Why and by Whom the American Alcoholism Treatment Industry is Under Siege

Written by Stanton Peele

In this barn-burner, Stanton stands alone in protecting the likes of Alan Marlatt, Peter Nathan, Bill Miller et al. from the onslaughts of John Wallace in his war on the "Anti-Traditionalists." One in a series of exchanges between Peele and Wallace, this is an important historical document. For example, it recounts how Peter Nathan, Barbara McCrady, and Richard Longabaugh's chapter on treatment in the Sixth Special Report to Congress was rewritten by Wallace. But it is also tremendously important for predicting and evaluating current developments in treatment and treatment evaluation. Of course, shortly after the article appeared, and despite Wallace's claims for its remarkable treatment success, the Edgehill-Newport clinic closed because insurers refused to pay its bills as a result of Stanton's articles. Since this time, however, Longabaugh now sides with Enoch Gordis in saying that current treatments (including the 12-step variety Wallace practiced at E-N) are great!

Moreover, in this forward-looking document, Stanton describes the concept of harm reduction by indicating that severely dependent alcoholics who may not abstain can still show improvement. And, in light of Gordis, Longabaugh, et al.'s tap dancing on the results of Project MATCH, do consider Gordis's quote, cited in this article, that "To determine whether a treatment accomplishes anything, we have to know how similar patients who have not received the treatment fare. Perhaps untreated patients do just as well. This would mean that the treatment does not influence outcome at all...."

Journal of Psychoactive Drugs, 22(1):1-13

Morristown, New Jersey

Abstract

Conventional disease-based inpatient alcoholism treatment is under attack in the United States and internationally because it accomplishes little beyond simple counseling and is less effective than other life-skill-oriented therapies. Nonetheless, disease-model adherents retain a stranglehold on American alcoholism treatment and attack all "nontraditionalists" who question their approaches. One such attack by Wallace (1989) is discussed. In addition, Wallace's claim that his treatment program at Edgehill Newport as well as other private treatment centers have remission rates ten times as high as those found for typical hospital treatments is examined critically. Finally, the group of researchers who question at least some elements of the standard wisdom about alcoholism and addiction is found to include nearly every major research figure in the field.

Keywords: alcoholism, controlled drinking, disease model, remission, treatment, outcome

In his response to my article in this journal (Peele 1988), John Wallace (1989: 270) casts himself as an upholder of scrupulous science and an open-mindedness toward critics as long as they do not perform "marginal scholarship, ideology masquerading as science, and faulty experiments." However, in his articles titled "The Attack of the Anti-Traditionalist Lobby" and "The Forces of Disunity," Wallace (1987a: 39; 1987c: 23) addressed his Professional Counselor readers about other concerns:

Obviously, it is in the interests of alcoholism counselors to pay greater attention to the politics of alcoholism and to appreciate the inroads the "Anti-Traditionalist" lobby already has made into universities, research centers, academic journals, and large government agencies ....

These forces of disunity tried first to divide the alcoholism field over the issue of controlled drinking, and then through various attacks upon sobriety, on the disease model of alcoholism . . . on the concepts, principles, and activities of Alcoholics Anonymous. Now it appears that the target has become the still emerging and fragile comprehensive system of alcoholism treatment services.

Among the members of the antitraditionalist lobby (in addition to me) Wallace named in his Professional Counselor articles are Alan Marlatt (Director of the Addictive Behaviors Research Laboratory at the University of Washington), William Miller (Professor of Psychology and Psychiatry and Director of Clinical Training at the University of New Mexico), Peter Nathan (Director of the Rutgers Center of Alcohol Studies), Martha Sanchez-Craig (Senior Scientist at the Ontario Addiction Research Foundation), and Nick Heather (Director of the Australian National Drug and Alcohol Research Centre). Wallace (1987b: 25) declared that his intention was to "scrutinize more closely the activities of this group and to take steps to ensure they do no harm." The following are some quotes from this group that Wallace (1987a; 1987b) criticized:

Given that the only clear, significant overall difference between residential and nonresidential programs is in the cost of treatment, it would seem prudent for public and private third-party payers to enact policy that de-emphasizes the hospitalization model of care where it is nonessential and encourages the use of less expensive but equally effective alternatives—(Miller & Hester 1986b: 803)

[The behavior of alcoholics results from their belief] that craving and loss of control are inevitable components of alcoholism rather than simply [from] the pharmacologic impact of alcohol. The realization grows that what we think and what we believe in and what we are convinced of is much more important in determining our own behavior than [is] a narrow physiologic response—(Nathan 1985: 171-172)

[Alcoholics Anonymous] preaches a doctrine of total redemption, teetotaling forever. And many a former alcoholic believes that a single drink will send him on the short, slippery slope to alcoholic hell. It's true that for some alcoholics who have been uncontrolled drinkers for many years and whose health has deteriorated, the option of moderation is no longer workable. However, the resolution never to have a drink again is not always a cure-all. The vast majority of alcoholics who try to abstain eventually return to the bottle or to another addiction—(Peele 1985: 39)

A radical alternative to development of surreptitious methods of early identification [of drinking problems to be treated] is to provide treatment services that would appeal to persons with less severe problems and to rely upon them to identify themselves. If those presenting for treatment were willing volunteers rather than apprehended "deniers," there might be better outcomes —(Sanchez-Craig 1986: 598)

However, the critics of traditional treatments of alcoholism include more powerful and influential objectors than me or any of the other researchers Wallace quoted. Consider the following statement from Enoch Gordis (1987: 582), director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA):

Yet in the case of alcoholism, our whole treatment system, with its innumerable therapies, armies of therapists, large and expensive programs, endless conferences and public relations activities is founded on hunch, not evidence, and not on science... ...Contemporary treatment for alcoholism owes its existence more to historical processes than to science...

After all [many feel], we have provided many of our treatments for years. We really are confident that the treatment approaches are sound... Yet, the history of medicine demonstrates repeatedly that unevaluated treatment, no matter how compassionately administered, is frequently useless and wasteful and sometimes dangerous or harmful.

Wallace vigorously defends the disease model of alcoholism, but he is wrong on the evidence. This article addresses this evidence in three major areas: (1) controlled-drinking outcomes, (2) the outcomes of standard disease treatments for alcoholics, and (3) how well the perspectives of major researchers jibe with the disease model.