Alcoholics Synonymous Heavy drinkers of all stripes may get comparable help from a variety of therapies

 Psychotherapy studies rarely generate as much anticipation as Project MATCH did. Mental health clinicians and addiction researchers anxiously awaited the results of this 8-year, $27-million investigation that asked whether certain types of alcoholics respond best to specific forms of treatment. The federally funded investigation promised to yield insights that would bring badly needed guidelines to alcoholism treatment and perhaps allow clinicians to tailor the current hodgepodge of approaches to the particular needs of each excessive imbiber.

 The coordinators of Project MATCH have finally served up their findings, but with a shot of disappointment and a twist of irony. At a press conference held last December in Washington, D.C., they announced that alcoholics reduce their drinking sharply and to roughly the same degree after completing any of three randomly assigned treatments.

 Trained psychotherapists administered the three programs. In 12-step facilitation therapy, the therapist familiarizes the client with the philosophy of Alcoholics Anonymous (which treats alcoholism as an illness treatable only through abstinence, support from other addicts, and personal surrender to God's spiritual authority) and encourages attendance at AA meetings. Cognitive-behavioral coping skills therapy focuses on formulating strategies for avoiding or dealing with situations that tempt one to drink. Motivational enhancement therapy helps clients to identify and mobilize personal strengths and resources that can reduce alcohol consumption.

 Treatment matching has operated on the assumption that alcoholics fall into categories best served by particular strategies. For instance, 12-step facilitation therapy and AA might work best with alcoholics searching for spiritual and religious meaning in their lives, cognitive-behavioral therapy may suit alcoholics who display serious psychiatric symptoms and thinking difficulties, and motivational enhancement could act as a tonic for heavy drinkers who express little desire or hope for improvement.

 The new findings, however, "challenge the notion that patient-treatment matching is necessary in alcoholism treatment," states Enoch Gordis, director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in Bethesda, Md. "The good news is that treatment works. All three treatments evaluated in Project MATCH produced excellent overall outcomes."

 Despite Gordis' optimism, opinions diverge sharply regarding the study's implications and the adequacy of its design. Some alcoholism researchers agree with the NIAAA director. They view Project MATCH as a critical step toward the ultimate goal of developing sophisticated therapeutic approaches that thwart the suspected biological causes of uncontrolled alcohol use.

 Others dub the federal effort an expensive dud. The absence of a control group of alcoholics who received no specific intervention raises the likelihood that volunteers improved because of intensive personal attention and encouragement rather than any specific treatment techniques, these investigators argue. At best, they contend, the data suggest that AA and other free self-help groups prove effective enough to replace professionally administered alcoholism treatments that command big insurance bucks.

 A third perspective holds that flaws in the design of Project MATCH leave open the possibility that many alcoholics benefit from treatment matching or could abandon their addiction on their own, outside the world of clinical interventions and AA.

 Scientific interest in developing treatments attuned to alcoholics' individual characteristics goes back at least 50 years. More than 30 small-scale studies published during the 1980s reported that treatment matching based on a number of individual characteristics held promise for alleviating alcoholism. In 1989, the NIAAA initiated Project MATCH (which stands for matching alcoholism treatments to client heterogeneity) to examine closely the most promising of those leads.

 A total of 1,726 people diagnosed as alcohol-dependent (a condition marked by daily intoxication or extended drinking binges that disrupt home and work activities) were recruited from outpatient clinics or facilities that provide care following hospital stays. The volunteers were randomly assigned to one of the three designated treatments, which were delivered over 12 weeks at 30 locations by 80 psychotherapists.

 Individuals also dependent on drugs other than alcohol were excluded from the study, although more than one in three volunteers reported having recently used an illicit substance.

 Alcohol use was monitored for 1 year after treatment ended, with particular attention paid to the influence of the following individual characteristics on recovery: sex, extent of prior alcohol consumption, the presence of psychiatric symptoms, aggressive and criminal tendencies, difficulties in thinking and reasoning, motivation to change, desire to find meaning in life, and number of family members and friends likely to promote continued alcohol abuse.

 Comparably large drops in alcohol consumption occurred for participants after courses of either 12-step facilitation, cognitive-behavioral, or motivational therapy, according to the NIAAA investigation, which appears in the January Journal of Studies on Alcohol. Before treatment, volunteers, on average, drank on 25 out of 30 days, a number that fell to 6 days of drinking per month by the end of the follow-up. The amount imbibed on drinking days also dropped markedly after treatment.

 In the year of follow-up, 35 percent of volunteers reported not drinking but 40 percent still had periods of heavy drinking on at least 3 consecutive days.

 Only one individual characteristic affected treatment responses, notes psychologist Gerard Connors of the Research Institute on Addictions in Buffalo, N.Y., a Project MATCH investigator. Alcoholics exhibiting few or no signs of psychological disturbance achieved abstinence through 12-step facilitation therapy more often than those with pronounced mental symptoms.

 It remains possible that treatment methods not included in Project MATCH, such as group or marital therapy, work especially well for certain types of alcoholics, Connors notes.

 For now, Gordis contends, it appears that individual therapies based on a variety of philosophies make approximately the same dent in alcohol use. The development of new drugs that diminish alcohol cravings will add to the impact of current psychosocial approaches, he holds.

"Treatment matches may become apparent when we get to the core of the physiological and brain mechanisms underlying addiction and alcoholism," Gordis asserts.

 Since the Project MATCH results were first openly discussed at a meeting of alcoholism researchers in Washington, D.C., last June, a dissenting interpretation of their significance has been advanced. Because encouragement to attend AA meetings achieves as much as the two professionally administered treatments under study, according to this view, free self-help groups for heavy drinkers may pack enough punch to justify abolishing insurance coverage for paid treatments. The self-help groups are organized by volunteers and supported through donations.

"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," contends psychologist Jeffrey A. Schaler of American University in Washington, D.C. "Why buy when the river gives it for free?"

 Moreover, the lack of a nontreatment control group that received as much regular attention and support during the 1-year follow-up as the group given treatment makes it impossible to tell whether any of the Project MATCH interventions had a specific impact, asserts psychologist Stanton Peele, a clinician and writer in Morristown, N.J.

 Even if the interventions did work, the findings apply only to the minority of alcoholics who voluntarily enter treatment in clinical settings, Peele argues. A majority of those who seek professional or AA-type treatment for substance abuse in the United States do so on the orders of judges (following arrests for drunk driving or other offenses) or employers, according to federal data.

 Recovery from alcohol dependence or milder alcohol abuse most often occurs outside the confines of hospitals, psychotherapists' offices, or self-help groups, further undermining confidence in such treatments, Peele adds.

 For instance, a pair of Canadian telephone surveys -- one nationwide and one in Ontario -- find that of the randomly selected adults, three in four who had recovered from an alcohol problem 1 year or more previously did so without any outside help or treatment. About one in three of those who recovered in the national sample continued to drink in moderation, a figure that rose to two in three in Ontario, report psychologist Linda C. Sobell of Nova Southeastern University in Ft. Lauderdale, Fla., and her coworkers in the July 1996 American Journal of Public Health.

 Similar results emerged from an analysis of interviews conducted in 1992 with 4,585 U.S. adults who had at some time been diagnosed as alcohol-dependent. In the year before the interviews, about one in four still had mild to severe alcohol problems, a similar proportion had drunk no alcohol, and the rest had imbibed in moderation, asserts NIAAA epidemiologist Deborah A. Dawson.

 Those who had received some sort of treatment were slightly more likely than their untreated counterparts to have had alcohol problems in the past year, Dawson reports in the June 1996 Alcoholism: Clinical and Experimental Research. For those whose recovery lasted 5 years or more, prior treatment raised the likelihood of abstinence, whereas lack of treatment upped the chances of drinking in moderation.

"Treatment studies may not be generalizable to alcoholics who do not seek treatment," Dawson concludes.

 Peele, who views alcoholism not as a medical disease but as a learned behavior employed to cope with life's challenges, goes further. Such evidence, combined with the fact that the expansion of treatment rolls during the past 20 years has failed to reduce substance abuse rates, indicates that professional and AA-type approaches often present more risks than advantages to alcoholics, particularly those coerced into treatment, he contends.

 George E. Vaillant, a psychiatrist at Brigham and Women's Hospital in Boston and director of a 50-year study of male alcoholics, takes a much less radical stance than Peele, although he still has reservations about the design of Project MATCH.

 Alcoholics Anonymous and behavioral interventions such as those in the NIAAA investigation provide more help over the long haul than any other forms of treatment, without regard to the personal characteristics of alcoholics, Vaillant argues.

"The Project MATCH findings are exactly what I would have predicted," the Boston researcher says.

 In his opinion, researchers need to examine differences between alcoholics who succeed in recovering and those who fail, rather than limiting themselves to a search for contrasts among professionally run treatments.

 Sustained recovery requires at least two of the following experiences, Vaillant theorizes: some sort of compulsory supervision (such as parole) or a painful alcohol-related event (such as a bleeding ulcer or a spouse's departure); finding a substitute dependency, such as meditation or AA meeting attendance; forming new, stable relationships that diminish addictive behaviors; and reformulating personal identity and the meaning of one's life through religious conversion or self-help group participation.

 Such factors went unexamined in Project MATCH, according to Vaillant. Most notably, large segments of all three treatment groups attended AA meetings (and were not discouraged by researchers from doing so), thus obscuring the role played by AA in successful recoveries, he argues.

"Project MATCH was poorly designed, to say the least," asserts psychologist G. Alan Marlatt of the University of Washington in Seattle, a pioneer in the development of behavioral treatments for alcoholism. "Everybody can now project their own views about alcoholism onto this study."

 Aside from the lack of a control group, the federal study also failed to evaluate directly the practice of patient matching, Marlatt holds. Volunteers were assigned to certain treatments not according to specific personal characteristics but at random; researchers tried to ferret out traits linked to improvement after therapy began.

 In addition, the relatively "pure" alcoholics recruited for Project MATCH may respond to treatment differently than the majority of alcohol abusers, who regularly use one or more illicit drugs as well, Marlatt says.

 While many questions remain about the effectiveness of alcoholism treatments, several psychotherapy studies -- including a large federal study of depression treatments -- find that some therapists are far better than others at fostering improvement in their clients. The quality of the relationship between a therapist and an alcoholic client probably exerts a major influence on how well a particular treatment works, Marlatt suggests.

 To put it another way, therapist-client matching may turn out to hold at least as much research promise as patient-treatment matching -- especially since the value of patient-treatment matching, at least for now, remains unclear.