Standard American Treatment Is Not As Worthwhile As People Think

Excerpted from an article by Stanton Peele about the Project MATCH study of alcoholism treatment

(4) Alcoholism treatment in the United States is not notable for its success. Gordis's fundamental summary of MATCH was that while its findings "challenge the notion that patient-treatment matching is necessary for alcoholism treatment, the good news is that treatment works" (emphasis added; Bower, 1997). But MATCH could make no categorical statements about the impact of treatment since it had no untreated control comparison. Moreover, so much about the MATCH clinical trial was unique that there is little reason to assume its results generalize to alcoholism treatment at large in the United States. On the other hand, the NIAAA has conducted a thorough assessment of treated and untreated remission rates as experienced in the general population—the National Longitudinal Alcohol Epidemiologic Survey (NLAES)—based on face-to-face interviews about drug and alcohol use and treatment and concurrent emotional problems.

The NIAAA's Deborah Dawson (1996) analyzed over 4,500 NLAES subjects whose drinking at some point in their lives qualified for a diagnosis for alcohol dependence (DSM-IV). Treated alcoholics were more heavily alcohol dependent on average than untreated alcoholics and, according to the NIAAA's Bridget Grant (1996) in the same journal volume, to also have a drug problem (thereby distinguishing these from MATCH subjects). NLAES found that a third of treated (and 26% of untreated) subjects were abusing or dependent on alcohol in the past year. Of those whose alcohol dependence appeared within the last five years, 70 percent who received treatment were drinking alcoholically in the past year. Although population differences color comparisons between treated and untreated outcomes in NLAES, the results nonetheless show that alcoholics undergoing treatment in the United States do not experience the reliable improvement rosily reported by NIAAA/MATCH officials. (See attached table.)

(5) American twelve-step treatment is of limited usefulness. Any documented success of twelve-step treatment would reflect well on American alcoholism treatment, since Roman and Blum (1997), in their National Treatment Center Study, found that 93 percent of drug and alcohol programs follow the twelve-step program. Margaret Mattson (1997), a principal NIAAA MATCH coordinator, declared: "The results indicate that the Twelve Step model, . . . the most widely practiced . . . in the US, is beneficial." But this conclusion is not consistent with a meta-analysis of all available controlled alcoholism treatment studies reported by Miller et al. (1995). Unlike MATCH, Miller et al. found that alcoholism treatments were clearly differentiated in terms of their demonstrated effectiveness, with brief interventions ranked first, followed by social skills training and motivational enhancement. Ranked at the low end were confrontation and general alcoholism therapy. The two tests of AA found it inferior to other treatments or even no treatment but were not sufficient to rank AA reliably.

Remarkably, Miller et al. noted a strong inverse correlation between the popularity of treatments practiced in the US and the evidence that these treatments work, with the typical program comprising "a spiritual twelve-step (AA) philosophy . . . and . . . general alcoholism counseling, often of a confrontational nature," usually administered by former substance abusers. That this conventional treatment is not effective is consistent with NLAES results, although not with the impression created by MATCH.

(6) TSF in MATCH differed from standard twelve-step treatment, which is overly directive and otherwise poorly delivered. Treatment in MATCH was not the same as treatment in the field. Manuals were developed and counselors carefully selected and trained, each treatment session was videotaped, and the tapes were monitored by supervisors. Jon Morgenstern, as part of a Rutgers research project which has observed standard treatment providers, has noted that they offer very poor quality therapy. One way in which usual twelve-step therapy might differ from its MATCH version is that it is often highly directive (to the point of being abusive).

(7) The most cost-effective therapy for any severity alcohol problem is brief interventions/motivational interviewing—that is, short-term, nondirective treatment. In both brief interventions and motivational interviewing, therapies found most effective by Miller et al., patients and counselors jointly discuss the patient's drinking habits and consequences in a nonjudgmental way that focuses the patient on the value of reducing or quitting drinking. Meanwhile, Motivational Enhancement Therapy would be the recommended treatment based on MATCH because it produced equal results at far lower cost. TSF and CBT were designed to be 12 weekly sessions while MET was designed to be only four sessions. However, MATCH patients on average attended only two-thirds of their sessions, so that MET in MATCH approached brief interventions. That the briefest treatment in MATCH worked as well as more extensive treatments challenges conventional wisdom that brief interventions are inappropriate for alcohol-dependent patients.

(8) Elaborate alcoholism treatment is not necessary for recovery; most alcoholics in the United States recover without treatment. MATCH indicated that people who seek to overcome alcoholism and have a supportive social environment can well do so with brief therapeutic interactions that focus their motivation and resources on improving their lives. The NLAES analysis of untreated alcoholics shows (a) that most alcoholics do not seek treatment and (b) that most of these stop abusing alcohol (Dawson, 1996).

(9) Nonabstinent remission is standard for American alcoholics. Not only do most alcoholics improve significantly without treatment, but they typically do so without quitting drinking. According to NLAES, from five years following a dependence diagnosis on, a majority of ever-alcohol-dependent people in the US are drinking without manifesting alcohol abuse/dependence. Untreated alcoholics are more likely to be in remission than treated alcoholics at all points since dependence onset because, although they are less likely to abstain, they are far more likely to drink without diagnosed problems.

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Stanton Peele, Ph.D. is a psychologist and attorney with a special interest in addiction and treatment. He has been awarded the Mark Keller Award from the Rutgers Center for Alcohol Studies and the Alfred Lindesmith Award from the Drug Policy Foundation, and is currently a consultant for the International Center for Alcohol Policies in Washington, D.C.