Ten Radical Things NIAAA Research Shows About Alcoholism

Written by Stanton Peele

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).

Palm eBook

The Addictions Newsletter (The American Psychological Association, Division 50), Spring, 1998 (Vol 5, No. 2), pp. 6; 17-19.

The National Institute on Alcohol and Alcoholism's (NIAAA) Project MATCH is the most elaborate clinical trial of psychotherapy ever conducted—in its ninth year, it has cost 30 million dollars and has involved most of this country's prominent clinical alcohol researchers. MATCH tested the hypothesis that alcohol treatment outcomes could be significantly improved by matching alcoholics on relevant dimensions with appropriate treatments. MATCH did not actually match alcoholics with treatments, but conducted a multivariate analysis on outcomes as predicted by a variety of traits in interaction with undergoing one of three types of treatment: Twelve-Step Facilitation (TSF), Cognitive-Behavioral Coping Skills Therapy (CBT), and Motivational Enhancement Therapy (MET).

MATCH results were reported in a long article by the collective Project MATCH Research Group (1997). None of the three treatments produced better outcomes overall, nor did any treatment produce better results for alcoholics with any given profile. Nearly all subjects were DSM-III-R alcohol dependent. Treatment was 12 weeks on an outpatient basis (for a purely outpatient group and a hospital treatment aftercare group), and patients were followed up for a year. Ten primary client characteristics were reported (e.g., motivation, psychiatric severity, gender). Outcomes were measured as days abstinent and drinks per drinking day. Among 64 tested interactions—16 proposed patient/treatment interactions by outpatient versus aftercare treatment by 2 outcome measures—one proved significant: in the outpatient group only, less psychiatrically severe subjects had 4 more abstinent days per month on average in TSF than in CBT treatment.

The idea of patient-treatment matching has for some time been regarded as the cutting edge in alcoholism treatment. The failure of MATCH's primary analysis to confirm the matching hypothesis revealed more than methodological oversights or the need for further analysis. It, along with other NIAAA and alcoholism research, shows that American conceptions of alcoholism and treatment policy are fundamentally wrong.

(1) The objectivist medical approach to alcoholism treatment does not work. Although psychologists were the primary movers in MATCH, MATCH typifies the modern medical approach to alcoholism which NIAAA director Enoch Gordis has promoted. In its aftermath, Gordis concluded, "Treatment matches may become apparent when we get to the core of the physiological and brain mechanisms underlying addiction and alcoholism." The idea underlying matching is often appropriate in medical treatment, but the failure to find benefit from matching contravenes the value of matching alcoholics to treatment based on their objective traits and symptoms. An alternate psychological approach is to allow alcoholics to select treatment types and goals based on their values and beliefs. Research by psychologists like Heather, Winton, and Rollnick (1982), Heather, Rollnick, and Winton (1983), Orford and Keddie (1986), Elal-Lawrence, Slade, and Dewey (1986), and Booth, Dale, Slade, and Dewey (1992), none American, has shown the superiority of subjective over objective matching, although this approach is not part of American alcoholism treatment.

(2) Individual and situational variables are more important for alcoholism outcomes than treatment variables. MATCH uncovered significant individual and setting factors including motivation and the drinking behavior of cohorts. In other words, MATCH found that outcomes of alcoholism were the results of who people are, what they want, where they reside, and who they spend time with. Alcoholism cannot productively be addressed like medical illnesses by relying on a strict diagnostic-treatment protocol.

This phenomenon is apparent in the overall results of MATCH. In several public presentations, MATCH researchers highlighted the overall improvement of patients, noting that subjects on average reduced drinking from 25 to 6 days per month and drank less on these days. However, this improvement occurred with alcoholics who were not typical of alcoholism patients in the United States. To start with, prospective subjects with simultaneous diagnosable drug problems were eliminated although, according to SAMHSA's (1997, February) national treatment admissions census (TEDS), "combined alcohol and drug abuse. . . [is] the most frequent problem at admission to substance abuse treatment."

Many additional filters were introduced by both the subjects and the researchers. Of 4,481 potential subjects identified, fewer than 1800 ultimately participated in MATCH. MATCH participants were volunteers, which places them at odds with the many coerced treatment referrals by the courts, employers, and social agencies. The MATCH team also eliminated potential subjects for reasons like "residential instability, legal or probation problems," etc. Another 459 potential subjects declined to participate because of the "inconvenience" of treatment. Subjects who actually participated in MATCH were more motivated, stable, noncriminal, and free of drug problems—all of which indicate greater likelihood of success. Thus overall MATCH results, like the MATCH analysis itself, illustrate that patients and their lives outside of treatment are more critical to alcoholism treatment results than the nature of their therapy.

(3) The characteristics of therapists and of interactions between patients and therapists are more important than type of treatment in alcoholism outcomes. While treatment type was not significant in MATCH, treatment site and site by treatment type effects were. In other words, the way particular therapists interacted with alcoholics had a substantial impact on patient outcomes whereas the label of the therapy they practiced did not.