The Harvard Mental Health Letter, December 1991, pp. 5-7, reprinted in R. Hornby (Ed.), Alcohol and Native Americans (Rosebud, SD: Sinte Gleska University, 1994), pp. 91-94, with 1997 Afterword
What We Now Know About Treating Alcoholism and Other Addictions
Morristown, New Jersey
Private treatment for alcoholism and drug abuse expanded greatly beginning in the late 1970s. Between 1978 and 1984, the number of beds in private alcoholism treatment centers more than quadrupled. In the '80s, hospitalization of adolescents in private psychiatric facilities mainly for drug and alcohol abuse, jumped 450 percent. Treatment centers launched advertising campaigns to compete for middle-class patients, and private hospitals sent salesmen to canvass parents, schools, and communities for business. The treatment industry also relied increasingly on coercion; a growing number of referrals are mandated either by courts or by employee assistance programs. Private insurance and federal funding have paid for all this on the assumption the drug and alcohol abuse are aspects of a disease call "chemical dependency." The high cost (on one estimate, an average of $18,000 per hospital stay) is a major burden on our health care system.
The boom has receded slightly in the last few years, as skepticism about the present system grows and insurers and employee assistance programs look for less expensive alternatives. The case of Kitty Dukakis illustrates this new questioning attitude toward private treatment. She graduated "successfully" from the well-known Edgehill-Newport treatment center, appeared on the cover of People magazine, and spoke widely about the disease of chemical dependency. Then, as she relates in her autobiography, she suffered a series of near-fatal relapses. If Betty Ford's public endorsement of alcoholism treatment embodied the enthusiasm of the 1970s, Mrs. Dukakis's story suggests the more somber assessment of the 1990s.
As a sign of the times, one prominent skeptic is Enoch Gordis, MD, the director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). After studying a large hospital program that he himself administered, Gordis concluded that "contemporary alcoholism treatment is, at best, of limited effectiveness." In 1987 he wrote that "...our whole treatment system, with its innumerable therapies, armies of therapists, large and expensive programs, endless conferences....and public relations activities is founded on a hunch, not evidence, and not on science."
Effectiveness of Treatment Methods
According to a 1986 review by William Miller and Reid Hester, many methods commonly used in the treatment of alcoholismincluding AA, alcoholism education, individual counseling, group therapy, and disulfiram (Antabuse®)"lacked scientific evidence of effectiveness." No controlled study, they added, had found that residential treatment was better than much less expensive outpatient treatment. In an editorial in the Journal of the American Medical Association, Dr. Forest Tennant wrote that "any sophisticated critic using statistical analysis to measure treatment effectiveness is appalled by the display of a media or sports star claiming cure thanks to a specific treatment center's helpwhich proclaims 80 to 90 percent cure rates."
The treatment industry's spokespersons often claim that all untreated alcoholics end up dead, deathly ill, or in jail. In fact, studies show so much natural remission that one investigator calls alcoholics who recover on their own "the silent majority." George Vaillant, a psychiatrist who supports the disease concept of alcoholism, worked in what he called "the most exciting alcoholism program in the world." It consisted of hospital detoxification, compulsory AA attendance, and a counseling program based on the disease concept. Yet Vaillant had to admit that his patients fared no better after eight years than alcoholics who were left to their own devices! He reflected. "Perhaps the best that can be said... is that we were certainly not interfering with the natural recovery process."
Illicit drug abuse is no different. Researchers at the Addiction Research Foundation in Toronto found that many untreated middle-class cocaine users were able to cut back or quit on their own when they found that they had begun to lose control. Cocaine addicts and alcoholics often testify that tobacco is the hardest drug of all to give up, yet more than 40 million Americans have done so. During the 1980s, according to a survey conducted by the Centers for Disease Control, 47.5 percent of smokers who tried to quit on their own succeededtwice the success rate of those who used treatment programs.
Whether people succeed in overcoming an addiction may not be determined primarily by the treatment they receive. Vaillant notes that "the most important single prognostic variable associated with remission among alcoholics who attend alcohol clinics is having something to lose if they continue to abuse alcohol." Among Vaillant's own patients at an urban municipal hospital, many of whom had little to lose, 95 percent relapsed at some point after treatment. Another study of an inner-city hospital alcoholism ward, by John Helzer and his colleagues, found that 93 percent of the patients were either dead or still abusing alcohol five to seven years after treatment. Private treatment centers ordinarily show better outcomes, partly because their clients are more likely to have families, jobs, and incomes.
As the decisive influence of these social circumstances proves, alcoholism is not a "primary" illness whose course is determined solely by some inexorable internal mechanism. The same is true of other addictions. As clinical researcher Frank Gawin puts it, "If crack were a drug of the middle or upper classes, we would not be saying it is so impossible to treat."
Training in Life Skills
The best way to discourage addictive behavior is to show people how to meet the demands of life without drinking or drug use. Miller and Hester found that the most effective programs provided alcoholics with training in stress management and self-control, social and negotiation skills, job skills, and work habits. The most successful program for hospitalized alcoholics ever evaluated is the community reinforcement approach, which systematically trains alcoholics in job and marital skills while arranging a work and home environment that sustains and rewards sobriety.
This social and behavioral approach is more common in drug treatment. Many therapeutic communities (TCs), for example, reject the idea that drug addiction is a disease and instead inculcate positive social attitudes and skills. The National Treatment Outcomes Prospective Study found that TCs and other public drug treatment programs often succeeded (no private centers were studied). The same study, however, found that public alcoholism programs were generally unsuccessful.
At the same time, more private alcohol treatment programs may be adopting the skills training and environmentally oriented approaches found most successful in clinical trials. A recent comparative study published by Diana Walsh and Ralph Hingson has found an advantage in private hospital treatment for the first time. Two groups of workers referred by employee assistance programs in Boston were assigned randomly either to AA or to various private inpatient programs. A third group of workers was allowed to choose primarily between AA and the hospital program. Two years later, drinking problems had improved most in the inpatient group and least in the AA group.
But the studies did not include a systematic outpatient or skills-training program, or a control group receiving no treatment. And even in the inpatient group only slightly more than a third of alcoholics abstained for the entire two yearsa rate much lower than those typically claimed by private treatment centers and AA. Finally, job performance was about the same in the three groups after treatment, which suggests that it would be most cost-effective for an employer simply to notify an employee about the problem and let him or her decide how to deal with it.
Any review of alcoholism treatment programs reveals how little of a medical nature is actually done for this so-called disease. Some genetically oriented researchers, like Kenneth Blum, maintain that we will soon be able to treat alcoholics and addicts with drugs that reverse their neurochemical deficiencies. No evidence to date suggests longterm reversals of addiction by this method; an independent controlled study found no positive effects of Blum's own amino acid therapy.
To sum up, here are some suggestions:
- Broaden the range of alcohol abuse services to eliminate the total dominance of the disease concept and of AA-based and inpatient treatment.
- Emphasize cost-effectiveness: find the services that accomplish the most per dollar and spend more on them.
- Devote much more effort to studying the example of people who quit or cut back on their own.
- Fund more research on the outcome of various treatments (the NIAAA and the National Institute on Drug Abuse have embarked on such programs.)
- Conduct more process research to observe what various treatment programs actually do, whatever labels they use.
- Consider drinking behavior in the context of a person's overall social functioning, including work, family, recreational, and community life.
- Emphasize the teaching of skillsjob training, communication skills training, stress management, marital counseling, and problem solving.
- Match patients to treatments. Instead of telling people who refuse conventional treatment that they are "in denial," build on their preferences to facilitate recovery.
- Try minimal intervention first, especially for the young, people who overindulge periodically, and other less severely impaired drinkers.
- Acknowledge controlled drinking as an acceptable goal. Almost alone among industrial nations, the American system demands total abstinence of all alcoholics. But most alcohol abusers never stop drinking entirely, and the evidence suggests that controlled drinking is a more attainable goal for some problem drinkers, just as abstinence works best for many.
- Instead of spawning a corps of accredited alcoholism counselors, often recovering alcoholics whose professional knowledge consists entirely of AA testimonials and twelve-step bromides, transfer much of the responsibility for treatment, especially in non-acute cases, to primary health care and community workers (who may also receive some specialized training).
In its 1990 report entitled Broadening the Base of Treatment for Alcohol Problems, the Institute of Medicine makes recommendations similar to these. Perhaps the endorsement of this prestigious body indicates that a critical mass has finally been reached for the creation of a pluralistic system of alcoholism treatment.
The editor of The Harvard Mental Health Letter, Lester Grinspoon, told me that this article provoked more negative feedback than he had ever received. In order to make sure that no one was misled by the article, Grinspoon quickly published a response by the ubiquitous John Wallace, who during this period responded to everything I wrote. Entitled "The Value of Alcoholism Treatment" (The Harvard Mental Health Letter, May 1992, pp. 4-5), the rejoinder begins:
According to Stanton Peele..., we "now know" the following about alcoholism treatment: 1. Controlled drinking should be a widely accepted goal. 2. Alcoholics Anonymous and related programs have not been shown to be effective. 3. Treatment is so expensive and widely used that it constitutes a major burden on our health care system. 4. Spontaneous remission and "natural recoveries" are so common that treatment is probably unnecessary. 5. Except for a few behavioral techniques, most current treatment methods and programs are not effective, and inpatient treatment is especially inefficient.
The evidence contradicts Peele's views on all these counts.
1. Controlled Drinking. The belief that alcoholics and other addicts can be taught to control the level of intoxication in their brains persists despite a long history of shoddy research, charges of scientific fraud, and failure to confirm initial findings....
Within only a few years, Wallace's center (Edgehill-Newport, which I described in my article in relation to Kitty Dukakis's treatment) was closed because insurers found it did not provide cost-efficient treatment, and all of my list of recommendations for alcoholism treatment and research were to a greater or lesser degree enacted.