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

Written by Stanton Peele

In evaluating Wallace's results, Longabaugh emphasized the layer after layer of qualification applied to patients before they were included in the study. This is how Wallace (1989: 260), on the other hand, characterized his research: "This study met reasonable standards of clinical research: . . . patients were randomly [emphasis added] selected from a pool of socially stable patients ...." The word "randomly" is key in Wallace's description here, because random selection is such a necessary step in making statistical deductions about a sample. The so-called random nature of Wallace's study takes on one further wrinkle. On the nationally televised ABC program "Nightline," Wallace, Chad Emrick, and others discussed the effectiveness of alcoholism treatment with host Dr. Timothy Johnson. The following is an excerpt from the program "Alcoholism Treatment Controversy" (ABC News 1989: 2,4):

Joe Bergantio, ABC News: Last year alone, 51,000 alcoholics opted for treatment in an inpatient program, at a cost of about $500 million health care dollars. Earlier this month, Kitty Dukakis decided to do the same .... The average cost of outpatient treatment for alcoholics is about $1,200. For a month-long inpatient program, it's $10,000. An increasing number of doctors are asking if inpatient care is worth the difference.

Dr. Thomas McLellan, Veterans Administration Hospital: Well, it's a fact that most people can do as well in an outpatient program as in an inpatient program.

John Wallace, Edgehill Newport: To say that outpatient treatment was just as effective as inpatient treatment is absurd.

Chad Emrick, Outpatient Treatment Center Director: Well, I have been reviewing the treatment outcome literature . . . for over 20 years now, and there have been a number of studies where patients with alcohol problems have been randomly assigned to either inpatient treatment or outpatient care . . . and the vast majority of these studies have failed to find any differences in outcome.... And when differences have been observed, oftentimes the differences seem to favor the less intensive treatment [emphasis added] ....

John Wallace:...I certainly don't agree with Dr. Emrick. I know his work and I respect his work, but . . . I believe that there's quite a different interpretation of the literature cited by Dr. Emrick .... What I think it shows is ... in the vast majority of these studies, the relapse rates were so high—whether they were treated as outpatient or whether they were treated as inpatient—that what these studies showed was that outpatient (in these particular programs) was equally ineffective to inpatient in these particular programs.

Dr. Johnson: Okay. If they're equally ineffective, as you put it . . .

Dr. Wallace: That's right.

Dr. Johnson:... then why waste money up-front with an intensive program? . . .

Dr. Wallace: Because there are other intensive inpatient programs like Edgehill Newport that show a dramatically higher recovery rate. In our latest randomly assigned [emphasis added] study of socially stable alcoholics treated in a middle-class alcoholism treatment program, 66% of our people are continuously abstinent from both alcohol and drugs, our alcoholics, socially stable alcoholics, at six months following treatment.

Note that the phrase "randomly assigned" was used by both Emrick and Wallace, but with entirely different meanings. Wallace apparently meant randomly selected from among his patients for follow-up—although, as Longabaugh showed, there are so many exclusionary principles involved in selecting this group that it is impossible to say in what way this so-called randomly selected group is related to the general pool of patients at Edgehill Newport. Emrick uses "randomly assigned" in its conventional research sense to mean patients who were randomly assigned to one treatment or another and whose outcomes were then compared with one another. But there is no random assignment of patients to any treatment groups in Wallace's research, and all receive the standard Edgehill Newport program.

To reiterate how important the creation of a comparison group is for drawing any conclusions about a treatment, consider Vaillant's (1983: 283-284) experience: "It seemed perfectly clear that . . . by inexorably moving patients from dependence upon the general hospital into the treatment system of AA, I was working for the most exciting alcohol program in the world. But then came the rub. Fueled by our enthusiasm, I and the director . . . tried to prove our efficacy. Our clinic followed up our first 100 detoxification patients .... [and found] compelling evidence that the results of our treatment were no better than the natural history of the disease." In other words, it was only after follow-up and comparison with nontreatment groups of comparably severe alcoholics that Vaillant could get a clear vision of his results, which were that his treatment added little or nothing to the long-run prognosis for his patients. As NIAAA director Enoch Gordis (1987: 582) declared: "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 ...."

What Does Wallace's Treatment Consist Of?

Wallace (1989), asserting that I do not understand modern alcoholism treatment as practiced at Edgehill Newport and other private treatment centers, listed the techniques he uses at Edgehill Newport; oddly, many are psychological and behavioral techniques he otherwise seems to disparage. In addition, Wallace (1989: 268) averred, "I do not argue that we must confront the alcoholic and demand abstinence, as Peele claims." Yet, first-person accounts of Edgehill Newport's program do not describe cognitive-behavioral or other therapy techniques. Instead, they concentrate exclusively on the program's commitment to the disease theory and the need for abstinence and on the conversion experiences patients undergo. Wallace (1990) himself described the didactic emphasis of his treatment program: "At Edgehill Newport, the disease model— including genetic, neurochemical, behavioral and cultural factors—is taught to patients ...."