesized interactions between the ten client characteristics and three treatment types were conceived. In the aftercare group, no significant impact on drinking outcomes was found for any of these interactions. In the outpatient group, less psychiatrically severe subjects had significantly more abstinence days in 12-step than in coping skills treatment. This advantage amounted, among subjects without psychopathology, to significantly more abstinence in seven of the 12 follow-up months, an average of about 4 more abstinent days per month.

There were a potential of 64 interactions — 16 (patient x treatment interactions) x 2 (outpatient v aftercare) x 2 outcomes (drinking days v # drinks on drinking days). Thus the study found one positive result out of 64 potential relationships, involving two of the three treatments, a difference not explicitly hypothesized. There were significant client characteristic effects — for example, among outpatients, higher motivation led to significantly better drinking outcomes, while in both the outpatient and aftercare groups greater social support for drinking (presumably excessive) predicted worse outcomes.

H. Conclusions

1. "The largest, statistically most powerful, psychotherapy trial ever conducted," and also by far the most expensive, produced little of value.
2. Research limitations — including (a) the highly selected nature of the client population and (b) the atypical, incredibly high level of quality control of treatment — make generalizations of these results dubious. "The overall effect of being part of Project MATCH, with extensive assessment, attractive treatments, and aggressive follow-up may have minimized naturally occurring variability among treatment modalities and may, in part, account for the favorable treatment outcomes" (JSA, p. 24).
3. The natural question is whether, given the same volunteer subjects and quality of therapist supervision, a totally nonspecific treatment involving minimal advice to quit or reduce drinking might have shown substantially the same benefits.
4. The principal result of this study was that relatively modest treatment contact (in terms of number and intensity of sessions) produced substantial and enduring drinking reductions among a fairly severe alcoholic population.

References

Bower, B. (1997, January 25). Alcoholics synonymous: Heavy drinkers of all stripes may get comparable help from a variety of therapies. Science News, 151:62-63.

Project MATCH Research Group. (1997). Matching alcoholism treatments to client heterogeneity: Project MATCH Posttreatment drinking outcomes. Journal of Studies on Alcohol, 58:7-29.