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VOLUME 2, ISSUE 3 PSYCHNEWS INTERNATIONAL May-June 1997
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FEATURE ARTICLE
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BAIT AND SWITCH IN PROJECT MATCH:
WHAT NIAAA RESEARCH ACTUALLY SHOWS
ABOUT ALCOHOL TREATMENT
Stanton Peele, Ph.D.
ABSTRACT
Project MATCH was an extremely expensive clinical
trial in which a volunteer, selected group of mainly
alcohol dependent patients who had a small number of
outpatient sessions of three different types of therapy
with a highly trained and monitored staff reduced their
drinking substantially over a year period. However, the
primary purpose of the study was to show that alcoholics
with different profiles will respond better to different
sorts of treatment, so that overall outcomes can be
improved by proper matching of alcoholics with treatment
type. Project MATCH results disproved the matching
hypothesis, which prominent clinical researchers had
pushed for years (Allen & Kadden, 1995; IOM, 1990;
Mattson, 1994; Miller, 1989).
In MATCH's aftermath, NIAAA director Enoch Gordis
and other MATCH representatives touted the surprisingly
good overall outcomes in the study, which they
interpreted to show that alcoholism treatment as
delivered in the U.S. (which in over 93 percent of
centers is 12-step treatment; Roman & Blum, 1997)
produces good results. This conclusion is unfounded.
Indeed, a concurrent community study (NLAES) by the
NIAAA revealed results of treatment as actually
experienced in the U.S. to be shockingly bad, leading to
outcomes worse than for those who went untreated for
their alcohol dependence!
The NIAAA's willingness to interpret MATCH results
to support ideas it could not properly test (in the
absence of a nontreatment control group) is disturbing
both because it is unscientific and because it seems to
be politically motivated. Moreover, several revisionist
commentators on Project MATCH (including the present
author) have been attacked by MATCH investigators. MATCH
and the NIAAA have embargoed alternative interpretations
in order to control these results and spin them to their
advantage and that of the alcoholism establishment.
The results that are consistent across both MATCH
and NLAES are that (1) minimal or no treatment produces
outcomes that are equal to/better than those from
longer/standard treatments; (2) patient traits and
initiative are far more important than treatment type or
intensity for recovery; (3) reduced drinking is the most
common outcome for alcohol-dependent individuals, an
idea that has been verboten on the American alcoholism
scene (Peele, 1992).
THE BASIC PROJECT
Project MATCH Overview. MATCH was organized by the
National Institute on Alcohol Abuse and Alcoholism to
assess the impact of three different types of alcohol
treatment (Coping Skills, Motivational Enhancement, and
12 Step) with special reference to patient
characteristics that might predict better outcomes for
each treatment for different types of alcoholics.
Treatment was on an outpatient basis (for a purely
outpatient group and an aftercare to hospital treatment
group). Subjects were treated for 3 months and outcomes
were measured at three-month points until a year after
treatment. The two primary outcome measures were days
abstinent and drinks per drinking day (Project MATCH
Research Group, 1997).
Project Staff and Resources. The cost of Project
MATCH was originally placed at $27 million. However,
John Allen, an NIAAA administrator, has since put the
cost at $35 million (Jeffrey Schaler, private
communication, May, 1997). The training manuals created
by MATCH include a foreword by Enoch Gordis announcing:
"Researchers in Project MATCH are among the most senior
and experienced treatment scientists in the field."
Overall, MATCH involved up to 130 clinical professionals
in its treatment, administration, and analysis
components.
Subjects. The study began with 1,726 subjects,
almost all of whom (>95%) measured alcohol dependent.
Potential subjects were assessed for alcohol
abuse/alcohol dependence according to DSM-III-R, but
were excluded if they had concurrent drug dependencies
(even though "combined alcohol and drug abuse show up as
the most frequent problem at admission to substance
abuse treatment"; SAMHSA, 1997). Initially, 4,481
subjects were identified. At initial screening, 459
declined to participate because of the "inconvenience"
of treatment (which the Project MATCH Research Team,
1997, p. 11, asserted was "attributable to logistical
considerations rather than... motivation"). Other
potential subjects were excluded for "failure to
complete the assessment battery; residential
instability; legal or probation problems, etc.," but no
figure is given for how many fell into each category.
Thus, subjects were volunteers with better than
average prognosticators (e.g., residential stability;
not also abusing drugs). But the study report did not
compare patients who were treated to those who were
eliminated from the study or to alcoholics in general.
Nonetheless, the Team contended, "nor is there reason to
believe that the recruitment procedures failed to
provide a broad range of clients typically seen in these
types of clinical settings" (p. 11).
About 10 years ago at the conference "Evaluating
Recovery Outcomes" (University of California, 1988, p.
23), MATCH principal investigator Richard Longabaugh
commented on a study at a private treatment center
[Edgehill Newport] which found that "66 percent of the
patients in the program were continuously sober at a
one-year follow-up. However, the program report was
limited to treatment of socially-stable patients...
[along with other filters]. Was this population
representative of the population they were treating?"
Longabaugh contended that since the research did not
analyze excluded subjects, "skeptics like myself" had to
conclude it was worthless as a comparative assessment of
treatment.
Treatment Delivery. Treatment was delivered
individually on an outpatient basis. Delivery involved
12 weekly sessions, except for motivational enhancement,
which was four sessions. Subjects on average completed
only two-thirds of their sessions (which seems like 3
sessions for motivational enhancement and 8 sessions for
the other two therapies). Treatment protocols and
standards for therapist certification were developed;
all sessions were videotaped and 25 percent were
monitored by supervisors. The care and quality control
of Project MATCH therapy differs substantially from
standard treatment provided for alcoholism patients in
the U.S. Jon Morgenstern, of the Rutgers Center of
Alcohol Studies, has observed alcohol counselors in
regular treatment settings and reports their standard of
therapy is extremely poor (personal communication, early
1997, at a PBS production meeting).
Client Measures. Treatment lasted 12 weeks with
three-month assessments up to 15 months. Ten primary
client characteristics were measured and reported (e.g.,
conceptual level, motivation, psychiatric severity,
gender). Additional secondary characteristics not yet
reported were also measured, including DSM diagnostic
categories, self-efficacy, alcohol dependence and seven
other traits and "several higher order and global
matching hypotheses."
Drinking Results. Subjects substantially reduced
drinking intensity and frequency of drinking across all
treatments, but relatively few did not drink at all.
Overall, drinking fell from an average of 25 days to 6
days per month and amount consumed on drinking occasions
was also reduced. About 20 percent of the outpatient
group and slightly over a third (35%) of the aftercare
group abstained throughout the year follow-up. However,
only 40% of aftercare and 46% of outpatient subjects
drank heavily for three straight days during the year
follow-up. In other words, a third of outpatient
alcoholics drank without bingeing compared with a fifth
who abstained.
Treatment and Interaction Effects. There were no
significant differences in drinking days overall or in
any month or any other main effects among the treatment
groups. Sixteen hypothesized interactions between the
ten client characteristics and three treatment types
were conceived. In the aftercare group, no significant
impact on drinking outcomes was found for any of these
interactions. In the outpatient group, less
psychiatrically severe subjects had 4 more abstinent
days per month on average in 12-Step than in Coping
Skills treatment.
Thus, 64 interactions were tested -- 16 (patient x
treatment interactions) x 2 (outpatient v aftercare) x 2
outcomes (drinking days v # drinks on drinking days) --
and one of 64 proved significant, an interaction
involving two of the three treatments that was not
explicitly hypothesized. When large numbers of
hypotheses are tested, some will be significant by
chance alone. Thus, the null hypothesis that matching
has no significance for outcomes was supported by this
study. There were significant client characteristic
effects, however -- for example, among outpatients,
higher motivation led to significantly better drinking
outcomes, while in both the outpatient and aftercare
groups greater social support for drinking (presumably
excessive) predicted worse outcomes.
CONCLUSIONS
1. "The largest, statistically most powerful,
psychotherapy trial ever conducted," and also by far the
most expensive, produced little new information.
2. Research limitations -- including a highly
selected client population and unusually high level of
quality control of treatment -- make generalization of
these results dubious. "The overall effect of being part
of Project MATCH, with extensive assessment, attractive
treatments, and aggressive follow-up may have minimized
naturally occurring variability among treatment
modalities and may, in part, account for the favorable
treatment outcomes" (Project MATCH Research Team, 1997,
p. 24).
3. The principal result of this study was that
modest treatment contact produced substantial and
enduring drinking reductions among an alcohol dependent
population. Motivational enhancement involving 4 or
fewer sessions produced results as good as treatments
involving several times as many sessions.
4. While no treatment characteristics were
significant, and virtually no treatment-patient matches,
psychological and contextual traits of alcoholics were
significant for outcomes.
5. Treatment outcomes were conceived primarily as
successful reduction in drinking, which is utterly at
variance with treatment goals as usually conceived in
the U.S., where 99 percent of programs urge abstinence
(Roman & Blum, 1997).
THE LARGER CONTEXT AND THE AFTERMATH OF PROJECT MATCH
Treatment Works!--NOT!
A June, 1996 presentation of MATCH results and a
December, 1996 MATCH press conference were highly
publicized (cf. Leary, 1996; Peele, 1996). MATCH
principals and NIAAA director Gordis emphasized the
remarkable success of alcoholism treatment. According to
Gordis: "The good news is that treatment works. All
three treatments evaluated in Project MATCH produced
excellent overall outcomes" (Bower, 1997, p. 62).
MATCH's lead researcher, Thomas Babor, of the University
of Connecticut, declared "participation in any of the
MATCH treatments would be associated with marked
positive change" (Alcoholism & Drug Abuse Week, 1997).
The effectiveness of treatment is heavily promoted
by government agencies in conjunction with the treatment
industry in the U.S. "Treatment Works! Month" is
celebrated on the Internet (www.health.org/csat/) and
other media: "Designed by SAMHSA (Substance Abuse and
Mental Health Services Administration)/CSAT (Center for
Substance Abuse Treatment) with the cooperation of the
National Association of Alcoholism and Drug Abuse
Counselors (NAADAC), these promotional materials will
help educate people throughout your state, county, city
or community about the true value of treatment and the
fact that it really works." If treatment works in the
U.S., then 12-step therapy must be highly successful. As
NIAAA MATCH coordinator Margaret Mattson concluded: "The
results indicate that the Twelve Step model, which is
the most widely practiced treatment in the U.S., is
beneficial" (Mattson, 1997).
But clinical research has not found that all
treatments are equally effective. Tolling decades of
controlled research on alcohol treatment, Miller and his
colleagues rated brief interventions, social skills
training, and motivational interviewing highest in
effectiveness, while general alcoholism counseling and
education lectures were at the bottom. Rated at the
bottom of the list of treatments without sufficient
evaluations to be reliably tested was Alcoholics
Anonymous. Yet alcohol treatment in America comprises
primarily these disproven elements -- "The negative
correlation between scientific evidence and application
in standard practice remains striking, and could hardly
be larger if one intentionally constructed treatment
programs from those approaches with the least evidence
of efficacy" (Miller et al., 1995, p. 33).
Another NIAAA research project provided an actual
comparison between treated and untreated alcoholics,
unlike MATCH. This is the National Longitudinal Alcohol
Epidemiologic Survey (NLAES) of subjects in the general
population who were assessed as alcohol dependent, and
who either received or did not receive (the large
majority) treatment. Its results were:
NLAES DATA ON ALCOHOL DEPENDENT SUBJECTS
Outcome categories Treated Untreated
(n=1,233) (n=3,309)
< 5 years since onset dependence
alcohol abuse 70% 53%
abstinent 11% 5%
drinking w/o abuse 19% 41%
20+ years since onset dependence
alcohol abuse 20% 10%
abstinent 55% 30%
drinking w/o abuse 24% 60%
Source: Dawson (1996)
Thus, a study designed and conducted by the NIAAA to
determine actual experiences of American alcoholics
yields a picture far different from the optimistic
results projected by NIAAA and Project MATCH officials
and the Treatment Works! coalition: i.e., those entering
alcohol treatment actually fare worse than untreated
alcoholics.
Although all subjects in NLAES were alcohol
dependent, treated subjects had somewhat more severe
symptoms than untreated subjects. But the goal of
government agencies and private treatment providers of
getting untreated alcoholics into treatment finds no
justification in these NIAAA data. The most obvious
results of NLAES are (1) alcohol dependence diminishes
over time in both treated and untreated groups, and such
"maturing out" dwarfs any benefit of treatment; (2)
while treatment encourages abstinence, it suppresses the
moderation of alcohol dependence that occurs naturally
in the majority of cases, so that more treated
alcoholics continue to drink abusively. The results of
both NLAES and MATCH indicate the abstinence fixation
that characterizes American alcoholism treatment is
deeply dysfunctional.
SPINNING PROJECT MATCH
The NIAAA faced in NLAES and MATCH a combination of
embarrassing results: the most expensive treatment study
ever conducted was a dud, while NIAAA research shows
that alcohol treatment in the U.S. doesn't work well.
MATCH researchers and the NIAAA acknowledged that "These
findings challenge the notion that patient-treatment
matching is necessary in alcoholism treatment" (Gordis
quoted in Leary, 1996). The NIAAA's Mattson (1997), a
major "matching" backer, declared, ".... based on the
main findings of Project MATCH, matching seems to add
little to improving treatment...."
But when outsiders commented on MATCH results,
MATCH researchers screamed murder. The first
announcement of results in Washington DC in June, 1996
made clear the virtual absence of significant matching
relationships, while Gordis said the results showed
alcoholism treatment worked well. When psychologist
Jeffrey Schaler gave his own interpretation of MATCH
results on Internet lists, Ronald Kadden, writing as
Chair of the Project MATCH Steering Committee, objected
to Schaler's discussion (Schaler, 1996). This quasi-
governmental communication charged that Schaler falsely
stated that Mattson had confirmed Schaler's summary of
MATCH results. The NIAAA later conceded that she had
indeed done so.
In my own case, a MATCH researcher, Richard
Longabaugh, of Brown, wrote on the APA addiction list
server (this quote, which is fairly incomprehensible, is
exact):
"I am a Project MATCH P.I., who has followed much
of the correspondences on this list server regarding
Project MATCH results. Contary [sic] to Stenton [sic]
Peele's conclusion, the results of Project MATCH are far
from concluded. There are at least two more papers (one
under review, and one in preparation) focusing on the
primary match of findings. That should be digested. Only
then do I think we will have a sufficient view of the
finding's (sic) to evaluate MATCH's contribution. To the
alcohol treatment knowledge base, I'd say publications
of these results are about a year away. On the other
hand, discussion is 'livelier' without the facts." (APA
Division 50 list server, April 16, 1997)
The NIAAA's and other "insider" researchers'
reactions to outside critiques is predictable in terms
of how bureaucracies behave. But it is nonetheless
startling to see researchers claim that others cannot
interpret their data, even as NIAAA administrators and
MATCH researchers do exactly that publicly! According to
Longabaugh, for instance, non-MATCH investigators should
not respond to interviews and published comments by
Gordis, Babor, and Mattson until at least another year,
despite the highly detailed, 22-journal-page research
article the Team has published.
The MATCH situation calls to mind the Dead Sea
Scrolls, to which "access [was] ... tightly controlled
by a small circle of scholars, who ... built their
careers on translating and analyzing the 2,000-year-old
religious works" ("Resurrection of the Dead Sea
Scrolls," 1991). Here, a government agency and its
representatives are trying to suppress free analysis and
interpretation of federally funded research. Another
case of suppression of free enquiry and exchange
involving alcohol was recently revealed in regard to the
NIH's refusal in 1972 to allow Harvard anthropologist
Carl Selzer to publish data revealing that moderate
drinkers had less heart disease than abstainers (Altman,
1997; Selzer, 1997). This cannot be tolerated by either
science or a free society.
REFERENCES
Alcoholism & Drug Abuse Week. (1997, January 6). P
1.
Allen, J.P., & Madden, R.M. (1995). Matching
clients to alcohol treatments. In R.K. Hester and W.R.
Miller (Eds.), Handbook of alcoholism treatment
approaches (2nd Ed., pp. 278-291). Boston: Allyn and
Bacon.
Altman, L.K. (1997, April 29). Experts see bias in
drug data. New York Times, pp. C1, 8.
Bower, B. (1997, January 25). Alcoholics
synonymous: Heavy drinkers of all stripes may get
comparable help from a variety of therapies. Science
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Dawson, D.A. (1996). Correlates of past-year status
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Leary , W.E. (1996, December 18). Responses of
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Mattson, M.E. (1994, September 22). Patient-
treatment matching. Alcohol Health & Research World, 18,
287-295.
Mattson, M.E. (1997, March). Treatment can
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bureaucracy: The consensus against controlled drinking
in America. Addictive Behaviors, 17, 49-62.
http://peele.sas.nl/lib/nathan.html
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Today, pp. 35-43; 68-70.
http://peele.sas.nl/lib/allornothing.html
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treatment center study. Athens, GA: Institute of
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Schaler, J. (1996, August/September). Selling water
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interest" and "political science." Journal of Clinical
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Evaluating recovery outcomes: A national conference. San
Diego: UCSD Extension.
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Stanton Peele, Ph.D., a social psychologist and author
of numerous books and articles, is internationally
recognized and respected as an authority on addiction
and social policy. Visit the Stanton Peele Addiction Web
Site at http://speele.sas.nl