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6 Is Treatment Necessary? Faced with this chapter's title question, one is tempted to respond reflexively, with both urgency and gruffness, "Of course it is! How can one seriously question the necessity of treatment for problems that destroy hundreds of thousands of lives and cost our country hundreds of millions of dollars each year?" Yet the diversity of alcohol problems (see Chapter 2) requires that this question be considered more thoughtfully. In the previous chapter, which is supplemented by the material in Appendix B. the considerable evidence that some people with alcohol problems respond in a definite and gratifying manner to some treatments has been extensively presented. In this chapter the committee addresses some additional facts that serve to fill out a more comprehensive and at the same time more complex picture of response to treatment. These include the findings that (aJ some people with alcohol problems overcome them without arty formal treatment experience; (bJ some people who receive formal treatment have worse drinking problems afterward* and (cJ some people who are coerced into treatment do not fare better than those who receive no treatment. Improvement in Alcohol Problems Without Formal Treatment The phenomenon of improvement without treatment is characteristically referred to as "spontaneous remission," a label that is misleading with respect to both of its two terms (Stall and Biernacki, 1986~. Available data suggest that the resolution of alcohol problems without recourse to formal treatment (Tuchfeld, 1981) is neither spontaneous (it often occurs as a consequence of readily identifiable antecedents) nor best viewed as a remission (it often is not a temporary hiatus in the natural course of a relentlessly progressive problem). In this report, therefore, the phenomenon will be referred to as Improvement in alcohol problems without formal treatment." That such improvement does in fact occur is beyond serious doubt, although (as will be seen) many questions about the phenomenon remain unanswered. The reversal of disease states without formal therapeutic intervention is well known in medicine. Specifically effective medical interventions have in general been available only during the twentieth century, yet humanity has survived. Furthermore, a decline of mortality rates from many diseases long preceded the introduction of specific treatment, probably as a result of such nonspecific factors as improved diet (McKeown, 1976~. It was at one time customary for medical students entering their training to be congratulated on choosing their profession wisely because a significant proportion of the problems they would be called on to address would take care of themselves. Walter B. Cannon (1871-1945) coined the term homeostas~s to reflect the tendency of the human organism to return itself to a dynamic steady state following various kinds of perturbations, including illnesses. Multiple mechanisms, such as the production of antibodies to potentially harmful invading organisms on the physical level or the development of various defense mechanisms on the psychological level, subserve this purpose. Wound healing is an important example. When extravagantly praised for his therapeutic efforts on the battlefield, Ambroise Pare (1517-1590), the father of modern surgery, commented: "I dressed the wound; God healed it." So powerful is the tendency for human problems to revert to normal unaided by intentional therapeutics that special means must be employed in therapeutic evaluations to 152
IS TREATMENT NECESSARY? 153 take reversions that are not due to treatment into account. The randomized controlled trial ARCH described in the previous chapter is commonly used for this purpose. Rigorous testing of efficacy is required even in instances in which success seems likely or is critically important (e.g., in tests of vaccines or of anticancer agents), in large measure because of the reality of improvement without formal treatment. Given the foregoing, it should not be surprising that improvement without formal treatment may also occur in alcohol problems. A number of lines of evidence suggest that it does. One is clinical observation. The first North American treatise on alcohol problems, prepared by Benjamin Rush (1745-1813), contains a number of examples of the cessation of alcohol problems in the absence of formal intervention. Two are presented here. A farmer in England, who had been many years in the practice of coming home intoxicated, from a market town, one day observed appearances of rain, while he was in market. His hay was cut, and ready to be housed. To save it, he returned in haste to his farm, before he had taken his customary dose of grog. Upon coming into his house, one of his children, a boy of six years old, ran to his mother, and cried out, "O mother, father is come home, and he is not drunk." The father, who heard this exclamation, was so severely rebuked by it, that he suddenly became a sober man. A noted drunkard was once followed by a favorite goat, to a tavern, into which he was invited by his master, and drenched with some of his liquor. The poor animal staggered home with his master, a good deal intoxicated. The next day he followed him to his accustomed tavern. When the goat came to the door, he paused: his master made signs to him to follow him into the house. The goat stood still. An attempt was made to thrust him into the tavern. He resisted, as if struck with the recollection of what he suffered from being intoxicated the night before. His master was so much affected by a sense of shame, in observing the conduct of his goat to be so much more rational than his own, that he ceased from that time to drink spirituous liquors. (Jellinek, 1943:339) Most contemporary evidence for improvement without formal treatment comes from studies of alcohol problems in the general population. By definition, it is not possible to study the phenomenon in a population undergoing formal treatment. However, this does flat mean that so-called spontaneous remission does not occur in treatment populations. Although improvement that occurs in an individual in treatment is characteristically attributed to the treatment provided, it may in fact be due to other causes. It is just such a possibility that RCIs and other research designs are used to explore. The results of a large number of studies in general populations and their implications for the understanding of improvement without formal treatment have been extensively summarized by Fillmore and her associates (1988) in a review prepared for the use of this committee. In general, two types of studies have been done: cross-sectional and longitudinal. In the first the status of alcohol problems of individuals in a large population has been examined at one point in time. In the second the status of alcohol problems of individuals in a smaller population has been examined at more than one point in time (usually two points). Although these studies do not directly examine improvement without formal treatment, a relatively consistent picture emerges from them. First, the prevalence of alcohol problems declines with age. People in younger age categories are more likely to have alcohol problems. As they grow older, their alcohol
154 BROADENING THE BASE OF lllEATMENT FOR ALCOHOL PROBLEMS problems are likely to decrease in severity or to cease altogether. Excess mortality from alcohol problems accounts for some proportion of this observation but not for all of it. The commonly advanced explanation for this "maturing out" of alcohol problems is the tendency of the young to "sow their wild oats" and subsequently, with increasing experience, to conform to social expectations. "Maturing out" is a pattern that has also been observed in persons with drug problems (Winick, 1962~. Second, although these changes with age occur in both men and women, the prevalence of alcohol problems among women is substantially less than among men. For example, the prevalence of Alcohol abuse and/or dependence during the year prior to interview in the f~ve-site Epidemiological Catchment Area (ECA) survey was 11.9 percent for men and 2.2 percent for women (Helzer and Burnham, in press). Correspondingly, the rate of "spontaneous remissions is higher among women (see esp. Fillmore, 1987~. Here, the explanation tends to be that the drinking of alcohol is more consistent with the tradi- tional social definition of the male role than of the female role; "the most obvious reason is that there are positive norms for heavy drinking among men, but not among women. Heavy drinking is considered appropriate masculine behavior" (Ferrence, 1980:117~. Therefore, there is less social pressure on females to begin drinking and more pressure on them to stop. Third, improvement without formal treatment is not a minor or insignificant phenomenon. In the population-based ECA study, for example, "remissions rates for all cases meeting DSM-III criteria for ~alcoholism" averaged between 45 and 55 percent at all five sites (Helzer and Burnham, in press). A summary statement on age, sex, and improvement without formal treatment, drawn from all currently available information, is that there is a higher prevalence of problems in youth, but erratic and non-chronic with a 50-60 percent chance of remission both in the long and short term among men and more than 70 percent chance of remission among women; in middle age, a much lower prevalence, but chronic with a 30-40 percent chance of remission among men and about a 30 percent chance of remission among women; in older age, a great deal lower prevalence of problems, which were more likely chronic, with a 60-80 percent chance of remission among men and a 50-60 percent chance of remission among women. (Fillmore et al., 1988:29) Fourth, although these general patterns are both clear and have been relatively stable across time and across jurisdictions, they are by no means universally descriptive. Not all persons with alcohol problems "mature out" of them, and some women do have very severe and very persistent alcohol problems. Although age and sex do seem to have an effect on the course of alcohol problems, there are many variations in such courses within each sex and age group. For example, in one longitudinal study that looked at drinking problems at two points in time (age 18 and age 31), 63.4 percent of the sample had a different problem status at age 31, but 36.6 percent of the sample had the same problem status (Temple and Fillmore, 1985~. In another longitudinal study (Vaillant, 1983) that looked at a population sample at multiple points in time, four separate courses were observed among those who had developed severe alcohol problems. In short, the drinking problems of some persons change over time, becoming worse or better or fluctuating; the drinking problems of other persons do not change over time. Fifth, at present it is not possible to predict with certainty whether the alcohol problems of a given individual will or will not improve over time. One reason is that, although relatively adequate data are available on the course of alcohol problems by age
IS TREATMENT NECESSARY? 155 and by sex, there appear to be a large number of additional variables that affect whether or not such problems persist and on which relatively few data are available. These variables may include such factors as social class, social stability, social setting, significant life events, severity of the alcohol problem, ethnicity, and comorbidity (the concurrent presence of other problems, especially psychiatric disorders and drug problems). The systematic study of the impact of these variables on the course of alcohol problems is a task for the future. If (as is probable) they prove to be important determinants, their number and variety underscore the probability of divergent courses for different individuals. Another way of saying this is that improvement without formal treatment is not a unitary phenomenon that uniformly affects all persons with alcohol problems. Rather, it is a heterogeneous phenomenon that affects different persons in a highly variable manner and for many different reasons. Thus, although formal treatment is helpful to some persons with alcohol problems, others improve without it. Formal treatment is not always necessary, but in our current state of knowledge it is not possible to predict for whom it is and for whom it is not necessary. Another significant consideration is that treatment is not only at times unnecessary but may actually be harmful. Deterioration in Alcohol Problems with Formal Treatment When an individual recognizes his or her alcohol problem and actively seeks assistance in resolving it, treatment is often viewed as a moral imperative and is considered by some to be a right (cf. Fried, 1975~. It has been argued that this is so whether or not the treatment has been shown to be effective (Halmos, 1966~. But what if the treatment being offered carries a significant risk of harming the person? In this circumstance, treatment is not simply unnecessary but can result in matters becoming worse than they would have been if no treatment or a different treatment had been provided. The point is that all treatment must be considered within the cony of a r~sk/benef~ analysis (cf. Institute of Medicine, 1989~. Risks are understood to accompany many forms of medical treatment. Penicillin, as well as other highly effective drugs, may result in sensitivity reactions or other side effects in some proportion of individuals. Nor are treatment risks necessarily limited to the individual under treatment; the adverse effects on unborn children of thalidomide and of the use of estrogens to prevent miscarriages come to mind. Some surgical procedures carry with them significant hazards. General anesthesia itself carries a small but definite risk of mortality. As with medical and surgical treatment, it is clear that there are numerous potential negative effects of treatment for alcohol problems (Emrick, 1988~. Potentially harmful alcohol treatment interventions include the use of vigorous negative confrontation techniques with individuals who lack the means to cope with the confrontation in a constructive manner (Annie and Chan, 1983; Miller and Sovereign, 1985~. Focusing on an individual's drinking problem to the exclusion of other disorders that require direct treatment (e.g., coexisting psychiatric disorders) may also be harmful. The routine rather than the selective use of antialcohol medications can be fraught with difficulty, and in general the rigid application of a treatment philosophy or a technical intervention without due consideration for individual differences is hazardous. Potentially harmful characteristics or behaviors of the treaters of alcohol problems also constitute a risk factor. For example, dependent individuals may be exploited to satisfy the needs of the therapist or of the treatment program. Other common difficulties attributable to treaters include being rejecting, cold, impersonal, unsupportive, or actually hostile with individuals in treatment, or insisting that the individual is just like the therapist and can only improve by doing exactly what the therapist has done to overcome
156 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS his or her alcohol problems. Certain characteristics or behaviors of the individual in treatment may also contribute to harmful treatment effects; some examples include low self-esteem, low involvement in or compliance with treatment, a lack of interpersonal skills, or reliance escape as a method of coping with stress. Inasmuch as alcohol treatment can result in harm, a reflexive "yes" to the question "Is treatment necessary?" may not only result in the wasteful use of treatment resources (through the delivery of unnecessary or ineffective treatment) but may actually lead to injury, albeit unintentioned. Treatment is therefore not to be undertaken lightly. Once again the absence of data does not permit a prediction of who will be harmed by treatment, anymore than it permits a prediction of who will not require formal treatment. Coerced Treatment for Alcohol Problems Perhaps the question "Is treatment necessary? would not be so crucial were it not for the fact that many individuals who are currently being treated for alcohol problems are forced to receive treatment (Boscarino, 1980; Furst, 1981; Weisner, 1987; State of Connecti- cut Drug and Alcohol Abuse Criminal Justice Commission, hereafter referred to as State of Connecticut, 1988~. Because of the major and increasing role played by coercion in the treatment of alcohol problems, the committee has included as Appendix C to its report a review of the topic prepared by one of its members. Much of the following discussion is based on this document. It is worth noting that a consideration of "statutory and voluntary mechanisms" for the provision of treatment was a specific element of the congressional charge to the committee. Coerced treatment has become an important issue not only in the United States but at an international level as well. A World Health Organization study found that 20 of the 43 countries investigated had some kind of diversion legislation allowing treatment to serve as an alternative to judicial action (Curran et al., 1987~. Moreover, criminal justice referrals in particular jurisdictions may be extensive; a study in one state found that, if all such referrals were accepted by alcohol treatment programs, they would occupy 64 percent of the total available rehabilitation beds (State of Connecticut, 1988~. Most prominent among the coerced at present are those who are sent to treatment by the courts for drunken-driving offenses (Fillmore and Kelso, 1987~. For example, one state experienced a 400 percent increase of driving while intoxicated (DWI) offenders into treatment programs for alcohol problems during 1986-1987 (State of Connecticut, 1988~. In some jurisdictions arrested drinking drivers are given their choice of alcohol treatment or criminal justice sanctions; in others they are automatically referred to treatment programs for alcohol problems (U.S. Department of Transportation, 1976; Weisner, 1986; Stewart et al., 1987~. Without denying that drunken driving is a critical social problem, it must nevertheless be emphasized that those persons who drink and drive constitute a group that overlaps with but is not identical to the group of individuals who have serious alcohol problems (Donovan et al., 1983; Vingilis, 1983; Wilson and Jonah, 1985; Perrine, 1986~. Other important sources of referral to treatment under coercion include civil commitment, diversion from the criminal justice system for public drunkenness and crimes other than DWI offenses in which alcohol has played a role, workplace referrals Unconstructive coercions), and referrals that come about as a result of carefully structured and highly confronting small group sessions (Johnson, 1973, 1986~. Presumably, the sum total of these referrals constitutes a very large and rapidly growing number. Unfortunately, there are at present no reliable data on this number for the country as a whole. Studies that have been carried out on the effects of treatment with coerced individuals vary greatly in terms of comparison groups and the outcome measures that are used. Drawing conclusions is not an easy matter. The committee's sense of the available
IS TREATMENT NECESSARY? 157 information is that, although certain groups of individuals (e.g., professionals, the regularly employed) may benefit on the whole from coerced treatment, and although certain types of coercion are more effective than others (e.g., effective coercion often involves severe penalties for failure to comply with treatment-so-called contingencies-that are an invariable consequence of that failure), involuntary treatment is by no means uniformly beneficial and in some instances may actually be harmful (Wells-Parker, 1989. Even when forced treatment proves to be beneficial, it may not be the most efficient way to resolve the problems at issue. For some individuals it may be unnecessary to provide more than a minimally coercive intervention to reach maximum effectiveness (Peck et al., 1985), yet coerced treatment characteristically involves much more than a minimal intervention. Coerced treatment also presents particularly difficult ethical and even legal issues (cf. Marco and Marco, 1980~. For example, are the individual's basic civil liberties endangered? Is the person being inappropriately labeled through a particularly aggressive coercion effort? Are coerced individuals treated with as much dignity and diligence as are persons who undertake treatment voluntarily? What of the issue of informed consent when persons are coerced into treatment? If people are treated against their will and harm ensues, who is liable? These and other ethical and legal considerations underscore the complexities that surrounds the forced treatment of any person with an alcohol problem. Treatment must be handled thoughtfully, objectively, and compassionately. An unthinking ~yes" to the question His treatment necessary?" places one at considerable risk for making improper treatment interventions. Implications for Treatment To review: many people with alcohol problems improve without formal treatment. Some people with alcohol problems are made worse by treatment. Compulsory treatment of alcohol problems is not always helpful. These findings are not surprising, and they apply to treatment situations other than the treatment of alcohol problems. Although they hardly require the abandonment of the therapeutic effort, they do make it clear that, as with all such efforts, a guiding principle should be to proceed with caution. For example, treatment should be considered only if the existence of an alcohol problem is highly probable. This dictum places a premium on the careful assessment of all individuals who are seeking treatment (see Chapter 10) but is especially pertinent for those acting under coercion. When the existence of an alcohol problem is uncertain, primary or secondary prevention efforts (see Chapter 9) or other measures (e.g., general psychotherapy, revocation of a driver's license) may prove to be more appropriate than treatment directed at alcohol problems. In addition, it is important to take care to find the optimal treatment for the particular problem of a given individual (see Chapter 11~. lDue account should be taken of the potential negative effects of all treatments; any treatment with the power to help is likely to possess the power to harm when injudiciously deployed. Furthermore, if a given intervention proves to be ineffective, an alternative intervention should be considered. Appropriate caution can also take the form of favoring interventions that fall short of the most intensive and costly treatment methods but that are effective for some individuals. Conservative palliation in many instances is to be preferred to radical interven- tion. Particular consideration is wisely given to less utilization of intensive and costly intervention for those groups, such as the young, the female, and the elderly, in which improvement outside of formal treatment is more likely. For such groups, emphasis may more reasonably be placed on supporting nontreatment factors that promote improvement (e.g., employment, recreation, interpersonal ties, other social supports).
58 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Further understanding and documentation of how people with alcohol problems improve without formal treatment should be helpful in approaching treatment in a cautious and logical manner. There is the intriguing possibility that such understanding may encourage the development of novel approaches to treatment itself. In this sense improvement with treatment and improvement outside of treatment are not adversaries but collaborators. Treatment Based on Knowledge of Improvement Without Treatment Therapy based on a knowledge of factors that are believed to be critical in producing improvement without formal treatment has been proposed in the field of smoking cessation (Marlatt et al., 1988; IOM, 1989~. A similar approach has been taken in the treatment of alcohol problems. In developing what came to be called a community reinforcement approach, its originators set out to "examine the natural deterrents of airnh^1icm Ulna ~ll`~.r to. n~t,~rn1 deterrents to maximize their effectiveness (Hunt a~lWIlVI1OJ.I-l ~ · · e Jut ~J~ Act ~_~_~_~- ·~ ^~ -~ ~ ~ and A~rin, 1973:91-92~. Their understanding of such natural deterrents was that Kiln the alcoholic state, one may incur social censure from friends as well as from one's family. Discharge from one's employment is likely. Pleasant social interactions and individual recreational activities cannot be performed as satisfactorily, if at all, when one is alcoholics (p. 9%~. They therefore set about enhancing their subjects' social, marital, familial, vocational, and recreational activities by providing specific counseling (e.g., job-seeking skills) as well as additional supports (e.g., a non-alcohol-related social club meeting on Saturday nights). However, they also took steps to ensure that these aids would be swiftly and certainly withdrawn if the individual resumed drinking. For example, if recourse to drinking caused marital difficulties, the spouse was advised to move out of the house until the individual being treated became sober and requested that he or she return. In a word, both the carrot and the stick were judiciously applied (Hunt and Azrin, 1973~. Its developers note that "[this] procedure does not require hospitalization except as a means of helping the patient through his withdrawal symptoms and physical disability, if any" (Hunt and Azrin, 1973:99~. Thus, the approach is in accord with the contemporary deemphasis on inpatient (hospital or freestanding residential) treatment (Saxe et al., 1983; Annis, 1986; Miller and Hester, 1986) and the importance of environmental variables in outcome (Cronkhite and Moos, 1978; Moos et al., 1979~. Controlled trials of the community reinforcement approach, as well as its individual components (Azrin, 1976; Azrin et al., 1982; Mallams et al., 1982; Sisson and Azrin, 1986) have been positive, and a major replication study is under way (W. R. Miller, University of New Mexico, personal communication, January, 1989~. Another therapeutic approach has been developed that complements the community reinforcement approach. Rather than dealing with those naturally occurring factors that facilitate the remission of alcohol problems, this approach deals with the naturally occurring factors that make them worse. It has been called relapse prevention (Marlatt and Gordon, 1985; Annis, 1986b; Annis and Davis, 1988~. Relapse prevention is based on the notion that the treatment strategies that will keep a person with alcohol problems from drinking once he or she has stopped may differ from the strategies that will enable him or her to stop drinking in the first place. There is evidence that a wide variety of techniques are effective in producing at least short-term elimination or reduction of alcohol consumption (Miller, 1988~. Relapse prevention builds on such an initial success and attempts to extend the elimination or reduction into the future. Alcoholics Anonymous and other self-help groups are often used therapeutically
IS TREATMENT NECESSARY? 159 in this manner and in some senses at least could also be thought of as relapse prevention measures. In one such approach (Annie, 1986b; Annis and Davis, 1988) a painstaking inventory is taken of those naturally occurring situations in which relapse to drinking is likely to occur. The therapist then helps the individual learn other ways of coping with such dangerous situations rather than by drinking. When the individual learns successfully to negotiate situations that previously resulted in relapse, the probability of relapse is lessened. One alternative coping strategy to resist drinking that has been explored is the use of an antialcohol drug, Temposil (citrated calcium carbimide), which is not currently available for therapeutic use in the United States (Peachey and Annis, 1985~. It is felt that, ideally, such a strategy would give way to more complex and psychosocially based treatment. Treatments that evolve along these lines may prove to be quite effective. Whether from the community reinforcement approach or the relapse prevention approach, or from other approaches that are yet to be developed, an important contribution to the treatment of alcohol problems may arise (along the lines suggested by Ambroise Pare) from encouraging the individual to come increasingly under the sway of naturally occurring factors that will facilitate the resolution of his or her problem. Pare helped nature along by inventing the surgical ligature (Vaillant, 1983~. In like manner the answer in the alcohol field to the title question of this chapter may be that treatment is sometimes a necessary supplement to natural healing processes. Summary and Conclusions There is ample evidence that a significant number of individuals who develop alcohol problems will be able to deal with those problems without undergoing formal treatment. As well, some persons have less positive outcomes as a result of treatment. The coercion of persons into treatment is an increasingly common phenomenon but is not invariably associated with positive outcome. It is also true, of course, that many persons benefit greatly from appropriate treatment (the previous chapter and Appendix B provide copious documentation that this is so) and that they may do so even under coercion and in some instances only under coercion. Yet each of these sets of facts must be balanced against the other in trying to respond to the title question of this chapter. Is treatment necessary? The committee believes the answer is a qualified ~yes" that must take into account the complexities of the issues involved in our current state of knowledge. How should one proceed? Cautiously, the committee believes, and with humility. Treatment for alcohol problems, like other treatments, should be applied judiciously, with due consideration given to individual differences. Treatment should not be foresworn, because it is helpful to many; but neither should it be provided-as a matter of course, because for some it is not necessary and for others it may be harmful. The extremes of unbridled therapeutic enthusiasm on the one hand and thoroughgoing therapeutic nihilism on the other must be avoided. In addition, improvement outside of formal treatment, negative therapeutic reactions, and the fact of coercion should be seen not only as complicating factors but as opportunities for learning more about treatment. Such strategies as the community reinforcement approach and relapse prevention are illustrative. We especially need to learn a great deal more about how to predict who does not need treatment, who will be harmed by treatment, and who will benefit from treatment only under coercion. The directions and recommendations provided by the committee in Section III of this report are in keeping with this goal. If implemented, the difficulties in making appropriate therapeutic decisions should diminish over time. In the meantime the guiding
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