Why and by Whom the American Alcoholism Treatment Industry is Under Siege - A New Attack on Alcoholism

Written by Stanton Peele

One account of the Edgehill Newport program and of how a patient came to it for treatment was included in a New York Times Magazine article (Franks 1985) titled "A New Attack on Alcoholism." The article began with a sweeping generalization: "The myth that alcoholism is always psychologically caused is giving way to a realization that it is, in large measure, biologically determined." Franks is clearly indebted to Wallace, whose name and program were mentioned in highly positive terms, while the article recounted a range of speculative biological research about alcoholism. Yet, all Franks (1985: 65) had to say about treatment approaches engendered by the new biological discoveries was contained in a single paragraph: "Most treatment programs are now designed to attack the illness on all fronts, and to lead alcoholics out of their shame and isolation and into a scientific and cognitive structure within which they can understand what has happened to them. Sometimes daily doses of Antabuse [a therapy Miller and Hester found was ineffective] are prescribed .... Dr. [Kenneth] Blum is currently testing a psychoactive agent which raises brain endorphin levels. Some treatment programs use an experimental machine which purports to stimulate electrically the production of endorphins and other euphoriants."

Franks (1985: 48) described a single case of alcoholism treatment in a sidebar titled "The Story of 'James B'." Franks knew James B as the father of a good friend.

If James B had denied his problem, so had we. He had been depressed over the death of his wife and the loss of his architectural business .... at last we had gathered into a crisis intervention team and surprised him.... Dr. Nicholas Pace ... who helped refine the crisis intervention technique, had advised us to use reason, histrionics, and even threats to strip James B of his defenses and deliver him to a treatment center....

"We think your disease is alcoholism...."

"That' s preposterous ! My problems have nothing to do with alcohol." . . . Coached about the new science of alcohol and the liver, we tried to convince James B that there was no shame in being an alcoholic.

"Look, can 't you understand?" James B said. 'I'm sick, yes; depressed, yes; getting old, yes. But that's all." . . .

After 14 hours of this scenario, some of us began to question whether he really was an alcoholic.... Then he let spill a few words. "Geez, if I couldn't go down to the pub for a few, I think I'd go nuts." "Aaah," Isabel said. "You just admitted it." . . .

That very night, we drove him to the Edgehill treatment center in Newport.

The sidebar ended by reporting that James B had accepted that he was a "diseased" alcoholic. Despite appearing in an article about biological discoveries and cures for alcoholism, everything mentioned is as old as AA and, even earlier, temperance and the Washingtonians. This diagnosis was conducted by nonprofessionals during a grueling 14-hour marathon session. Furthermore, the diagnosis was so shaky that it depended finally on James B's casual mention that he counted on his visits to the pub. Contrast this lay diagnostic process with the extremely stringent diagnosis of alcoholism called for by Madsen (1988: 11), an ardent disease-model and AA proponent: "I do not believe that we have a single study of alcoholism in which it can be demonstrated that every subject is clearly alcoholic. This can have catastrophic results [emphasis added] for the conclusions of such studies.... This over-diagnosis is due to inexperienced or too eager researchers, sloppy diagnosis, and a lack of responsibility. . . . Alcoholism is classifiable by valid scientists who have had adequate field experience."

Madsen sees catastrophe resulting from misdiagnosing problem drinkers as alcoholics. One reason may have to do with controlled drinking, which Madsen (1988: 25) thinks is impossible for true alcoholics, but is rather simple for other problem drinkers: "Any third-rate counselor should be able to help a non-addicted drinker moderate his or her drinking." If one accepts Madsen's argument that moderation is so readily accomplished by non-addicted drinkers, then it is essential to distinguish between the non-addicted alcohol abuser and the addicted (or alcoholic) one. Wallace and colleagues (1988: 248) provided a description of the diagnostic criteria they used to classify alcoholics: patients "met NCA [National Council on Alcoholism] criteria for the diagnosis of alcoholism, and/or had drug abuse/dependence diagnoses, required inpatient care, and had restorative potential."

It seems that perhaps everyone who is admitted to Edgehill Newport would qualify for the outcome study, and therefore Edgehill admissions policies are quite relevant to this research. One wonders, for example, if the James B case is typical of the subject population in Wallace and colleagues' (1988) study. Furthermore, are any of those who apply or who are referred for treatment in Wallace's program referred to more appropriate, non-disease treatments because they are non-addicted drinkers? Edgehill Newport admissions policies received national attention when Kitty Dukakis was admitted to the hospital. In press conferences and interviews, Kitty and Michael Dukakis (and many collaterals) reported that Mrs. Dukakis only began having drinking problems following her husband's defeat for the presidency, when she had had, according to Michael Dukakis, too much to drink on two or three occasions.

These reports prompted a great deal of media speculation, as well as interviews with alcoholism experts, about whether Kitty Dukakis was an alcoholic. Many treatment professionals and Kitty Dukakis herself explained that her prior dependence on amphetamines was the basis for her diagnosis of alcoholism. This claim received so much attention that Goodwin (1989: 398) discussed it in the pages of the Journal of Studies on Alcohol: "Kitty Dukakis, checking in for alcoholism treatment, opened up a perennial question: Does one drug dependence lead to another? It was amazing how many authorities said yes, absolutely. If Mrs. Dukakis was hooked on diet pills at one time in her life, she was likely to become hooked on something else, like alcohol. There is almost no evidence for this."

One is reminded of Madsen's insistence that those treating a person for alcoholism must establish that the person is an "addicted drinker" or else face the possibility of "catastrophic" misdiagnosis. Furthermore, one must judge whether or not the patient population on which Wallace and colleagues (1988) reported their results has the same degree of alcohol dependence as found among the highly dependent subjects in other studies, such as the Rand report. It may not make much sense, therefore, to compare the abstinence rates of those at Edgehill Newport with studies of hospitals whose outcomes Wallace denigrates.

In light of his research, let us review Wallace's (1987c: 26) demands: ". . . we must insist that researchers in the treatment field give us research that is every bit as adequate and unbiased as research in other areas of alcohol studies." In his rejoinder to me, Wallace (1989: 259, 267) declared: "It is concluded that marginal scholarship, partial and/or inaccurate representations of research, and inappropriate generalizations do not constitute the basis for drawing reliable and valid conclusions about alcoholism treatment" and that good science and treatment require "(1) an insistence on fairness; (2) attention to scientific method and data; (3) healthy skepticism; and (4) reasonable caution."