In the popular science periodical put out by the New York Academy of Sciences and the newsletter of the addiction division of the American Psychological Association, Stanton turns Project MATCH and other NIAAA and mainstream research on their ears to show that alcoholism cannot be dealt with as a medical disease. Instead, such research shows, even highly dependent drinking is an interchange between drinker and environment, shifts considerably over time, allows for moderated drinking, does not particularly respond to treatment (and almost not at all to standard, overly-aggressive 12-step therapy that dominates the American treatment scene), and responds best to brief helping interactions in which the drinker is the principal actor.
In the APA Division 50 newsletter, the president of Division 50 states, "Project MATCH delivered what it was paid to do," while Richard Longabaugh, who commented on Stanton's paper, noted, "This response is undertaken with considerable apprehension as it has been my impression over the years that offering a view at variance with Dr. Peele's is rarely 'a day at the beach.'" Please note the remarkable points of concurrence between the views Stanton expresses and those expressed by William Miller in his David Archibald Lecture, (see Addiction, 93:163-172, 1998).
The Sciences, March/April, 1998, pp. 17-21
All Wet
The gospel of abstinence and twelve-step, studies show, is leading American alcoholics astray
Stanton Peele
The week before Christmas 1996, as people dashed to the liquor store for reinforcements and clinked their glasses at holiday parties, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) convened a press conference in Washington, D.C. The purpose was to herald the findings of Project MATCH, a government study devised to learn whether certain kinds of alcoholics respond best to specific forms of psychotherapeutic treatment. For example, twelve-step therapy and Alcoholics Anonymous (AA)—based in part on lifelong abstinence and personal surrender to a "higher power"—might work best for those seeking spiritual and religious meaning in their lives. Coping-skills therapy could help antisocial and emotionally disturbed alcoholics. And motivational therapy might best suit drinkers who show little desire for improvement, by spurring their desire to change.
Project MATCH had taken eight years to design and execute and had cost $27 million—the biggest and most expensive psychotherapy study ever mounted. It had encompassed thirty treatment sites and eighty therapists throughout the United States, along with dozens more of the country's most experienced investigators in alcoholism treatment, who had supervised and analyzed the study. The results of MATCH, much anticipated, promised to set firm guidelines for the therapy best suited to the particular needs of any given problem drinker.
Enoch Gordis, a physician and the director of NIAAA, stepped up to the microphone. "The good news is that treatment works," he announced. The therapies tested in Project MATCH all led to "excellent" overall results, he said.
But Project MATCH failed to find the links its organizers and most other alcoholism investigators had expected. The results showed virtually no differences in drinking reduction attributable to matching a patient's traits with a specific treatment. In fact, few clinical trials exist to show that the most popular American treatment for alcoholism, the twelve-step approach, is effective at all. Moreover, the results of both Project MATCH and a major 1996 NIAAA study showed that most people who had once struggled with alcohol abuse could later cut down on their drinking—a result that is anathema to the devotees of AA, to the U.S. medical establishment and to the American way of temperance.
Last December the MATCH collaborators published a further analysis of their study in the British journal Addiction, which basically repeated their earlier conclusions. Thus the group's official position remains the same as a year ago: All is well with alcoholism treatment in America. In that view, whatever therapy people are pushed toward—which in the United States effectively means a twelve-step program with the aim of total abstinence—they will be fine. Such an outlook, Gordis's overoptimistic interpretation notwithstanding, represents a public-relations triumph for the alcohol-treatment industry in America. But the blanket assurance that "treatment works" does precious little for most people who drink too much.
I'LL CALL HER ALICE (NOT HER REAL NAME). She is a woman I interviewed who tasted liquor for the first time in college and promptly went on party alert. She dropped out of school and drank heavily throughout her early twenties. Three to five times a week she got drunk, both alone and with a shifting cast of friends. During one nine-month binge and for several shorter stretches she drank virtually every night, polishing off nearly a pint of Scotch before she went to bed. Several times during her decade of drinking she was homeless.
Nevertheless, when she went home to visit her parents, sometimes for a couple of weeks, there was a major change in Alice's behavior. All she drank was wine over dinner with her father (her mother was a teetotaler). She did not want her parents to know how badly she was messing up her life; she controlled herself so she would not lose their love and support.
Alice had attended a few AA meetings, but she found the confessional atmosphere stultifying and oppressive. The turning point for her came when, at age twenty-nine, she got a job as a receptionist in a dentist's office. The dentist reminded her of her father, a pharmacist; he was a new authority figure she wanted to please. She began spending her spare time with her coworkers—people who did not abuse alcohol. Alice realized she wanted to be like them: steady and productive. She took classes to become a dental hygienist, and she began drinking in moderation, wine with dinner only. In short, Alice's new job and new friends helped jump-start her desire for a stable life.
Alice is in her forties now, married with children, and still drinking moderately. Her case may sound unique: an alcoholic who recovered without treatment and who continues to drink. In fact, her story is typical of former alcoholics in the United States, according to NIAAA research. Indeed, Project MATCH, while finding no difference in results based on the kind of treatment received, did find that personal motivation and the drinking behavior of peers made a significant difference in a patient's success.
Alice and others like her demonstrate the need for a treatment focus besides AA and similar twelve-step programs. In the United States, unlike most other Western countries, alcoholism therapy clings to abstinence as the only acceptable goal. (In Britain and Australia, for instance, controlled drinking as a treatment goal is widely accepted.) According to a 1997 survey by the sociologists Paul M. Roman of the University of Georgia in Athens and Terry C. Blum of the Georgia Institute of Technology in Atlanta, nearly 99 percent of the treatment programs in the United States advocate abstinence.That black-and-white view of alcoholism stems not from scientific evidence but from attitudes forged in the early nineteenth century, a topic I have discussed previously in this magazine [see "The New Prohibitionists," March/April 1984, and "Ain't Misbehavin'," July/August 1989]. Drinking in colonial America was widespread, accepted and overwhelmingly benign. But as the American frontier expanded, between 1790 and 1830, healthy social customs began to warp. Taverns, once places for entire families to gather, became male preserves in which the only women likely to be present were prostitutes. In such an atmosphere of male independence, alcoholism rates rose dramatically. In response, the Anti-Saloon League and similar temperance organizations flourished, culminating in Prohibition in 1919.
Prohibition collapsed in 1933. But it did not die—it simply moved off the streets and into the hospitals. In the eighteenth century the Philadelphia physician Benjamin Rush had propounded the idea that the chronic drinking of hard liquor causes a specific disease, one that makes it impossible for the drinker to imbibe moderately. Rush's idea took hold. By the latter half of the twentieth century, both AA and the American medical establishment had elaborated it into the theory that some people have an inbred susceptibility to alcoholism. The disease theory of alcoholism and its attendant focus on abstinence became orthodoxy in the United States.
THE MEDICALIZATION OF ALCOHOL ABUSE HAS spawned much interest in fine-tuning treatments for the problem. Project MATCH (which stands for Matching Alcoholism Treatments to Client Heterogeneity) was not the first effort to assess alcoholism therapies; a team led by the psychologist William R. Miller of the University of New Mexico in Albuquerque has been examining many smaller such studies for two decades. In 1995 Miller and his colleagues rated forty-three kinds of treatment by combining the results of 211 controlled trials that had compared the effectiveness of a treatment with either no treatment or with other alcoholism therapies. The treatment with by far the best overall score was "brief intervention"—followed by social-skills training and motivational enhancement.
Brief intervention shares elements with motivational enhancement, one of the treatments tested by Project MATCH, in that the patient and the therapist create a mutually agreed-upon goal. In brief intervention, the goal is usually reduced drinking; in motivational enhancement, it is either reduced drinking or total abstinence.
In a brief-intervention session, the health-care worker simply sums up the goal: "So we agree you will reduce your drinking from forty-two drinks a week to twenty, no more than four on a given night." Motivational enhancement is a bit more subtle: the therapist nudges, though does not direct, the patient's own values and desire for change. The dialogue in a motivational- enhancement session might go like this:
THERAPIST: What is most important to you?
PATIENT: Getting ahead in life. Getting a mate.
T. What kind of job would you like? What training would that take?
P. [Describes.]
T. Describe the kind of mate you want. How would you have to act, where would you have to go, to meet and deal with a person like that?
P. [Describes.]
T. How are you doing at achieving this?
P. Not very well.
T. What leads to these problems?
P. When I drink, I can't concentrate on work. Drinking turns off the kind of person I want to go out with.
T. Can you think of any way to improve your chances of succeeding at work or with that kind of mate?
Yet those same therapies ranked at the bottom of the Miller team's list, with far less proof of their effectiveness than other treatments. The conclusion, then, is startling: The most frequently used therapies in American alcoholism treatment are those for which there is the least evidence of success.
THE 1996 NIAAA STUDY MENTIONED EARLIER was also surprising. That study stemmed from the National Longitudinal Alcohol Epidemiologic Survey (NLAES), conducted in 1992 by the U.S. Census Bureau. Census field workers did face-to-face interviews with nearly 43,000 respondents across America, a general sample of U.S. adults eighteen years of age and older. Each interview probed the use of alcohol and drugs over a person's entire life, with a focus on the preceding year.
Deborah A. Dawson, an NIAAA epidemiologist, then analyzed interviews with 4,585 NLAES subjects who had at some time in their lives been alcohol dependent (the most severe diagnosis of an alcohol problem). Only a quarter of the group Dawson studied had ever been treated for alcoholism; those people had had somewhat worse drinking problems initially than the ones who had gone untreated. In the year before the interviews, about a quarter of all the subjects still had mild to severe alcohol problems; a similar proportion had not touched a drop; and the rest had drunk without abuse.
Those who had received some kind of treatment were slightly more likely than their untreated counterparts to have had a drinking problem in the previous year, Dawson reported in the June 1996 issue of the journal Alcoholism: Clinical and Experimental Research. For those whose alcohol dependence had first appeared in the preceding five years and who had been treated, 70 percent had had a drinking problem in the past year. For those whose drinking problems had emerged twenty years or more before, twice as many of the treated alcoholics as the untreated ones were still abusing booze (20 percent versus 10 percent). Among the long-term group, fully 60 percent of the untreated subjects had reduced their drinking to the point where they had no diagnosable problem.
On the basis of a study such as Dawson's, in which the treated and untreated groups differed in the initial severity of their problems, it would not be fair to claim that therapy leads to worse results than no therapy. But the finding that so many treated alcoholics still had a drinking problem, while so many untreated alcoholics could moderate their drinking over time, certainly contradicts the impression created by the MATCH report, as well as popular American ideas about alcoholism.
WHY DOES MILLER'S AND DAWSON'S RESEARCH indicate that current treatments are ineffective, whereas MATCH purportedly showed that treatment works so well? It is worth taking a closer look at Project MATCH, to discover just what it did and what it found.
The MATCH results were published directly after the NIAAA press conference, in a detailed report in the January 1997 issue of Journal of Studies on Alcohol. The complicated design of MATCH included two groups of patients: an outpatient group and an aftercare group, made up of outpatients who had recently received hospital treatment. The patients were not deliberately matched to a treatment at the outset. Rather, each patient was assigned randomly to a treatment, and the success of the match was measured afterward on the basis of how well that person fulfilled predictions of success for that treatment, according to his or her personal traits.
Twelve-step and coping-skills treatment were each scheduled in twelve weekly sessions; motivational-enhancement therapy involved four sessions spaced over the twelve-week period. The year of follow-up showed comparably good results for all treatments. Before treatment, the subjects imbibed, on average, on twenty-five days out of thirty; that number fell to six days of drinking a month by the end of follow-up. The amount consumed on drinking days also dropped markedly after treatment.
Going deeper into the MATCH methodology shows why its results could differ so dramatically from those of other research. Virtually all the subjects were alcohol dependent. But people simultaneously diagnosed with a drug problem were excluded from the study. The implications of that exclusion are substantial. According to a survey of treatment admissions published last year by the Substance Abuse and Mental Health Services Administration in Rockville, Maryland, the combined abuse of alcohol and drugs is the most frequent problem for patients at the time of admission to treatment for substance abuse. On that ground alone, the statistical validity of extrapolating from the Project MATCH sample to the alcohol-abuser population as a whole is seriously compromised.
But much more than that was going on in the selection of subjects for MATCH. Initially, 4,481 potential subjects were identified; fewer than 1,800 of them were actually included. The MATCH participants were volunteers. Yet in real life, patients are increasingly being referred for treatment by the courts, by their employers or by social agencies. They are threatened with prison, loss of a job or loss of benefits if they do not get help. Furthermore, Project MATCH dropped potential subjects for reasons such as lack of a permanent home address and for legal or probation problems. Others declined to participate because of the "inconvenience" of treatment. Compared with the volunteers excluded from the study, those who participated in MATCH were motivated, stable and free of criminal or severe drug problems—all of which predict a greater likelihood of success.
Not only were the patients in MATCH atypical, but they did not receive typical alcoholism treatment. Counselors were carefully selected and trained. Each treatment session was videotaped, and the tapes were monitored by supervisors. The quality of the treatments in MATCH seems to be a far cry from that of standard treatment programs in the United States. In such programs the counselors are generally former alcoholics themselves, whose subsequent training has exposed them only to more of the therapy they received—namely, the twelve-step philosophy.
In The Truth About Addiction and Recovery, a book I cowrote in 1991 with Archie Brodsky, a senior investigator in the psychiatry department at Harvard Medical School, we noted that twelve-step treatment is typically delivered in an authoritarian, directive fashion. Patients are told their behavior is wrong and their lives are not working, and they are lectured to quit drinking. Such behavior on the part of the therapist does not jibe with effective therapy, which helps patients to "own" their problems and participate in the solutions. For that reason patients in alcoholism treatment are regularly tagged as being "in denial." In our experience, when their values and perceptions are respected, patients are more willing to identify and address their problems rather than fight the process of treatment.
Yet twelve-step therapy could be delivered in many ways. One wonders whether the success of that treatment in MATCH arose in part from a style of twelve-step therapy different from the one in standard treatment programs. Unlike AA, the MATCH twelve-step treatment did not rely on group support; instead it concentrated on individual therapy sessions. The MATCH results, then, may point to the critical importance of the therapist's style of practice. Although MATCH did not find plug-in solutions, it did find that treatment success differed significantly depending on where the patients got help. That suggests that certain training programs, counselors and supervisors offer far better help than others, regardless of the kind of therapy they practice. Thus the research eye might do better to focus on how superior counselors deliver their therapy, whatever name that therapy goes by.
OTHER RESULTS OF PROJECT MATCH ALSO challenge standard assumptions about alcoholism. The treatments that led to such excellent results required only about eight hours of outpatient therapy (the subjects, on average, attended only two-thirds of their scheduled twelve sessions). Yet the National Council on Alcoholism and Drug Dependence recommends hospital stays of several days for alcohol-dependent patients in the United States.
Although all the MATCH treatments led to equivalent results, not all were equal in effort and expense. The results of motivational enhancement were as good as those of the other therapies, but they required only a third as many sessions. And many studies show that even fewer sessions can be beneficial. Brief intervention is often restricted to a single session and follow-up. Although brief-intervention therapy has generally been reserved for nondependent alcohol abusers, several studies have looked at minimal treatments for people who are alcohol dependent. For example, in 1977 the psychiatrist Griffith Edwards and his colleagues at the Addiction Research Unit (now the National Addiction Center) of London's Maudsley Hospital compared a full hospital treatment program with a single advice session for an alcoholic population. No differences in outcome were found. Comparable studies conducted throughout the 1980s in Missouri, New Zealand and Canada confirmed that conclusion.
But perhaps the biggest heresy that MATCH supports—inadvertently so—is the value of reduced drinking as a goal in alcoholism treatment. The MATCH organizers chose to present their success in terms of the number of drinking days and the amount imbibed on those days. They did not trumpet the news of their subjects' abstinence rates. That figure was not particularly impressive: about 20 percent of the outpatient group and 35 percent of the aftercare group abstained throughout the follow-up period. Yet in the outpatient group, a third drank without bingeing.
The data from Project MATCH and other mainstream research conflict in many ways, but they make this much clear: Since the majority of alcoholics do not stop drinking, whether treated or untreated, whether measured in the general population or following a gold-standard set of treatments, the ironclad insistence on abstinence as the only goal of therapy is perverse indeed.
Those who treat alcoholics—and American society as a whole—need to recognize that the aim of reduced drinking may be the best and only achievable goal for many alcoholics. Clinicians must also develop alternatives to traditional therapies—treatments that could well be briefer and less expensive than the ones now in use. Above all, everyone must acknowledge that alcoholics are not powerless. With the right resources, more often than not they hold the keys to their own recovery.
