Psychology Today, April 1983, pp. 38-42
Through a Glass Darkly
Can some alcoholics learn to drink in moderation?
The answer, at least in this country, may be more political than scientific.
Morristown, New Jersey
In the July 9, 1982, issue of Science, an article by Mary Pendery, Irving Maltzman, and L. Jolyon West claimed that controlled drinking is not a viable treatment for alcoholism. The article was an attack on an earlier study that had found that controlled drinking was superior to abstinence for alcoholics. Pendery, Maltzman, and West were highly critical of Mark and Linda Sobell, the authors of the earlier study; Maltzman accused them of fraud.
The Science article received a great deal of news coverage, which created the impression that controlled drinking could not possibly succeed with alcoholics and that there was no basis for claiming that it could. It seemed that the disease theory of alcoholismthat an alcoholic has an inbred and irreversible predisposition toward excessive consumption of alcoholwas beyond question.
What the news reports failed to show was that scores of studies, done before and after the Sobells' work, have found that alcoholics can drink in a controlled manner. Actually, the controversy between Pendery et al. and the Sobells represents a larger disputeone between those espousing the disease theory and those who favor a research approach that leads to far more complex notions about the nature of alcoholism.
The charges raised by the Pendery group were investigated by the Addiction Research Foundation of Ontario, which exonerated the Sobells in a 1982 report that has received scant attention. Other investigations are in progress, but whatever their results, it is clear that the controlled-drinking approach is a dead issue in the United States. The question is whether its demise was based on reasoned evidence and scientific scrutiny, or on superficial reporting arising from popular conceptions about alcoholism and alcoholics.
The Sobell controversy began in 1970, when Mark and Linda Sobellthen students at the University of Californiadesigned a study to compare what happened to alcoholics treated in two different ways. The Sobells assigned 20 patients at Patton State Hospital in California to a behavior-modification program designed to produce moderate drinking. Another 20 received standard hospital treatment aimed at total abstinence. The Sobells' published resultsincluding one- and two-year follow-upsindicated that patients in the controlled-drinking group functioned better than those instructed to abstain.
In 1973, Pendery, an alcoholism counselor in San Diego, and Maltzman, a psychologist at UCLA, began their own investigation of the former patients in the Sobell study. The Sobells refused to release the names of the subjects. This set off a prolonged legal battle, during which another research team, headed by psychologist Glenn Caddy, performed a three year follow-up of the original study, confirming its results. The Pendery group believes that Caddy's work, which was supported by the Sobells, added nothing to the debate.
Eventually, Pendery and Maltzman obtained a list of the patients. They did not find it easy to get funding, however, and for several years Pendery paid for most of the research herself. It was only in 1979 that she was able to enlist the help of West, head of the Department of Psychiatry at the UCLA Medical School. West helped to find some financial support, and became the third author of the Science article.
The published article was actually a revision of an earlier draft, which the editors of Science had felt might be libelous. Nevertheless, the draft had been widely circulated and had formed the basis for many of the early press reports on the dispute. The draft also led to the appointment of an investigating committee by the Addiction Research Foundation, which now employs the Sobells.
Pendery and her colleagues refused to participate in the committee's deliberations, making its report inconclusive. Pendery, on the advice of her lawyers, declinedbecause, she said, the committee did not have the subpoena powers or right of cross-examination it needed to fulfill its mandate. More basically, Pendery said, this body could not possibly hope 'to judge the Sobells' state of mind 10 years ago,' and discover whether they had intentionally misrepresented their results. Yet Pendery and Maltzman apparently did just that in their own investigation, which depended on patients' recollections of events up to nine years in the past.
The committee selected by the ARF consisted of four distinguished professionals, representing the fields of law, medicine, psychology, and university administration. None of them had a previous connection with the alcoholism controversy. In the continuing dispute, which in some ways resembles the endless litigation that Charles Dickens describes in Bleak House, this committee's report stands out as a reminder of the basic methods and goals of science.
The report notes that a central principle of science is that data should be available for re-examination. Unfortunately, many researchers do not honor this standard. (See 'Science's Faulty Fraud Detectors,' Psychology Today, November 1982.) The Sobells were at fault for not making their data accessible to those with opposing viewpoints. If they were concerned about the motives of investigators so clearly hostile to research on controlled drinking, they might have provided for independent supervision of the handling of their research materials.
The ARF committee identified eight allegations of research misconduct or error raised by the Pendery group. On seven of these, the Committee supported the Sobells. On the eighth, while they found no proof that the Sobells had contacted their subjects every other week, as they had claimed, neither did they find any indication of fraud. Furthermore, the committee also found that the Pendery group's claims of little follow-up were unjustified. While they couldn't cite exact figures, the committee members were impressed by how much documentationfrom postcards to tape recordings of interviews the Sobells were able to provide, 10 years after their study.
One reason for the gross discrepancies between the Sobell and Pendery reports is the heavy reliance by both groups on the patients' subjective impressions. Patients typically manifest an emotional immediacy effect: They endorse whatever treatment they are receiving at a given time and whoever is administering it. Thus, Linda Sobell who conducted the interviews with subjectsmay have elicited favorable comments about the behavioral treatment from patients who were eager to please her.
The Pendery group, unfortunately, seems to have taken this confounding factor one step further. In its later stages, Pendery's work has been endorsed by some former Sobell subjects calling themselves the 'Alcoholism Truth Committee.' Pendery and her colleagues do not seem to be aware of how this kind of relationship with patients can preclude objective inquiry. Moreover, it establishes a dangerous precedent for recruiting clients and former clients to testify to the merits of competing forms of therapy.
The ARF report noted that the Science article contained no new information of any kind. The principal measure with which Pendery assailed the Sobells' study was how much hospitalization the controlled-drinking subjects underwent after treatment. The committee found that the Sobells had presented and interpreted these data fully in their own published reports; indeed, the Sobells noted more hospitalizations than did the Pendery group.
The committee was also critical of the role of the press. The report noted that coverage of the dispute did not reveal the easily discovered fact that the 'revelations' contained in the article were old news. Even more troublesome was the glossing over of the Science article's omission of follow-up data on the abstinence group. Television, radio, and newspaper reports highlighted the fact that four out of the 20 controlled-drinking subjects had died since the original study was made. What Pendery did not report, and what the press did not discover independently, was that six out of 20 abstinence-treated subjects had died in that period, four from what were judged to be alcohol-related causes.
Pendery and her co-workers say that such comparisons miss the point, since they only wished to demonstrate that controlled drinking had not worked. This is scientific legerdemain. The Sobells' research agrees with other findings that individuals who require hospital treatment of any kind for alcoholism do not have a good prognosis, regardless of what type of therapy is used. The question is which type offers the best prospects for these patients. Pendery has done nothing to establish the relative effectiveness of the two possible strategies in alcoholism treatment.
Fresh data might help us find the answer to this question. Instead, Pendery has announced her intention to challenge the randomness of the assignment of subjects to the two Sobell experimental conditions, an issue thoroughly examined by the ARF committee. In any event, the most that can come from such continued assaults on the Sobell study is a conclusion that one piece of research was not all that it claimed to be. The ARF committee contests the scientific value of this approach, since the Sobells' work is a small part of a much larger body of research. Systematic studies of alcoholism treatment have regularly shown the viability of controlled drinking, even when these results surprised investigators or ran contrary to their expectations. The Sobells, working with E. Mansell Pattison, a leading alcoholism researcher, identified 74 such studies. Nick Heather and Ian Robertson, two Scottish researchers, found this to be an underestimate in their 1981 book, Controlled Drinking (Methuen & Co.).
How is it possible that the value of controlled drinking has been established so many times, and yet we have a national alcoholism policy that seems to ignore such treatment? The explanation lies in a seemingly irreconcilable dichotomy between a clinical outlook that recognizes what a client says as the only reality, and an 'objectivist' perspective that accepts the results of studies of anonymous subjects. Those with the clinical outlook claim that they have never known an alcoholic who could moderate his drinking. It is nearly impossible to contradict this claim, as shown by the fact that the Pendery group recognizes that one of the Sobells' subjects is now indeed a moderate drinker. Their explanation: He was never really an alcoholic.
In the last follow-up that the Sobells conducted (19 to 24 months after patient training), they found that the 20 controlled drinkers functioned well, on the average, for 160 of the 183 days. The 20 patients who had been trained to be abstinent functioned well for 80 days on the average. "Functioning well" was defined as having no drinks or consuming less than the equivalent of six ounces of 86 proof alcohol on that day.
The clinical/objectivist dichotomy is a fundamental one in the alcoholism field. Pendery takes the position of Alcoholics Anonymous, which considers alcoholism a disease. The Sobells, on the other hand, are part of a research tradition in psychology that approaches alcoholism as one of a variety of behavioral disorders. Since the disease concept has become the endorsed view of the medical establishment and of Alcoholics Anonymous, it has dominated the treatment field. Research defying the concept's defining principlethat alcoholics have a biological allergy that causes them to lose control whenever they drink, making moderate drinking impossibleis invariably attacked.
One study that brought on such opposition was the 1976 Rand Report. The Rand Corporation was commissioned by the National Institute on Alcohol Abuse and Alcoholism to analyze data that had been collected at the NIAAA's treatment centers. Initially examining 2,339 male alcoholics, and following up 597 of them 18 months later, Rand researchers found that 24 percent had been abstaining for a substantial period of time, compared with 22 percent who were drinking normally. (Note that these findings and the Sobells' are not comparable, since the people whom the Rand researchers studied were not being taught to drink moderately.)
On the morning that the report was released, the National Council on Alcoholism denounced it as being 'dangerous, misleading, and not scientific.' Thus began a campaign against the Rand Report and its results for which it is difficult to find a recent parallel in science. In response, the Rand researchers conducted an extensive four-year follow-up study. They broadened their sample, scrutinized their definitions, analyzed subgroups of subjects, and extended the period over which subjects were examined. Their conclusions upheld the viability of controlled drinking for all types of alcoholics. This version of the Rand Report suffered the unusual fate of having its results reinterpreted by its own funding body, the NIAAA, to the effect that 'those who were dependent on alcohol cannot go back to normal drinking.'
The fate of the Rand Report helps to explain why there is nearly unanimous acceptance of the disease concept of alcoholism despite some substantial empirical gaps in the theory behind it. Its chief drawback has been the failure to locate a biological basis for the alcoholic's inability to control his or her drinking. On the other hand, research has shown that cultural, social and cognitive factors play a crucial role in alcoholism. For example, alcoholics respond with alcoholic behavior when they are told that they are drinking liquor but are not, while they behave normally when they drink disguised alcoholic beverages. (See 'The Think-Drink Effect,' Psychology Today, December 1981.)
In Love and Addiction, I analyzed addiction in cognitive terms. One conclusion was that alcoholics are more likely to relapse after taking a drink if they believe that such a relapse is inevitable. Alan Marlatt and Judith Gordon, psychologists at the University of Washington, have developed a form of treatment, relapse prevention, in which clients are taught that they are capable of halting their consumption of alcohol, or any substance, at any point. In other words, a drink is a drink, and not a reason for abandoning self-restraint.
The assault on controlled drinking denies this possibility, and it has prevailed in forming the climate of opinion about alcoholism in the United States. According to Peter Nathan, a professor of clinical psychology at Rutgers University, no alcoholism center in the United States is using controlled drinking as official policy. In contrast, Heather and Robertson, the Scottish researchers, report that in the United Kingdom 'most treatment centres now accept the principle of controlled drinking.' This difference between the two countries in public policy is not the result of scientific inquiry. Rather, it reflects political forces and prejudice in America that forbid a reasonable discussion of the issues. The essential question is whether, in this atmosphere, we can find the best ways to combat alcoholism.