What You Can Change . . . And What You Can't*: The Complete Guide to Successful Self-Improvement (53 page)

This is not just an academic quibble. If this were a new treatment area, controlled study would not yet be mandatory. But this is a problem that costs the United States $100 billion or more annually and for which elaborate and expensive treatment has been going on for more than four decades. Fully cognizant of the practical problems, I nevertheless believe that controlled long-term studies are overdue.

The most complete reviews of controlled studies of alcoholism have been reported by William R. Miller of the University of New Mexico. On the whole, he is less optimistic than I am about AA and more optimistic about behavioral training (marital therapy, self-control training, and social skills training). My reservations about the behavioral modalities concern the need for large groups and very-long-term follow-up. Otherwise our reviews coincide. See H. Holder, R. Longabaugh, W. Miller, and A. Rubonis, “The Cost Effectiveness of Treatment for Alcoholism: A First Approximation,”
Journal of Studies on Alcoholism
52 (1991): 517–40; W. Miller, “The Effectiveness of Treatment for Substance Abuse: Reasons for Optimism,”
Journal of Substance Abuse Treatment
9 (1992): 93–102.

17
. J. Orford and G. Edwards,
Alcoholism
—
A Comparison of Treatment with Advice, with a
Study of the Influence of Marriage
(Oxford: Oxford University Press, 1977). See also Herbert Fingarette’s discussion of this study in his
Heavy Drinking
(Berkeley: University of California Press, 1989), 70–95.

18
. Chap. 8 of Vaillant,
The Natural History of Alcoholism
, is must reading for all who would not have their hearts broken and rebroken by the chronic relapses of their patients and relatives. See also National Institute on Alcohol Abuse and Alcoholism, “Seventh Special Report to the U.S. Congress on Alcohol and Health” (Washington, D.C.: Public Health Service, 1990) (DHHS publication number ADM 90–1656); and W. Miller and R. Hester, “Inpatient Alcoholism Treatment: Who Benefits?”
American Psychologist
41 (1986): 794–805.

19
. This study stands alone as being methodologically adequate and as supporting the usefulness of hospital treatment. See D. Walsh, R. Hingson, D. Merrigan, et al., “A Randomized Trial of Treatment Options for Alcohol-Abusing Workers,”
New England Journal of Medicine
325 (1991): 775–82. If replicated, it may be a watershed for inpatient alcoholism treatment.

20
. E. Chaney, M. O’Leary, and G. Marlatt, “Skill Training with Alcoholics,”
Journal of Consulting and Clinical Psychology
46 (1978): 1092–1104. This seems like a promising treatment package, and it should be followed up on a large scale. It is, however, too small-scale and tentative to warrant recommendation now.

21
. See
chapter 12
, “The Place of Expert Help” in J. Orford,
Excessive Appetites
, for a telling review of psychotherapy and alcoholism.

22
. The full range of psychotropic drugs have been tried in alcoholism. None seem to work. See J. Halikas, “Psychotropic Medication Used in the Treatment of Alcoholism,”
Hospital and Community Psychiatry
34 (1983): 1035–39; and J. Sinclair, “The Feasibility of Effective Psychopharmacological Treatments for Alcoholism,”
British Journal of Addiction
82 (1987): 1213–23.

There have been two apparent exceptions, neither of which, however, has worked out when large-scale controlled studies were done.

The first apparent exception was Antabuse (disulfiram). For the best studies of Antabuse (double blind, placebo controlled) see J. Johnsen, A. Stowell, J. Bache-Wing, et al., “A Double-Blind Placebo Controlled Study of Male Alcoholics Given a Subcutaneous Disulfiram Implantation,”
British Journal of Addiction
82 (1987): 607–13; and J. Johnsen and J. Morland, “Disulfiram Implant: A Double-Blind Placebo Controlled Follow-up on Treatment Outcome,”
Alcoholism: Clinical and Experimental Research
15 (1991): 532–38.

The second apparent exception was lithium: In the first well-done study, a 67 percent abstinence rate after one year in a controlled, random-assignment design was found. See J. Fawcett, D. Clark, C. Aagesen, et al., “A Double-Blind Placebo-Controlled Trial of Lithium Carbonate Therapy for Alcoholism,”
Archives of General Psychiatry
44 (1987): 248–56. These results were promising, and were thought to be independent of lithium’s effect on manic-depression, until a major replication was undertaken: A double-blind study of 457 male alcoholics, both depressed and not depressed, showed no effect of lithium on alcohol drinking. See W. Dorus, D. Ostrow, R. Anton, et al., “Lithium Treatment of Depressed and Nondepressed Alcoholics,”
Journal of the American Medical Association
262 (1989): 1646–52.

23
. The aversion treatments make up a large literature. The best recent reviews are found in the debate between Terry Wilson and Ralph Elkins. See G. T. Wilson, “Chemical Aversion Conditioning as a Treatment for Alcoholism: A Reanalysis,”
Behaviour Research and Therapy
25 (1987): 503–16; R. Elkins, “An Appraisal of Chemical Aversion (Emetic Therapy) Approaches to Alcoholism Treatment,”
Behaviour Research and Therapy
29 (1991): 387–413; G. T. Wilson, “Chemical Aversion Conditioning in the Treatment of Alcoholism: Further Comments,”
Behaviour Research and Therapy
29 (1991): 415–19. The lone controlled study is D. Cannon, T. Baker, and C. Wehl, “Emetic and Electric Shock Alcohol Aversion Therapy: Six-and Twelve-Month Follow-up,”
Journal of Consulting and Clinical Psychology
49 (1981): 360–68.

I have to remark, again, that it is little short of a scandal that the therapies for alcoholism that patients have had for decades—inpatient hospitalization, aversion, and AA—do not have large-scale, random-assignment, controlled studies to document their alleged effectiveness. This is particularly scandalous when there is so much precedent showing that in this area, controlled studies usually suggest that treatment does not improve on the natural recovery rate.

24
. J. Volpicelli, A. Alterman, M. Hayashida, and C. O’Brien, “Naltrexone in the Treatment of Alcohol Dependence,”
Archives of General Psychiatry
49 (1992): 876–80; S. O’Malley, A. Jaffee, G. Chang, et al., “Naltrexone and Coping Skills Therapy for Alcohol Dependence,”
Archives of General Psychiatry
49 (1992): 881–87.

25
. Here are the three most useful sets of references as to whether AA works.

First, two studies in addition to Vaillant’s that show better prognosis for people who attend more AA meetings: M. O’Leary, D. Coastline, D. Haddock, et al., “Differential Alcohol Use Patterns and Personality Traits Among Three Alcoholics Anonymous Attendance Level Groups: Further Considerations of the Affiliation Profile,”
Drug and Alcohol Dependence
5 (1980): 135–44; V. Giannetti, “Alcoholics Anonymous and the Recovering Alcoholic: An Exploratory Study,”
American Journal of Drug and Alcohol Abuse
8 (1981): 363–70.

Second, the only studies that actually use a randomized assignment to treatment: One (K. Ditman, G. Crawford, C. Forgy, et al., “A Controlled Experiment on the Use of Court Probation for Drunk Arrests,”
American Journal of Psychiatry
124 [1967]: 160–63) shows no difference among AA, clinic attendance, and no treatment; another (J. Brandsma, M. Maultsby, and R. Welsh,
Out-Patient Treatment of Alcoholism
[Baltimore, Md.: University Park Press, 1980]) shows that AA does worse (more dropouts) than insight therapy, behavior therapy, or paraprofessional behavior therapy. Both these studies use court-referred involuntary subjects. They strongly suggest that AA is not useful for such subjects, on average, but they do not bear directly on the effectiveness of AA with voluntary subjects. A third randomized-assignment study, Walsh et al., “A Randomized Trial of Treatment Options,” assigned alcoholic workers to AA or to hospital-based detoxification (but with a strong AA component) and found that those assigned to AA alone did most poorly.

Third, some studies that look at AA effectiveness with voluntary attenders, but with substandard methods: D. Smith, “Evaluation of a Residential AA Program,”
International Journal of the Addictions
21 (1986): 33–49; AA World Services, “Analysis of the 1980 Survey of the Membership of AA” (unpublished report, New York, 1981); G. Alford, “Alcoholics Anonymous: An Empirical Outcome Study,”
Addictive Behaviors
5 (1981): 359–70.

This literature is usefully reviewed by B. McCrady and S. Irvine, “Self-Help Groups,” in R. Hester and W. Miller, eds.,
Handbook of Alcoholism Treatment Approaches
(New York: Pergamon, 1989).

26
. When data first came to light that some alcoholics could recover and still tipple, AA attacked in full force. For the beginnings of the
scientific
debate, see M. Sobell and L. Sobell, “Second Year Treatment Outcome of Alcoholics Treated by Individualized Behaviour Therapy,”
Behaviour Research and Therapy
14 (1976): 195–215, versus M. Pendery, I. Maltzman, and L. West, “Controlled Drinking by Alcoholics? New Findings and a Re-evaluation of a Major Affirmative Study,”
Science
217 (1982): 169–75. “Alcoholics could die because of this,” AA spokesmen were quoted as saying. That at least a few alcoholics recover through controlled drinking is now widely accepted. G. Nordstrom and M. Berglund, “A Prospective Study of Successful Long-term Adjustment in Alcohol Dependence: Social Drinking Versus Abstinence,”
Journal of Studies on Alcohol
48 (1987): 95–103; J. Orford and A. Keddie, “Abstinence or Controlled Drinking in Clinical Practice: A Test of the Dependence and Persuasion Hypothesis,”
British Journal of Addiction
81 (1986): 495–504; G. Edwards, A. Duckitt, E. Oppenheimer, et al., “What Happens to Alcoholics?”
Lancet
(30 July 1983), 269–71.

For the data that less-severe alcoholics recover through controlled drinking and that more-severe alcoholics recover through abstinence, see Vaillant,
The Natural History of Alcoholism
, 221–35.

27
. M. Sobell and L. Sobell,
Individualized Behavior Therapy for Alcoholics: Rationale, Procedures, Preliminary Results, and Appendix
(California Mental Health Research Monograph no. 13) (California Department of Mental Hygiene, 1972); Pendery et al., “Controlled Drinking by Alcoholics?” See especially H. Fingarette’s lucid discussion on pages 124–29 of
Heavy Drinking
, and the references in note 26, above.

28
. See
chapter 2
, “Can Alcoholics Control Their Drinking?” of H. Fingarette’s lucid little book
Heavy Drinking;
and A. Marlatt, “The Controlled Drinking Controversy,”
American Psychologist
38 (1983): 1097–1110.

29
. S. Curry, G. A. Marlatt, and J. Gordon, “Abstinence Violation Effect: Validation of an Attributional Construct with Smoking Cessation,”
Journal of Consulting and Clinical Psychology
58 (1987): 145–49; and G. A. Marlatt and S. Tapert, “Harm Reduction: Reducing the Risk of Addictive Behaviors,” in J. Baer, G. A. Marlatt, and R. McMahon, eds.,
Addictive Behaviors Across the Lifespan: Prevention, Treatment and Policy Issues
(Newbury Park, Calif.: Sage, 1993), 243–73.

30
. See
chapter 5
, “Heavy Drinking as a Way of Life,” in Fingarette,
Heavy Drinking
.

31
. See
chapter 7
, “Social Policies to Prevent and Control Heavy Drinking,” in Fingarette,
Heavy Drinking
.

PART FOUR
epigraph

1
. In J. S. Grant, ed.,
The Enthusiasms of Robertson Davies
(New York: Penguin, 1990), 235–36.

CHAPTER
14
Shedding the Skins of Childhood

1
. P. Davis,
The Way I See It
(New York: Putnam, 1992), 33–42.

2
. Adapted from John Bradshaw’s immensely popular
Homecoming: Reclaiming and Championing Your Inner Child
(New York: Bantam, 1990), 227, 239.

3
. Useful reviews: Divorce: R. Forehand, “Parental Divorce and Adolescent Maladjustment: Scientific Inquiry vs. Public Information,”
Behaviour Research and Therapy
30 (1992): 319–28. This review is a good corrective to the alarmist popular literature on divorce. It seems to be conflict, and not divorce per se, that does the harm. Parental Death: G. Brown and T. Harris,
Social Origins of Depression
(London: Tavistock, 1978). Birth Order: R. Galbraith, “Sibling Spacing and Intellectual Development: A Closer Look at the Confluence Models,”
Developmental Psychology
18 (1982): 151–73. Adversity (generally): A. Clarke and A. D. Clarke,
Early Experience: Myth and Evidence
(New York: Free Press, 1976); M. Rutter, “The Long-term Effects of Early Experience,”
Developmental Medicine and Child Neurology
22 (1980): 800–815.