Why and by Whom the American Alcoholism Treatment Industry is Under Siege
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 One in a series of exchanges between Peele and Wallace, this is an important historical document.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
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.
Controlled-Drinking Outcomes for Alcoholics
The Incidence of Controlled Drinking in Treated Alcoholics
In his rejoinder to my article, Wallace (1989) reviewed the controlled-drinking research reported by Foy, Nunn and Rychtarik (1984), a longer follow-up of this study by Rychtarik and colleagues (1987a), and my description of this research. Foy, Nunn and Rychtarik (1984) found better outcomes at six months for a group of severely dependent veterans treated with a goal of abstinence compared with those given controlled-drinking training. These differences were not significant at the end of a year, and at a follow-up of from five to six years reported by Rychtarik and colleagues (1987a: 106), "results showed no significant differences between groups on any dependent [outcome] measure." Moreover, at the longer follow-up, 18.4% of all subjects were controlled drinkers ("no days of greater than 3.6 oz. of absolute ethanol consumption" and "no record of drinking-related negative consequences" over the prior six months), while 20.4% were abstaining.
Fewer than 10% of the subjects in the Foy-Rychtarik experiment engaged in abstinence or controlled drinking throughout the study follow-up period. Instead, the subjects frequently shifted among abstinence, problem drinking, and moderate drinking categories; Wallace (1989) devoted an entire page to reproducing a table from Rychtarik and colleagues (1987a) that shows just this. Rychtarik and colleagues (1987a: 107) characterized the data presented in this table as being essentially similar to that in the Rand reports (Polich, Armor & Braiker 1980; Armor, Polich & Stambul 1978) and that of Helzer and colleagues (1985) "in demonstrating the marked instability of individuals' drinking patterns." Ironically, this instability—which Wallace cited as a sign of the lack of impact of controlled-drinking training—undercuts the lurid imagery he has used to describe the dangers of controlled-drinking training (Wallace 1987b: 25-26): ". . . when thousands of lives and so much human tragedy is [sic] at stake .... we must not forget that it is the duty of members of the various professions to defend the public against quackery."
When Wallace (1989: 263) claimed that I implied that the 18% of treated alcoholics who ended the experiment six years later drinking in a controlled fashion were from the group who received training in controlled drinking, a "conclusion [which] would indeed be wrong, but I believe it is the one Peele is hoping his readers will draw," he is barking up the wrong tree. I am mainly concerned with how people come to grips with their drinking problems on their own over the course of their lives; not with justifying any brand of therapy. As a result, for me, alcoholics who are trained to abstain but who become controlled drinkers are far more interesting than those who are trained to become controlled drinkers and who do so.
In 1987 I reviewed the history of such controlled-drinking outcomes (Peele 1987c) in an article titled "Why Do Controlled Drinking Outcomes Vary by Investigator, by Country and by Era?" In that article, I summarized the following research results reported in standard treatment programs that did not train controlled drinkers: Pokorney, Miller & Cleveland (1968) found that 23% of alcoholics were drinking in a moderate manner one year after being discharged from the hospital; Schuckit and Winokur (1972) reported that 24% of women alcoholics were moderate drinkers two years after discharge from the hospital; Anderson and Ray (1977) reported that 44% of alcoholics drank non-excessively during the year after undergoing inpatient treatment.
More recently, the Journal of Studies on Alcohol published a Swedish study (Nordström & Berglund 1987) in which "social drinking was twice as common as abstinence" (21 subjects were social drinkers and 11 abstainers) among 70 hospitalized alcohol-dependent male subjects in a good social-adjustment condition who were followed up two decades after their hospitalization. When combined with 35 randomly selected poor-adjustment patients, the overall controlled-drinking percentage for the entire hospitalized group in the Swedish study was 21% (compared to 14% abstaining).
In a follow-up study of 57 married alcoholics 16 years after treatment in a Scottish hospital, McCabe (1986) found almost the same percentages who were controlled drinkers (20%) and abstainers (14.5%). It is interesting that such high controlled-drinking outcomes prevailed in studies that followed up treated alcoholics approximately two decades after their hospitalization. In these studies, alcoholics became more likely to moderate their drinking over time, some after several years of abstaining. Moreover, Nordström and Berglund (1987: 102) found that "5 of 11 abstainers, but only 4 of 21 social drinkers, had relapses at least one year [after achieving] . . . the final type of successful drinking pattern."
Level of Alcohol Dependence and Controlled Drinking
The Foy-Rychtarik study found no relationship between level of alcohol dependence and controlled-drinking versus abstinence outcomes at five to six years. Regarding this assertion on my part, Wallace (1989: 264) stated, "It is important that results of this study concerning alcohol dependence be reported because they directly contradict Peele," whereupon he quoted once again the one-year results of Foy, Nunn and Rychtarik (1984) that "preliminary findings" indicated "dependence appears to have played a key role" in moderation versus abstinence outcomes. In their longer report of the five- to six-year follow-up study, Rychtarik and colleagues stated (1987b: 28) that "the Foy et al. (1984) study found that the degree of dependence was predictive of ability to drink in a controlled/reduced fashion in the first year following treatment. The results of the regression analysis on 5 -6 year data failed to replicate this finding."
Ironically, although Wallace has been criticizing the Rand reports for more than a decade, it is the Rand research that first provided a scientific basis for the idea that more dependent alcoholics are less likely (but not completely unlikely) to moderate their drinking than less severely dependent drinkers. However, the entire relationship between level of alcohol dependence and the ability to reduce drinking has been questioned by a series of increasingly sophisticated psychological analyses. Wallace (1989) pointed out that Orford, Oppenheimer and Edwards' (1976) British group found controlled-drinking outcomes were more likely for alcoholics with fewer dependence symptoms at intake. It is therefore extremely interesting that Orford designed a treatment experiment specifically for the purpose of comparing whether controlled drinking was more closely related to level of alcohol dependence or to one's "personal persuasion" that one could achieve controlled drinking.
In this study with 46 subjects, Orford and Keddie (1986: 495) reported that "no support was found for the dependence hypothesis: . . . there was no relationship between level of dependence/severity and the type of drinking outcome (ABST or CD)." Instead, they found that the patients' "persuasion" that one type of outcome was more achievable was more important in determining outcome. Another study, reported at the same time as the Orford and Keddie research by another British group, replicated these findings with a larger group (126) of subjects. Elal-Lawrence, Slade and Dewey (1986: 46) did not find a relationship between severity of drinking problems and outcome type, but "that alcoholism treatment outcome is most closely associated with the patients' own cognitive and attitudinal orientation, past behavioral expectations, the experience of abstinence and the freedom of having his or her own goal choice .... This may be the time to act with caution before reaching another . . . conclusion that only the less severely dependent problem drinkers can learn to control their drinking."
Changing Criteria for Controlled-Drinking Outcome—The Helzer Study
The main purpose of my 1987 article on controlled drinking was not to discount reported differences in controlled drinking versus abstinence outcomes, but to understand these differences across time, across countries, and across investigators. I concluded that definitions of alcoholic remission and relapse change according to cultural and political climates. Wallace (1989) called me to task for not mentioning in my article Edwards' (1985) critique of Davies' (1962) study reporting significant numbers of controlled drinkers in a hospital treatment population (although I didn't mention the Davies article either). In my 1987 article on controlled-drinking outcomes, I discussed Edwards' and Davies' findings along with almost 100 other conflicting reports of controlled-drinking outcomes in terms of how the criteria for what comprises moderate drinking vary by era and by country.
Both Wallace and I made a great deal of the study by Helzer and colleagues (1985). Wallace (1987b: 24) originally characterized the results of this study as follows: "Only 1.6 percent [of alcoholic patients] appeared able to meet criteria for 'moderate drinking.' More than 98% of the males in the Helzer study were unable to sustain moderate drinking patterns when moderate was defined most liberally as up to six drinks per day" (actually, this result applied to males and females combined in the study). Wallace implied here that alcoholics in the study were attempting to moderate their drinking, but they were not. When asked by the researchers, most claimed that it was impossible for alcoholics to resume moderate drinking and the hospital regimen assuredly discouraged them from believing they could do so.
As I pointed out, the 1.6% moderate drinking figure needs to be augmented by considering the 4.6% of alcoholics who drank moderately, but did so for only up to 30 of 36 of the previous months, while abstaining the rest of the time. In his response, Wallace (1989: 264) first declared, "Peele was apparently distressed that I did not mention that an additional 4.6 percent were mostly abstinent (with occasional drinking)," as though I were oversensitive in thinking that such a provocative outcome group should be "mentioned" in a discussion of this study. On the next page, however, Wallace conceded that "with regard to the . . . group of 4.6 percent occasional but moderate drinkers . . . Peele could have a point." The point is that slightly over 6% of a very severely alcoholic group became moderate or light drinkers. The larger group in this study in which I was interested, however, was the 12% who drank more than "six drinks per day," but who had that many drinks no more than four times in any one month during the previous three years. In his response, Wallace (1989: 264) labeled this a group who "were drinking heavily but denying alcohol-related medical, legal, and social problems." But Helzer and colleagues (1985) found no indication of any such problems for this 12% despite having checked hospital and police records and questioning collaterals, and their interpretation that this group is "denying" problems is an a priori one that reflects the political climate of the times.
Wallace (1989: 264-265) described his fundamental objection to this group: ". . . alcoholics who are drinking in excess of seven or more drinks [this should read "drank seven or more drinks" or" in excess of six drinks"] per day on four or more days in any one month are engaging in at risk drinking whether or not they are denying present medical, legal or social problems .... Peele, however, is obviously distressed that Helzer and colleagues would 'disqualify from remission' any alcoholic who 'got drunk four times in any one month in a three year period.' Personally, I do not believe it is acceptable for anybody, let alone an alcoholic, to get drunk four times in any one month." In his article, Wallace (1989: 267) repeated two insinuating questions from his earlier articles: "Is it possible that Dr. Peele would not mind a moderately 'stoned' American population at all? Furthermore, is it possible that Dr. Peele finds something inherently wrong and unappealing about sober consciousness?"
Here Wallace accused me of being too permissive because I recognize that most alcoholics will continue to drink and many people seek experiences of intoxication. At the same time, disease theorists consider me hopelessly moralistic because I maintain the best antidote to addiction is for a society to refuse to accept addictive misbehavior as an excuse for itself (Peele 1989). Indeed, in a response to my article "Ain't Misbehavin': Addiction Has Become An All-Purpose Excuse" in The Sciences, Wallace (1990) wrote a letter to the editor accusing me of being a "law and order" zealot who wants to punish addicts. What confuses Wallace is my acceptance that people will drink but my intolerance for crime, violence, and other misbehaviors associated with substance abuse that are now frequently excused as being an uncontrollable result of addiction (as when drunk drivers use an alcoholism defense after killing or maiming another driver).
Value issues aside, the question in the Helzer study (1985) is whether or not people who drink more than six drinks at a time a few times a month are actively alcoholic. In particular, if they were formerly alcoholics, could this amount of drinking, however heavy one considers it to be by one's personal standards, represent an improvement in their drinking behavior? In the Rand study (Polich, Armor & Braiker 1980: v), for example, the median level of drinking at intake was 17 drinks per day. Is it important to note whether a person who once drank 17 drinks per day later drank seven drinks or more only as many as four times during any one month in the previous three years? If one believes that "once an alcoholic always an alcoholic," the only question to ask is whether the person has stopped drinking entirely or, in an almost unachievable standard of moderate drinking, if they drink without ever getting drunk.
Improvement Versus Perfection in Treatment Outcomes
In progressively restricting what is called controlled drinking, important clinical details have been increasingly missed, such as the substantial reduction in drinking levels and drinking problems that some people undergo over the course of their lives even though they do not abstain. I used the Tennant (1986: 1489) editorial in the Journal of the American Medical Association to make this point: 'There are now ample epidemiological outcome data to call for other goals in treatment of alcoholism in addition to continuous abstinence." I also reported on Gottheil and colleagues' (1982: 564) study of hospitalized alcoholics that found between a third and over half "engaged in some degree of moderate drinking" and that those who were classified as moderate drinkers "did significantly and consistently better than nonremitters at subsequent follow-up assessments." Furthermore, the Gottheil group declared that "if the definition of successful remission is restricted to abstinence, the treatment centers cannot be considered especially effective and would be difficult to justify from cost-benefit analyses."
It would seem to be worthwhile to know that nonabstaining alcoholics can still do "significantly and consistently better" on various outcome measures than active alcoholics, rather than to rush to lump them—based on their occasional drunkenness—with the most abandoned, out-of-control alcoholics. I want to illustrate this difference in perspective with what I consider to be one of the most intriguing outcome studies ever conducted in the alcoholism field. Goodwin, Crane and Guze (1971) classified 93 ex-felons as "unequivocal alcoholics" and followed their course for eight years after prison, during which time only two were-treated for alcoholism. These researchers classified 38 of the ex-felons as being in remission, although only seven of them were abstinent, indicating a nonabstinence remission rate of a third.
Among the continuing drinkers in remission, l7 were categorized as moderate drinkers (drinking regularly while "rarely getting intoxicated"). But more fascinating were the remaining men that these researchers placed in the remission group—eight continued to get drunk regularly on weekends, while another six switched from spirits to beer and still "drank almost daily and sometimes excessively." Clearly, Wallace would not consider these men to be in remission. Yet Goodwin, Crane and Guze categorized them thus because these men, who had previously been imprisoned, now no longer got drunk publicly, did not commit crimes or other antisocial acts when intoxicated, and stayed out of jail. In other words, Goodwin and colleagues saw a significant overall improvement in the drinkers' lives as sufficient grounds for declaring that they were no longer alcoholics.
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).
The prestigious journal Science, which has published a number of pieces that support disease models of alcoholism, published an article in 1987 that asked "Is alcoholism treatment effective?" and concluded that the best predictor of outcome is the type of patient who enters treatment, rather than the intensiveness of the treatment (Holden 1987). This article referred to Miller and Hester's work and also to Helen Annis, a researcher at the Ontario Addiction Research Foundation (ARF). ARF has for some time de-emphasized hospital treatment, preferring even to deal with detoxification in a social, rather than a medical, setting. Indeed, Annis and other researchers have reported that withdrawal is less severe when carried out in a non-medical setting (Peele 1987b).
As a result, the Canadian national health system generally does not pay for hospital care for alcoholism . Private treatment centers in Canada have thus actively begun marketing their services in America. This difference between the American and the Canadian systems is reflected even more strongly in Britain. Wallace (1989) labeled as "inappropriate" Britain's decision to de-emphasize inpatient treatment, a decision I quoted Robin Murray as saying was based on the British having found the benefits of such treatment to be "marginal." Murray and colleagues (1986: 2) commented on the sources of this difference between Britain and the United States: "It is perhaps worth noting that whether or not alcoholism is considered a disease, and how much treatment is offered, has no bearing on the remuneration of British doctors."
How Well Does Wallace Support His Claims for His Treatment Program?
As one can see from the range of negative findings about alcoholism treatment (particularly hospital treatment) both within the United States and internationally, the value and especially the cost-effectiveness of such treatment are under severe attack. For example, Medicare has attempted to impose a limitation on payment for hospital treatment for alcoholism, creating a battle that has continued to rage for more than five years and that has yet to be resolved. If one takes seriously assertions like those by Madsen (1989) and Wallace (1987c) that AA is tremendously effective, how then can the costs of inpatient treatment—which range from $5,000 to $35,000 a month—be justified? Indeed, what about Vaillant's (1983) report that his patients did no better than untreated comparison groups, or the untreated remission rate reported by Goodwin, Crane and Guze (1971) of 40% over eight years for alcoholic ex-felons?
Thus, some importance was attached to the document to which Wallace (1989) alluded in his rebuttal: the Sixth Special Report to the U.S. Congress on Alcohol and Health (Wallace 1987d), in which he made his claims about the efficacy of private treatment and his own Edgehill Newport program. Actually, the treatment chapter in this report was originally assigned to—and a first draft written by— Peter Nathan (Director of the Rutgers Center of Alcohol Studies), Barbara McCrady (Clinical Director, Rutgers Center of Alcohol Studies), and Richard Longabaugh (Director of Evaluation at Butler Hospital in Providence, Rhode Island). Nathan and colleagues found that inpatient treatment produced no greater benefits than did outpatient treatment and that intensive alcoholism treatment was not cost-effective. NIAAA asked Wallace to revise this draft, which he did by softening its major points and eliminating a number of references and key conclusions by the original authors, after which Nathan, McCrady, and Longabaugh withdrew their names from the document (Miller 1987).
Wallace (1989) mentioned specifically two studies in his rebuttal to my article that he likewise emphasized in the Sixth Special Report. The first is a 1979 study of inpatient treatment by Patton conducted at Hazelden, which reported a continuous abstinence rate of over 60% at one year following treatment. Wallace (1989: 260) indicated that he does not fully trust these results, and he revised the remission figure in this study to a more defensible "lower bound of 50%." He then cited his own published account of a 66% continuous abstinence rate six months after treatment at his Edgehill Newport program (Wallace et al. 1988). Longabaugh (1988), an outcome researcher who was originally asked to write the treatment outcome chapter for the Sixth Special Report, discussed the results from these studies along with the general conclusions of the Wallace authored Sixth Special Report at a conference titled "Evaluating Recovery Outcomes."
Longabaugh began by noting that the number of beds in private alcoholism treatment centers quintupled between 1978 and 1984. At the same time, he pointed out, there was no evidence to support the effectiveness of these for-profit units. Longabaugh (1988: 22-23) quoted Miller and Hester (1986b: 801-802): "Although uncontrolled studies have yielded inconsistent findings regarding the relationship between intensity and outcome of treatment, the picture that emerges from controlled research is quite consistent. No study to date has produced convincing evidence that treatment in residential settings is more effective than outpatient treatment. To the contrary, every study has reported either no statistically significant differences between treatment settings or differences favoring less intensive settings." He indicated that this result contrasted with the conclusions of the Wallace chapter in the Sixth Special Report, which claimed that the high relapse rate observed in the majority of the treatment programs studied made it impossible to generalize about comparative cost-effectiveness.
Longabaugh described two studies from the Sixth Special Report regarding programs that produce a 50% or higher abstinence rate, and how they differed from public programs that reported far poorer outcomes. Longabaugh (1988) indicated that "the problem in making comparisons is to use a common yardstick," and he described how "one study claiming that over 60% of patients were abstinent one year after treatment in fact had a known success rate of 27.8% when the sample was subjected to more careful and accurate examination." The study to which Longabaugh referred is the Hazelden follow-up study (Patton 1979), which is the one outcome study other than at his own treatment center that Wallace (1989: 260) described favorably. Longabaugh (1988) revised the 61% success rate reported in this study further downward—beyond the 50% at which Wallace himself placed it—based on information Patton reported on the exclusion of various groups in this research. For example, in calculating the program's success rate, the original investigators eliminated from the baseline treatment group (or denominator) patients who stayed less than five days in treatment and others who had relapsed and returned for treatment during the follow-up period. Hazelden's announced policy is that relapse and repeat treatment is an acceptable natural consequence of the disease of alcoholism that must be reimbursed by insurers.
Longabaugh (1988) concluded that it was impossible to evaluate results from "for-profit, free-standing programs with better-prognosis patients because there have been no results [based on controlled-comparison research] reported to date for those kind of treatment programs." He further noted that NIAAA has received no applications to conduct such research. Instead, the only outcome studies that can be expected from such programs "are single-program studies of doubtful value."
Longabaugh (1988) then reviewed Wallace and colleagues' (1988) study, which found that 66% of patients in the program had been continuously sober at follow-up. However, as Longabaugh noted:
. . the program report was limited to treatment of socially stable patients who were judged to have restorative potential; they had been transferred from detoxification to rehabilitation, indicating that it was expected they would participate fully in a rehabilitation program; they were married and living with a spouse with no plans to separate; they had sufficient resources to pay for treatment; they were asked to participate in the study in the third week of treatment, after any dropouts would have been removed from the sample; they had been "regularly discharged from the program" with no accounting of patients who were not "regularly'' discharged.
Longabaugh finally raised the question, "Was this population representative of the population they were treating? We don't know the answer .... More important, this treatment for this group is not compared with any alternative. It is not compared with a hospital program, an outpatient program, with AA, or no treatment whatsoever .... any other intervention [might be as effective with such a group], perhaps even including no intervention at all."
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 ...."
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."
A Whole Different Perspective
Wallace's and My Different Backgrounds and Perspectives
That alcoholism treatment is under siege is obvious. In the last paragraph of the third part of his "Waging the War for Wellness" series, Wallace (1987c: 27) issued a clarion call to alcoholism professionals: "We must recognize and resist the various tactics and strategies of the Anti-traditionalist lobby to divide us. We must stand shoulder to shoulder in solidarity. Otherwise, alone and divided we will be weak and easy targets for those who do not want to pay for alcoholism services [emphasis added]." Throughout his rebuttal of my article, Wallace (1989: 270) adopted a tone of injured innocence: "Despite Peele's efforts to discredit me by unjustly accusing me of intolerance and wishes to persecute, my convictions about the necessity for competent science to guide clinical practice remain intact." Wallace paints me as the persecutor. Yet the point of view he espouses is by far the dominant one in the United States. At the same time, as Miller and Hester (1986a: 122) indicated: "The list of elements that are typically included in alcoholism treatment in the United States . . . all lack adequate scientific evidence of effectiveness."
Whenever investigators question any tenets of the American treatment system, they are liable to be vilified. One well-known case was the Rand research. In 1976, Wallace participated in the NCA's press conference assailing the first Rand report: "I find the Rand conclusions of no practical beneficial consequences for treatment and rehabilitation." Others, like Samuel Guze, felt differently (Armor, Polich & Stambul 1978: 220-221): "Alcoholism and Treatment, a Rand report . . . is interesting, provocative, and important. The authors are obviously well-informed, competent, and sophisticated. They appear to recognize and appreciate the complex issues that their report covers .... What the data do demonstrate is that remission is possible for many alcoholics and that many of these are able to drink normally for extended periods. These points deserve emphasis, because they offer encouragement to patients, to their families, and to relevant professionals."
More than a decade later, Wallace (1987b: 24) was still attacking this report and its four-year follow-up and anyone who took them to indicate moderation of drinking problems was a real possibility, "Considering the scientific inadequacies of the first Rand report and the actual data from the second...." Others feel differently, including Mendelson and Mello (1985: 346-347), editors of the Journal of Studies on Alcohol and themselves preeminent alcoholism researchers: "Despite the gradually accumulating data base [on controlled-drinking outcomes], the 1976 publication of . . . the Rand Report was responded to with outrage by many self-appointed spokesmen for the alcoholism treatment community .... When this data base was followed again after four years, there were no significant differences in relapse rates between alcohol abstainers and non-problem drinkers .... [The Rand study] was evaluated with the most sophisticated procedures available ...." Whatever Mendelson and Mello's opinions, virtually no one in the United States (although not around the world) practices controlled-drinking therapy for alcoholics, and the practical applications of the Rand reports and of much other research, such as the techniques cited by Miller and Hester (1986a), are negligible. That is the power of the current alcoholism treatment establishment, which NIAAA director Gordis (1987) noted when he said, "Contemporary treatment for alcoholism owes its existence more to historical processes than to science ...."
My own work in the alcoholism field includes a number of critical summaries of views of alcoholism and other drug addictions and their treatment and prevention. Wallace (1989) referred to one of these articles, "The Implications and Limitations of Genetic Models of Alcoholism and Other Addictions" (Peele 1986), that cast doubt on genetic claims about alcoholism. Recently, another of my articles (Peele 1987a) received the 1989 Mark Keller Award for the best article in the Journal of Studies on Alcohol for the years 1987-1988. I also address addiction and alcoholism professionals at conferences, such as the 1988 [DHHS] Secretary's National Conference on Alcohol Abuse and Alcoholism, where I debated with James Milam whether or not alcoholism is a disease. In this sense, some important venues have answered Wallace's (1989: 259) question—"Can Stanton Peele's Opinions Be Taken Seriously?"—in the affirmative.
Nonetheless, my role in the alcoholism field is that of an outsider. When I name research professionals (mainly physicians)—such as Enoch Gordis, Donald Goodwin, Samuel Guze, Jack Mendelson, Nancy Mello, George Vaillant, John Helzer, Lee Robins, Forest Tennant, Robin Murray, and Griffith Edwards—to support my positions, and when I asked in my original article in this journal (Peele 1988) whether Wallace considered these mainstream figures to be anti-traditionalists, I was being ironic. I meant through this device to illustrate how poorly conventional wisdom does at explaining the results and views of the most prominent of alcoholism researchers. For example, the Goodwin, Crane and Guze(1971) article that described remission among former convicts who continued to drink could never be published today in the aftermath of the furor created around the Rand reports.
I described alcoholism treatment in Great Britain in my original article as a way of showing that the supposed biological basis of alcoholism and of its medical treatment does not travel well across the Atlantic. I do not understand Wallace's (1989) reasoning in his response to my quotes of Robin Murray's negative findings on genetic causation as well as his statement that British psychiatry finds that the disease approach to alcoholism does more harm than good. Wallace seemed to be saying that this is a slap at British and American researchers who study biological sources of alcoholism. My point was that the defection of almost the whole of a nation from the disease model does not support Wallace's (1989: 269) view that "in the future, I think that the type of arguments mounted by Peele against biological factors in alcoholism and in favor of controlled drinking will be dismissed readily as prescientific or even as ascientific."
In a major speech (Newman 1989), Wallace indicated where he thinks alcoholism treatment based on modern neuroscientific discoveries is headed. In the first place, he does not find them inconsistent with AA and "spiritual" recovery: "I think behavior affects neurochemistry. When you get in AA you get in touch with your good molecules." Here is how Wallace describes the future: "Treatment is going to be transformed over the next ten years. There will be a lot more so-called New Age initiatives, including body massage, meditation, and attention to diet."
That the British are going in the opposite direction from this country is clear in the description put forward in the pro-disease trade publication, the U.S. Journal of Drug and Alcohol Dependence (Zimmerman 1988: 7):
The ten men and women who live at the Thomybauk recovery home in Edinburgh have all had trouble with alcohol, but don't call them alcoholics or suggest that they have a disease.
They're problem drinkers. They developed a dependence on alcohol. They aren't being treated for alcoholism but are trying to learn to deal with personal problems in a way that avoids getting drunk. If they want to try to drink again and control it, their counselors at Thomybauk wouldn't object.
Thomybauk would be considered a novel, if not dangerous, course of treatment for alcoholism in the United States, where the traditional disease concept of alcoholism makes total abstinence the widely accepted goal of treatment. In England and Scotland, and Mach of the rest of the world, it's the other way around [emphasis added]. The majority of medical and psychiatric practitioners frown on the idea that persons who have once lost control of their drinking must, above all, avoid a "first drink" if they expect to sustain their recovery. In the eyes of these doctors, it is insisting on abstinence that may jeopardize alcoholic recovery. They prefer to work with a concept of alcohol dependence which has varying degrees of severity and may leave the door open for a return to social drinking by some patients.
Wallace (1989: 266) particularly objected to my citing data from Robins and Helzer regarding returned Vietnam veteran heroin addicts: "For the record, I have personally long admired the work of these researchers. My admiration is not diminished by their careful, forthright, and fascinating study of heroin use and addiction among Vietnam Veterans. Helzer and Robins' discussions of their findings on the possible use of narcotics by previously addicted soldiers without readdiction is a model of restraint .... One does not come away from reading Helzer and Robins' work with the feeling that opiate or other drug use has been sanctioned or encouraged. I am of the opinion, however, that the same cannot be said of Peele's work."
Here is what Robins and colleagues (1980) found: (1) "Heroin use progresses to daily or regular use no more often than use of amphetamines or marijuana" (p. 216); (2) "Of those men who were addicted in the first year back. . . of those treated, 47 percent were addicted in the second period; of those not treated, 17 percent were addicted" (p. 221); and (3) "Half of the men who had been addicted in Vietnam used heroin on their return, but only one-eighth became re-addicted to heroin. Even when heroin was used frequently, that is, more than once a week for a considerable period of time, only one-half of those who used it frequently became re-addicted" (pp. 222-223). These data undermine the foundation of the beliefs on which Wallace bases his entire model of addiction and addiction treatment. Given his respect for these researchers and their work, what does Wallace make of these findings? Where in his writings or work does he make use of them?
Robins and colleagues (1980: 230) tried to deal with their "uncomfortable" results in the last paragraph of their article, which was subtitled "How Our Study Changed Our View of Heroin": "Certainly our results are different from what we expected in a number of ways. It is uncomfortable presenting results that differ so much from clinical experience with addicts in treatment. But one should not too readily assume that differences are entirely due to our special sample. After all, when veterans used heroin in the United States, only one in six came to treatment."
The Robins group's research suggests a model of addiction as something other than a lifetime disease. The exploration of normal human development out of addiction is especially crucial today because of the rapid expansion of the application of the disease concept, not only to people with milder drinking problems, but—in treatment centers such as Hazelden and CompCare and others—to labeling and treating (including hospitalizing) those suffering from such diseases as "codependence" and addictions to sex, gambling, overeating, and shopping. This madness must be exposed for what it is.
The author is grateful to Chad Emrick, Richard Longabaugh, and Archie Brodsky for their input.
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