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

Written by Stanton Peele

Evaluating Treatment Outcomes

What Is the Standard Remission Rate for Alcoholism Treatment?

When he is confronted with poor remission rates in hospital programs, Wallace blames poor treatment methods, while claiming that his and other private treatment programs use far superior methods. For example, Rychtarik and colleagues (1987a) found that only four percent of their patients abstained continuously over the five- to six-year follow-up period. Wallace (1989) predictably attributed these results to the futility of the behavioral methods utilized in the study, which he contrasted with the results of therapy at Edgehill Newport and comparable treatment centers. Rychtarik and colleagues (1987b: 29), on the other hand, claimed that "the long-term effects of the present broad-spectrum behavioral treatment program do not appear to vary much from the results of more traditional treatment for chronic alcoholics."

In reviewing the Edwards group's finding that treated alcoholics and those given a single session of advice had equally good outcomes (Edwards et al. 1977), Wallace (1989: 268) concluded that "by American standards of outcome, the British were not giving particularly good advice or good treatment" since "90% of the men had drunk again" within a relatively short time period. What are the standard abstinence and/or remission rates following American treatment programs? We have seen that Wallace disparages Rychtarik and colleagues' discovery of four percent continuous abstinence over five to six years. He has consistently deprecated the Rand report's finding (for NIAAA treatment centers) that only seven percent of men abstained throughout the course of the study's four-year follow-up. But other researchers Wallace has cited favorably have revealed similar results.

For example, Vaillant (1983) found that 95% of his hospital and Alcoholics Anonymous (AA) treatment group resumed alcoholic drinking at some point during an eight-year follow-up; overall their outcomes were no different than comparable groups of alcoholics who went totally untreated. Helzer and colleagues' (1985) research showed even more disturbing results for hospital alcoholism treatment. While they announced that their results discounted the value of controlled-drinking therapy, they evaluated hospital treatment that certainly did not practice controlled-drinking therapy. And, of the four hospital treatment settings studied (Helzer et al. 1985: 1670), "the alcohol-unit inpatients . . . fare[d] the worst. Only 7 percent survived and recovered from their alcoholism, by either maintaining abstinence or controlling their drinking" [emphasis added]. Featuring as the main finding in this study that only 1.6% of patients became moderate drinkers and therefore controlled-drinking therapy is useless, but that nonetheless over 90% of those receiving standard alcoholism treatment died or were still alcoholic, is like congratulating oneself on performing a successful operation while the patient has died.

Comparing Wallace's Claims for Alcoholism Treatment With Others' Results

Wallace and colleagues (1988) reported a successful remission rate for treated alcoholics of almost 10 times that revealed by Helzer and colleagues (1985). If Wallace genuinely believes that successful treatment methods that can create high abstinence rates have been devised and are readily available, are the alcoholism ward studied by Helzer and colleagues and Vaillant's hospital (Cambridge Hospital) liable for medical malpractice claims? What remission rates have Wallace and other private centers claimedand what have they demonstrated? Wallace (1989) called me most to task for my statement that "although well-controlled studies typically find few alcoholics who abstain for several years following treatment, Wallace and representatives of many other treatment centers often report successful outcomes in the neighborhood of 90 percent" and for my saying these claims are not reported in legitimate refereed journals.

Actually, Wallace and colleagues (1988) claimed a two-thirds (66%) remission rate for socially stable patients without coexisting drug problems at Edgehill Newport, as defined by continuous abstinence for six months following treatment. I apologize for associating Wallace with reported success rates even higher than the one he claims. Nonetheless, I maintain that—in contrast to well-controlled studies of hospitalized alcoholics that typically find fewer than 10% of alcoholics have abstained throughout varying follow-up periods after treatment—Wallace speaks for a group of private treatment centers that claim substantially higher abstinence rates, from 60% to 90%. These claims are invalidated by close scrutiny of the research methods used by the treatment personnel investigating their own patients and they are misleading and detrimental to realistic evaluation of alcoholism treatment.

Wallace has been quite concerned, understandably, to defend the success of expensive private treatment centers like Edgehill Newport against detractors of such programs, of which I am not the first. I repeat from my original article a quote that appeared in a Journal of the American Medical Association editorial (Tennant 1986: 1489): "The serious problem of alcoholism has been lost in the competitive hype among alcoholism treatment centers. Any sophisticated critic using statistical analysis to measure treatment effectiveness is appalled by the display of a media or sports star claiming cure thanks to a specific treatment center's help—which proclaims 80% to 90% cure rates."

For example, in a recent article in a national magazine, The Public Interest, Madsen (1989) wrote: "Treatment programs based on AA principles, such as the Betty Ford Center, the Navy Alcohol Recovery Program, and the Employee Assistance Programs, have recovery rates up to 85%." Madsen's article was an attack on Fingarette's (1988) book Heavy Drinking: The Myth of Alcoholism as a Disease; indeed, Madsen (1988) has written an entire pamphlet attacking this book. Yet, although he assails Fingarette's scientific credentials in both his publications, Madsen nowhere refers to a single piece of research that supports his claims about the effectiveness of AA-type programs. In fact, Miller and Hester (1986a) reported that the only controlled investigations of AA as a treatment modality have found it to be inferior for general populations not only to other kinds of treatment, but also to receiving no treatment!

Wallace (1987c) specifically addressed Miller and Hester's (1986b) claim that inpatient treatment is no more effective and considerably more expensive than less intensive alternatives, along with Edwards and colleagues' (1977) demonstration that an advice session was as good as hospital care in producing remission from alcoholism—remember that Wallace also lauds Edwards (1985) for attacking controlled-drinking outcomes. But there are more, many more, assaults on inpatient treatment effectiveness. For example, the U.S. Congress, through its Office of Technology Assessment, declared that "controlled studies have typically found no differences in outcome according to intensity or duration of treatment" (Saxe, Dougherty & Esty 1983: 4).