_____________________________________________________________________ VOLUME 1, ISSUE 5 PSYCHNEWS INTERNATIONAL August/September 1996 _____________________________________________________________________ SECTION C: THE FIFTH COLUMN -------------------------------------------------------- Note: The Fifth Column is a regular, independent column written by Jeffrey A. Schaler, Ph.D. Opinions and comments are invited. Please send them to the PsychNews Int'l mailbox: firstname.lastname@example.org -------------------------------------------------------- SELLLING WATER BY THE RIVER THE PROJECT MATCH COVER-UP Jeffrey A. Schaler, Ph.D. "These contradictions are not accidental, nor do they result from ordinary hypocrisy: they are deliberate exercises in doublethink. For it is only by reconciling contradictions that power can be retained indefinitely." (Orwell, 1981, Pp. 176- 178) "'This world is not this world.' What I think he meant was that, after Auschwitz, the ordinary rhythms and appearances of life, however innocuous or pleasant, were far from the truth of human experience." (Lifton, 1986, p. 3) On June 25, 1996, I attended a symposium entitled "Project MATCH: Treatment Main Effects and Matching Results." That public presentation was sponsored by the 1996 Joint Scientific Meeting of the Research Society on Alcoholism (RSA) and the International Society for Biomedical Research on Alcoholism in Washington, D.C. Project MATCH (Matching Alcoholism Treatment to Client Heterogeneity) cost American taxpayers approximately $25 million. It is described here by Dr. Enoch Gordis, director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA): This study is the first national, multisite trial of patient-treatment matching and one of the two largest current initiatives of NIAAA. Established under a cooperative agreement that allows direct collaboration between the Institute and the researcher, the project involves nine geographically representative clinical sites and a data coordinating center. Researchers in Project MATCH are among the most senior and experienced treatment scientists in the field. Both public and private treatment facilities, as well as hospital and university outpatient facilities, are represented. (Gordis, 1995, p. vii) The National Academy of Sciences Institute of Medicine report entitled _Broadening the Base of Treatment for Alcohol Problems_ (1990) appears to have been the impetus for this ambitious project. That report described heavy drinkers as a heterogeneous population. Hypothetically, said the authors, a single treatment approach, e.g. Alcoholics Anonymous-based treatment, to helping heavy drinkers is not therapeutic for everyone. (1) Since drinkers vary, treatment should vary. Matching treatment protocol to the heterogeneous nature of the heavy-drinker population makes sense. Project MATCH studied whether three treatment approaches varied in effectiveness when clients were matched accordingly (treatment deemed most appropriate). The three independent variables were twelve-step facilitation (TSF) therapy (Nowinski et al., 1995), cognitive-behavioral coping skills therapy (CBT) (Kadden et al., 1995), and motivational enhancement therapy (MET) (Miller et al., 1995). "Because the three treatments can be readily taught and incorporated into a variety of treatment settings, the study could have a major impact on delivery of treatment services" (Project MATCH Research Group, 1993, p. 1142). The generalizability of findings appeared strong. The dependent measures included percentage levels of abstinence and drinks per day. The findings presented by the Project MATCH Research Group at the symposium in Washington, D.C., include the following: 1. There were excellent overall outcomes, which means that a substantial number of subjects became abstinent or reduced their daily consumption of beverage alcohol. 2. There were few differences in the effectiveness of the three treatment approaches, and any differences were not statistically significant. Those assigned to TSF did slightly better than those assigned to the CBT group. The MET group did the least well. Again, those differences were attributable to chance only. 3. Matching clients to particular treatments has no effect. Mismatches are not a major obstacle. 4. TSF is associated with better outcomes (based on the dependent measures used). But, again, the difference is attributable to chance only. I reported those findings on several Internet mail lists at St. John's University in Jamaica, N.Y., and discussion ensued. The accuracy of my report was confirmed (at my public suggestion) by Alex Taylor, a reporter from the Drug Policy Foundation (DPF) in Washington, D.C. Mr. Taylor wrote a story on the MATCH report for the _Drug Policy Letter_ (News item, 1996). He telephoned Margaret E. Mattson, Ph.D., Project MATCH staff collaborator and monograph series editor, Division of Clinical and Prevention Research at NIAAA. She consented to have her conversation with him tape-recorded for his story. Taylor read my report of findings to Dr. Mattson and she confirmed them as accurate on June 28, 1996. Strangely, on July 19, 1996, Dr. Mattson posted a letter sent to me via certified mail from Dr. Ronald Kadden, chair of the Project MATCH Steering Committee, on email@example.com (a public Internet mail list described as "Academic & Scholarly discussion of addiction related topics"). She also posted a private letter I had not yet received in the mail on a public list of which I am not a member. Dr. Gerard Connors, a principal investigator with the Project MATCH Research Group at the Research Institute on Addictions, Buffalo, N.Y., did the same thing. He posted the letter on a recovery-based, controlled-drinking mail list (firstname.lastname@example.org), one I created. They each prefaced the posted letter with the following statement: "Ron Kadden, in his capacity as Chair of the Project MATCH Research Group, has asked me to post this message. The actual letter has been mailed to Dr. Schaler." Here is the first part of the letter: Dear Dr. Schaler: It has come to the attention of the Project MATCH Research Group that there has been considerable discussion on the Internet regarding the results of the trial. Unfortunately, several of the communications that we have been shown contain a number of inaccuracies and thus do not adequately represent the trial nor its results as presented at RSA. Further, none of the results or interpretations that are being circulated have been confirmed by Dr. Margaret Mattson or anyone else in the Project MATCH Research Group, despite assertions they were. I forwarded a copy of the posted letter to the DPF reporter (Taylor), as he had informed me that Mattson had confirmed my report of the findings as accurate. Taylor immediately telephoned Mattson, Gordis, Kadden, and Anne Bradley (the press secretary for NIAAA), to discuss Kadden's public assertion that "none of the results or interpretations that are being circulated have been confirmed by Dr. Margaret Mattson or anyone else in the Project MATCH Research Group, despite assertions they were." Mattson, Gordis, and Kadden did not return Taylor's messages. Dr. Thomas F. Babor (another principal investigator of the MATCH project) and Ms. Bradley returned Taylor's call. (Note: Taylor never called Babor.) Babor refused to have his conversation with Taylor taped. He confirmed my report of the findings to Taylor as accurate but claimed that the TSF variable was different from Alcoholics Anonymous (AA)-based treatment, i.e. he asserted that the MATCH study did not test the effectiveness of AA. NIAAA Press Secretary Anne Bradley consented to having her conversation with Taylor taped. He informed her that Mattson's confirmation was taped with consent. Bradley stated in her official capacity (on tape with her consent) that Mattson HAD confirmed my report of the MATCH findings as accurate. NIAAA thereby contradicted Drs. Mattson and Kadden and the Project MATCH Research Group. Apparently, Drs. Mattson, Connors, and Kadden, in their official capacities as members and representatives of the Project MATCH Research Group, were lying. They used their federally funded professional positions to publicly state I was untruthful when in fact THEY were untruthful. Clearly, they acted unethically. Will they be reprimanded or censured for doing so? Is such unethical behavior sanctioned by federal research funds? What motivated their duplicitous behavior? THIS AA IS NOT THIS AA Dr. Kadden's letter to me continued: Some of the inaccuracies involve the treatments. For example, the Twelve Step Facilitation treatment is NOT a test of Alcoholics Anonymous. It would be useful for interested parties to refer to the treatment manuals, which are available from the National Clearinghouse for Alcohol and Drug Information. When is AA not AA? Apparently, when psychologists working for the government call it TSF. Kadden's assertion that TSF and AA are substantively different is patently absurd. However, I suggest readers judge this for themselves. For example, here is why the TSF variable, referred to as "the Twelve-Step approach of AA," was selected: "The Twelve-Step approach of AA was selected because of widespread belief in the effectiveness of this approach....Given the widespread popularity of the AA Twelve-Step approach, any matching effects found for it would be highly transportable" (Project MATCH Research Group, 1993, p. 1132). Consider the following quotations from the TSF manual that Kadden suggests "interested parties" refer to, especially in light of Kadden's and Babor's assertions that the TSF variable is not synonymous with the approach of AA: Twelve Step Facilitation Approach. This therapy is grounded in the concept of alcoholism as a spiritual and medical disease. The content of this intervention is consistent with the 12 Steps of Alcoholics Anonymous (AA), with primary emphasis given to Steps 1 through 5. In addition to abstinence from alcohol, a major goal of the treatment is to foster the patient's commitment to participation in AA. During the course of the program's 12 sessions, patients are actively encouraged to attend AA meetings and to maintain journals of their AA attendance and participation. Therapy sessions are highly structured, following a similar format each week that includes symptoms inquiry, review and reinforcement for AA participation, introduction and explication of the week's theme, and setting goals for AA participation for the next week. Material introduced during treatment sessions is complemented by reading assignments from AA literature (p. x)....The therapeutic approach underlying this manual is grounded in the principles and 12 Steps of AA (p. xi)....The program described here is intended to be consistent with active involvement in Alcoholics Anonymous....It adheres to the concepts set forth in the "Twelve Steps and Twelve Traditions" of Alcoholics Anonymous....The overall goal of this program is to facilitate patients' active participation in the fellowship of AA. It regards such active involvement as the primary factor responsible for sustained sobriety ("recovery") and therefore as the desired outcome of participation in this program (p. 1)....This treatment program has two major goals which relate directly to the first three steps of Alcoholics Anonymous (p. 2)....The two major treatment goals are reflected in a series of specific objectives that are congruent with the AA view of alcoholism (p. 3)....Central to this approach is strong encouragement of the patient to attend several AA meetings per week of different kinds and to read the "Big Book" ("Alcoholics Anonymous") as well as other AA publications throughout the course of treatment (p. 4)....The goal of the conjoint sessions is to educate the partner regarding alcoholism and the AA model, to introduce the concept of enabling, and to encourage partners to make a commitment to attend six Al-Anon meetings of their choice (p. 5)....[P]atients should be consistently encouraged to turn to the resources of AA as the basis for their recovery (p. 6)....Suggestions made by the 12-Step therapist should be consistent with what is found in AA-approved publications such as those that are recommended to patients (p. 8)....Encouraging patients to actively work the 12 Steps of Alcoholics Anonymous is the primary goal of treatment, as opposed to any skill that the therapist can teach (p. 10)....The therapist acts as a resource and advocate of the 12-Step approach to recovery (p. 11)....In this program, the fellowship of AA, and not the individual therapist, is seen as the major agent of change (p. 14)....The 12-Step therapist should not only be familiar with many AA slogans but should actively use them in therapy to promote involvement in AA and advise patients in how to handle difficult situations (p. 15)....In approaching alcoholic patients using this program...[t]here is...no cure for alcoholism; rather, there is only a method for arresting the process, which is active participation in the 12-Step program of Alcoholics Anonymous (p. 33). (Nowinski et al., 1995) Once again, Drs. Babor and Kadden and the Project MATCH Research Group have contradicted themselves. Why would they try to obscure the fact that TSF is essentially the same as AA? Would their obvious attempt at cover-up change had the findings been different, e.g. if a statistically significant difference in treatment effects had been found? Cui bono? SPIN DOCTORS Dr. Kadden concluded his letter with the following: We recognize that there is some impatience in the field to draw inferences from our findings. However, we believe that this can only be done in a scientifically valid way once the entire field has access to the findings. We therefore respectfully request that you and others wait for the paper that is to be published in the Journal of Studies on Alcohol in Jan. 1997 before drawing any conclusions, or implications regarding policy issues. Thank you for your consideration of this request. For the Project MATCH Research Group, Ronald Kadden, Ph.D. Chairman, Project MATCH Steering Committee Whose impatience? How do they "recognize" this impatience? What inferences? It's a simple statement of fact that the findings were confirmed. Remember, the Project MATCH Research Group (employee) works for the American taxpayer (employer). We are confronted with a situation here in which a group of employees tell a select group called "scientists" about the results of their publicly funded project. Then, the employer is told by the employees not to talk about the findings, i.e. the employees dictate employer behavior! Clearly, such gerrymandering (masquerading as science) protects the interests of a few in the name of the welfare of many. Base rhetoric is a bad habit among addiction-treatment and -research professionals. (2) Dr. Stanton Peele, a renowned expert on the interpretation of addiction research, wrote this about the Project MATCH Research Group's shameless attempts at spin doctoring: The MATCH researchers and NIAAA administrators have insisted that interested professionals not discuss the results they announced at an open conference until they can spin them in their uncontested presentations and articles. They are acting like the military officials who embargoed their reports on missile hits during the Gulf War (and perhaps with the same aim of covering up exaggerated claims of success). But isn't a research organization, unlike a military one, supposed to encourage open discussion of ideas and data? Not, apparently, when the principals are nervous about spending multimillions while failing to support the patient-treatment matching approach that they have been touting for years! (Personal communication, August 1996). (3) The Project MATCH Research Group's "respect[ful] request" is a euphemism for state-sanctioned restrictions on freedom of speech. NIAAA tried to pressure the Drug Policy Foundation into not publishing the news item by Alex Taylor. One reason for doing so is suggested above by Dr. Peele: The results of the $25 million project "[fail] to support the patient-treatment matching approach that they have been touting for years." In other words, according to the researchers' findings, it makes no difference whether heavy drinkers are treated as a homogeneous or as a heterogeneous population. They didn't get the results they were hoping for, so they began to backpedal. They tried to implement damage control by drawing the inference that "treatment works." That claim, by Dr. Gordis, did not hold up. There is another possible reason for the Project MATCH Research Group's cover-up, one that is potentially far more damaging to the researchers and the addiction-treatment industry, one that members of the self-help movement, as well as health-insurance and health-management corporations, will be most interested in (not to mention American taxpayers and their legitimate representatives in Congress). (4) SELLING WATER BY THE RIVER What might the Project MATCH Research Group's motivation for cover- up be? Note there was no statistically significant difference among cognitive-behavioral coping skills, motivational enhancement therapy, and twelve-step facilitation therapy in terms of achieving abstinence or reducing drinking. CBT and MET are generally part of professional- treatment programs. TSF is based in a self-help program, i.e. Alcoholics Anonymous. The reasonable answer to the question posed is this: The Project MATCH Research Group is afraid its findings will support the abolition of professional treatment for heavy drinking. There's no reason to pay for professional treatment when free self-help programs such as AA (or free self-help programs based on CBT or MET) are equally effective. Paying for treatment when a consumer can get it free simply doesn't make sense. Here's another way of considering the Project MATCH findings as presented at the conference in Washington: Contemporary, cognitive- based, "scientifically proven effective" approaches to helping heavy drinkers such as CBT and MET appear to be no more effective than the essence of one based on old-time religion, i.e. the essence of AA principles and philosophy. Whether the clients are matched or not matched to the most appropriate treatment, the effectiveness is the same insofar as achieving abstinence or reducing the number of drinks consumed (Schaler, in press)! Again, since the TSF variable represents the essential features of AA, and there's no difference between TSF and the other two variables in terms of achieving abstinence or reducing drinking, why pay for CBT- or MET-based treatment when AA is free? Health-management organizations, insurance companies, and Congress should consider that interpretation carefully. It could be used to justify major (if not complete) cutbacks in funding for treatment of heavy drinking. That would be a wise policy. Moreover, the self-help movement is growing steadily and continues to meet the diverse needs of heavy drinkers. In addition to AA there is now SMART Recovery, a secular, cognitive-behavior-therapy approach that is abstinence oriented. Diverse secular-based controlled-drinking programs are growing in number, too. (5) All these programs are autonomous and free. The Project MATCH findings support the idea that selling treatment for heavy drinking alongside free self-help programs such as AA is like selling water by the river, to coin a Zen saying. Why buy when the river gives it for free? Yes, this would likely destroy the economic foundations of the addiction-treatment industry. So what? If the members of that industry sincerely care about heavy drinkers seeking help (as they so often claim to), why wouldn't they welcome the lifting of an economic burden for these people, i.e. having to pay for treatment? Whose interests are really being served here? Dr. Enoch Gordis, director of the NIAAA, appears to have realized these implications. He began the discussion at the RSA symposium by claiming the Project MATCH findings showed that "treatment works." This, he asserted, was because so many people became abstinent or reduced their drinking through all three treatment approaches. At least four members of the audience moved quickly to the microphone and delivered essentially the same rejoinder. I was one of them and made the following statement: "I would like to reiterate what has just been said. There was no control group. With all due respect, Dr. Gordis, there is no evidence in this study to show that treatment is effective. In fact, there are studies showing no treatment is as effective as treatment" (Edwards et al., 1977; Chick et al., 1988; Sobell et al., 1996). The MATCH study findings could mean the end of the addiction- treatment industry--and be a boon to the self-help movement. Dr. Gordis tried to avoid this conclusion by attempting to divert discussion to "treatment works." Question: Why didn't the Project MATCH Research Group challenge Dr. Gordis on that idea? It is clear that AA-type self-help is as effective as cognitive-behavioral coping skills and motivational enhancement therapy. The whole idea of treatment effectiveness is suspect. Stanton Peele suggests the following study: "Divide the money spent on MATCH by the number of alcoholics MATCH treated, then give this amount to each of a new group of alcoholics and see how much they improve without any professionals in sight" (Personal communication, August 1996). THIS SCIENCE IS NOT THIS SCIENCE In summary, Dr. Margaret Mattson confirmed my report of the MATCH findings as accurate and then posted a letter by the Project MATCH Research Group claiming she had never confirmed them. That's the first contradiction. NIAAA contradicted the assertions in Dr. Kadden's letter. That's the second contradiction. The claim by Drs. Kadden and Babor that twelve-step facilitation therapy and Alcoholics Anonymous are substantively different from one another is contradicted by the official manuals they recommend. That's the third contradiction. On the one hand, the Project MATCH Research Group findings were presented at an open symposium. On the other hand, it asks that those findings not be discussed. That's the fourth contradiction. Dr. Enoch Gordis asserted that the MATCH study findings show "treatment works." Yet a control group was not used for comparison. That's the fifth contradiction. These contradictions expressed by NIAAA and the Project MATCH Research Group "are not accidental, nor do they result from ordinary hypocrisy: they are deliberate exercises in doublethink." They are not acts of aggression directed toward any one individual but toward individualism and autonomy (in the form of self-help groups such as AA, for example) as general forces threatening the authority of the state. They are directed toward people who dare to oppose the sanctity of a "therapeutic state" and the economic interests of the treatment industry. There will undoubtedly be attempts to reconcile these contradictions: "For it is only by reconciling contradictions that power can be retained indefinitely." (Orwell) We will likely hear how $25 million and the failed cover-up were committed on the behalf of "people in need." But that's a smoke screen, a cloud of obscurantism. When that means of evasion fails, indignation will surely follow: How dare we question their motives! How dare we hold NIAAA and the Project MATCH Research Group accountable for duplicity! How dare we question "science"! But this science is not this science. The "ordinary rhythms and appearances of [science], however innocuous or pleasant, [are] far from the truth of human experience." (Lifton) NOTES 1. See generally Donovan, D.M., and Mattson, M.E. (Eds.) (1994). Alcoholism treatment matching research: Methodological and clinical approaches. Journal of Studies on Alcohol, Supplement No. 12, December. 2. See Peele, S. (1986). Denial--of reality and freedom--in addiction research and treatment. Bulletin of the Society of Psychologists in Addictive Behaviors, 5, 149-166 (available at Stanton Peele's Web site: http://www.frw.uva.nl/cedro/peele/). 3. See also Peele, S. (1996). Recovering from an all-or-nothing approach to alcohol. Psychology Today, Sept./Oct., 35-43 & 68-70. 4. I urge readers to bring these issues to the attention of their congressional representatives, e.g. request a congressional investigation into possible mismanagement of federal funds. Ask your representative to consider the issues raised here in light of insurance bills requiring parity for treatment coverage between real diseases like cancer, heart disease, and diabetes and fake ones like addiction. 5. I do not recommend Moderation Management, Inc. (MM), a nonprofit organization whose founders appear (in my opinion) to be jockeying for financial gain, i.e. profit status. I was a founding member of the MM Board of Directors and resigned, severing all relations with that organization on August 16, 1996. REFERENCES Chick, J., Rison, B., Connaughton, J., Stewart, A., and Chick, J. (1988). Advice versus extended treatment for alcoholism: A controlled study. British Journal of Addiction, 83, 159-170. Edwards, G., Orford, J., Egert, S., Guthrie, S., Hawker, A., Hensman, C., Mitcheson, M., Oppenheimer, E., and Taylor, C. (1977). Alcoholism: A controlled trial of "treatment" and "advice." Journal of Studies on Alcohol, 38, 1004-1031. Gordis, E. (1995). Foreword. In Nowinski, J., Baker, S., and Carroll, K. Twelve Step Facilitation Therapy manual. A clinical research guide for therapists treating individuals with alcohol abuse and dependence. National Institute on Alcohol Abuse and Alcoholism Project MATCH Monograph Series Volume I. U.S. Department of Health and Human Services, Rockville, Md. Institute of Medicine. (1990). Broadening the base of treatment for alcohol problems. Washington, D.C.: National Academy of Sciences Press. Kadden, R., Carroll, K., Donovan, D., Cooney, N., Monti, P., Abrams, D., Litt, M., and Hester, R. (1995). Cognitive-Behavioral Coping Skills Therapy manual. A clinical research guide for therapists treating individuals with alcohol abuse and dependence. National Institute on Alcohol Abuse and Alcoholism Project MATCH Monograph Series Volume III. U.S. Department of Health and Human Services, Rockville, Md. Lifton, R.J. (1986). The Nazi doctors: Medical killing and the psychology of genocide. New York: Basic Books. Miller, W.R., Zweben, A., DiClemente, C.C., and Rychtarik, R.G. (1995). Motivational Enhancement Therapy manual. A clinical research guide for therapists treating individuals with alcohol abuse and dependence. National Institute on Alcohol Abuse and Alcoholism Project MATCH Monograph Series Volume II. U.S. Department of Health and Human Services, Rockville, Md. News item. (1996). "Free Advice on Treating Alcoholics" in Summer 1996 issue of the Drug Policy Letter (p. 5). To subscribe, call the Drug Policy Foundation in Washington, D.C.: (202) 537-5005 or write email@example.com. Nowinski, J., Baker, S., and Carroll, K. (1995). Twelve Step Facilitation Therapy manual. A clinical research guide for therapists treating individuals with alcohol abuse and dependence. National Institute on Alcohol Abuse and Alcoholism Project MATCH Monograph Series Volume I. U.S. Department of Health and Human Services, Rockville, Md. Orwell, G. (1981). Nineteen eighty-four. New York: New American Library. Project MATCH Research Group. (1993). Project MATCH: Rationale and methods for a multisite clinical trial matching patients to alcoholism treatment. Alcoholism: Clinical and Experimental Research, 17, 1130-1145. Schaler, J.A. (in press). Spiritual thinking in addiction treatment providers: The Spiritual Belief Scale. Alcoholism Treatment Quarterly. Sobell, L.C., Cunningham, J.A., and Sobell, M.B. (1996). Recovery from alcohol problems with and without treatment: Prevalence in two population surveys. American Journal of Public Health, Vol. 86, No. 7, 966-972. Jeffrey A. Schaler, Ph.D., is an adjunct professor of justice, law and society at American University's School of Public Affairs in Washington, D.C.; an adjunct professor of psychology at Montgomery College in Rockville, Md.; and a member of the part-time faculty (psychology) at Johns Hopkins University in Baltimore, Md. He lives in Silver Spring, Md.
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