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Page 5 of 8
In a frank article entitled, "Ideal Mental Health Services for Alcoholics and Problem Drinkers: An Exercise in Pragmatics," Nathan (1980) described how political issues sabotaged a controlled-drinking program he tried to develop. Nathan was asked by the chairman of a hospital board--who was "himself a member of Alcoholics Anonymous" but who was "convinced that AA was not the only answer to alcoholism"--to create a controlled-drinking program for "problem drinkers." Nathan agreed to develop such a program with colleague Terry Wilson "because I felt that development of the program would be a worthwhile service and that a great deal of valuable data on the kinds of alcoholics and problem drinkers responding positively to controlled drinking treatment would be gathered."
Nathan (1980) reviewed evidenced on the effectiveness of CD therapy, carefully developed a treatment protocol and aftercare program, and then tried to implement the program. The hospital submitted the program to a review which resulted in requests for "a series of minor but annoying changes." Nathan and Wilson felt these changes expressed the ambivalence of the hospital toward a "treatment designed to convert...uncontrolled problem drinkers to controlled social drinkers, a treatment goal totally at variance with the abstinence goal of Alcoholics Anonymous," which was an important constituency for the hospital's inpatient program. Nathan and Wilson reiterated that the program was geared solely towards problem drinkers, and not alcoholics.
Finally, the program went ahead with a carefully worded press release describing the program and seeking clients. When this announcement produced only a small group of potential clients, Nathan and Wilson planned a more aggressive advertising effort. Before they could proceed, however, the hospital withdrew its support for the program because of threats by representatives of AA that they would stop referring patients to the hospital's profitable inpatient program. Nathan (1980, p. 296) concluded, "Above all, do not assume that an ideal mental health service for alcoholics and problem drinkers can survive the pragmatics of the marketplace simply by the force of its empirical justification."
Nathan's experience in this case illustrates that, although the idea of CD therapy for problem drinkers is apparently less controversial than it is for chronic alcoholics, it remains difficult to implement a program in the United States that applies CD therapy with any group of alcohol abusers. As Nathan (1980) made clear, co-existence of abstinence and controlled-drinking programs under the same aegis seems politically impossible. In addition, every attempt to identify problem drinkers for whom CD therapy is indicated also nets drinkers who are measured as alcohol dependent by standard diagnostic instruments (Heather, 1986; Sanchez-Craig & Lei, 1986). Furthermore, in the United States, people with any sort of drinking problem will usually be diagnosed and treated as alcoholics (Hansen & Emrick, 1983).
As a result, according to an interview Nathan gave in 1982 about the Sobell-Pendery dispute, "there is no alcoholism center in the United States using the technique [CD therapy] as official policy" (Fisher, 1982, p. 8). This situation may be unique to the United States. In Britain, Heather and Robertson (1982) found that over three-quarters of National Health Service alcohol treatment units offered CD therapy. Moreover, including even Councils on Alcoholism, over 90% of the surveyed units thought CD therapy was appropriate for some clients whether or not the units practiced such therapy. In 1990, the same attitudes prevailed in the United Kingdom (Rosenberg, Melville, Levell, & Hodge, 1992). Rush and Ogborne (1986) found 37% of Canadian treatment units offered CD therapy, including about a fifth of inpatient and detoxification facilities along with a majority of community outreach centers.
Institutional, Economic, And Legal Factors In The Rejection Of CD Therapy
Nathan's (1980) description of his failed attempt to establish a controlled-drinking program appeared in the same year the second volume of the Rand study reported a four-year follow-up of NIAAA-funded alcoholism treatment center outcomes. Like the initial 18-month follow-up, the second Rand report found substantial nonproblem drinking remission among alcoholics. Like the first report, it was loudly criticized by representatives of the alcoholism treatment industry, including a concerted attack organized by the National Council on Alcoholism. Moreover, the two different directors of the NIAAA at the time of the two reports both affirmed that, despite the Rand results, abstinence was the "appropriate goal in the treatment of alcoholism" (Peele, 1984). In 1982, when Nathan's description of his private CD therapy practice was published, the Pendery et al. assault on the Sobells' CD treatment research appeared.
On accepting the Rutgers Center directorship in 1983, Nathan had to deal with an important defection by a major financial supporter of the Center. According to Lender and Martin (1982), "when the Journal of Studies on Alcohol published a number of articles with conclusions similar to Rand's, one major private contributor to alcoholism research proceeded to cut the Rutgers Center of Alcohol Studies, the Journal's publisher, out of his will" (p. 193). This was R. Brinkley Smithers, a recovering alcoholic who was president of the National Council on Alcoholism until 1965, and who had donated $30 million to the alcoholism field through either personal donations or through the Christopher D. Smithers Foundation (named for his father).1
Smithers was the Center's largest private benefactor (Smithers Hall, the Center building, was named after the elder Smithers after the son gave the Center a grant when it moved from Yale in 1962). By 1983, when Nathan took over the reins at Rutgers, Smithers' relationship with Rutgers had cooled dramatically. By 1986, the relationship had been restored, and Smithers personally gave Rutgers $3.54 million as a part of an overall $6.7 million gift for alcohol studies.2 Smithers had proved himself to be a demanding donor in the past, willing to withhold funds from a program that did not adhere to his views on alcoholism (including that "the goal of treatment should be total abstinence from all addicting substances") in connection with a previous $10 million grant to Roosevelt Hospital (Minetree, 1986, p. 243).3
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