That Time When a Devastating Attack on a Seminal Controlled Drinking Study Set Us Back Decades
Recent reports on the harm reduction movement portray its rude health—yet simultaneously, a catastrophic event could at any point challenge its growing acceptance.
To me, the situation recalls a disastrous confrontation that long negated a hugely promising development, before “harm reduction” was even a phrase. This contributed to countless tragic deaths—although one in particular sticks in my mind.
The confrontation took place in 1982—specifically around non-abstinent recovery from (or improvement in) alcoholism. It was to seriously impede the field of addiction for decades, and it dramatically altered my life and my career.
Beginning early in the 1970s, Mark and Linda Sobell—a husband-and-wife team of PhD students conducting research at the Patton State VA Hospital near San Diego—used behavioral techniques to teach 20 chronic “alcoholics” to moderate their drinking.* They called their treatment IBTA (Individualized Behavior Therapy for Alcoholics), which is generally referred to as controlled drinking therapy (CD).
The Sobells reported significantly better outcomes for the CD patients after one and two years (I’ll elaborate below) when compared with 20 patients who underwent the standard 12-step, abstinence-oriented program at the hospital. (Subjects had been randomly assigned to either one of the two groups.)
What a bold experiment! On the other hand, what a crazy idea to confront America’s AA-abstinence monolith in the 1970s and into the ‘80s, as it totally dominated American treatment before the term “harm reduction” had ever been heard.
Mark and Linda Sobell
Sure as the rain will fall, the forces of AA and America’s temperance tradition stormed down on the Sobells and all who dared support them. It was a hurricane. And, along with the Sobells, I was caught in it.
Why me, you might ask. I had no academic or institutional position, and I didn’t do controlled drinking research. I was an addiction theorist and therapist, a scholar and writer, and a commentator on America’s preoccupation with addiction as an irreversible disease. But that was enough for me to be buried in the deluge.
The principal attack on the Sobells’ research came from Mary Pendery, a 12-step and abstinence advocate who worked at Patton State as an alcoholism counselor. Pendery pursued the Sobells and their research for the better part of the 1970s, tracking the CD subjects, even recruiting some of them to her cause. Pendery really picked up a head of steam when she was joined in her efforts by Irving Maltzman, a UCLA psychology professor, and L. Jolyon (Jolly) West, the head of UCLA’s psychiatry department.
Together, the three authored a piece in the highly prestigious Science journal in July 1982+ that virtually accused the Sobells of fraud (an earlier draft in fact did so, but was revised). What the Science article actually did was trace the CD subjects, noting each case of relapse that the subjects suffered, as well as noting four deaths among the 20 in the following decade.
The results of Pendery et al. formed the basis for numerous national media accounts, always emphasizing the fatal effects of CD therapy. CBS Evening News showed a lake where one controlled-drinking subject drowned. 60 Minutes, in a 1983 segment strongly supporting the Pendery et al. argument, filmed Harry Reasoner walking alongside the grave of one subject.
By then, the Sobells were working at the Addiction Research Foundation (now called the Centre for Addiction and Mental Health) in Toronto. The ARF quickly commissioned four distinguished professionals to review the dispute. Provided with remarkable documentation the Sobells had kept over the years (such as correspondence with the subjects), this committee cleared the researchers of the claims against them and their research made by Pendery et al.
How were they able to reach this conclusion?
Pendery et al. had in fact failed to follow up the abstinence group, so that their only data were hospitalizations and deaths for the CD subjects. The committee was able to establish that the Sobells had themselves reported all of the CD group’s relapse events reviewed by Pendery et al. What’s more, it turned out that six of the abstinence-only group had died during the Pendery group’s follow-up period!
Of course, this suggested that both treatments had failings, only that the group taught techniques for controlling their drinking had fewer. Indeed, the committee found no evidence to dispute the Sobells’ essential result: that, in the final six months (19 through 24) of the experiment, the 20 CD subjects functioned well (drinking minimally or not at all) on average for 160 of the 183 days, while the 20 patients who had been trained only to abstain functioned well for 80 days on average.
These comparison results scientifically destroyed the Pendery et al. argument that the CD group’s outcomes disproved the viability of moderation training.
While these successful results were unacceptable, even incomprehensible, in 1982, they are now considered commonplace under the rubrics of “harm reduction” and “relapse prevention” (the latter referring to techniques for preventing some renewed drinking—even problematic drinking—from turning into full-bore relapse).
And so the Sobells were able to defend themselves in their professional lives, and they went on to become tenured faculty at the Nova Southeastern University in Florida, where they still happily reside.
A Long-Term Blow to Controlled Drinking Therapy
Alas, the Sobells and their allies were not similarly protected from public opprobrium, nor from vilification by the 12-step industrial complex.
One rehab director (at Rhode Island’s prominent Edgehill Newport Center) wrote a journal article damning a “gang of eight” CD supporters (including Alan Marlatt of the University of Washington, Bill Miller, of the University of New Mexico, and myself). Little concerned with the ARF report, the treatment industry maintained a consensus that CD treatment had been completely refuted, that it was even immoral—a view that continued beyond the end of the 20th century.
Indeed, despite the ARF committee’s affirmation of the value of CD therapy for the seriously alcoholic Patton State patients, even its most distinguished practitioners—including Marlatt and Miller—were careful to claim that it applied to problem drinkers, not “alcoholics.”
But distinguishing a separate group with alcohol problems as “alcoholics” is no longer considered valid. Even in the current DSM, hardly a cutting-edge publication, AUDs (alcohol use disorders) are rated as “mild,” “moderate,” or “severe.” Indeed, DSM-5 (and DSM-IV before it, for which I served as an advisor) carefully defines “remission” (i.e., recovery) in terms of problems alone, thus eliminating the issue of whether drinking per se comprises “relapse”—something the abstinence-only, traditional treatment crew maintains as an article of faith.
Coming to the present, with the advent of Motivational Interviewing and brief interventions, as well as harm reduction and relapse prevention, all serious practitioners and researchers in the field have become, if not unconcerned with abstinence as the only measurement of treatment success, at least far less fixated on it. Here is one of many examples:
Commonly presumed unsuitable for dependent drinkers, the evidence is stacking up that brief advice after screening can lead even these drinkers to cut back. This study of heavy drinking Taiwanese hospital patients provides one of the most convincing demonstrations yet that brief intervention can work in this setting, and the drinking reductions were particularly steep among dependent patients.
Harm reduction, of which controlled drinking was the principal manifestation in the last century, suffered a similarly bad fate in the decades following the Pendery et al. broadside. Here is Ethan Nadelmann’s description of this tragedy in relation to the 12 Steps and syringe access programs:
Where the 12-step thing has the most to own up to is its role in impeding harm reduction interventions to stem the spread of HIV/AIDS. Why was it that Australia and England and the Netherlands were able to stop the spread, and keep the number for injecting drug users under 5-10%, and the U.S. was not? It’s that notion that abstinence is the only permissible approach, that we are not going to “enable” a junkie by giving him a clean needle. There has to be a kind of owning up to that role in hundreds of thousands of people dying unnecessarily.
That America’s abstinence fixation continued as long as it did, to the detriment of so many souls, can to some degree be laid at the feet of Pendery et al. and Science.
And What About Me?
It so happens that I wrote two critical pieces in the immediate aftermath of that 1982 dispute for American Psychological Association’s flagship publications, American Psychologist and Psychology Today. (PT had just been purchased by APA—my article was in the first official APA issue!)
My American Psychologist piece, “The Cultural Context of Psychological Approaches to Alcoholism,” pointed out about CD therapy that there was no longer any “alcoholism center in the United States using the technique as official policy.” Yet, on the evidence, I maintained, the technique, now known as harm reduction, was important across the range of addiction and alcoholism problems. I took some shots for those views. The Edgehill Newport Center director, John Wallace, authored an article titled, “Can Stanton Peele’s Opinions Be Taken Seriously?” (I’ll let readers guess where John came down on that question.)
My Psychology Today piece, titled “Through a Glass Darkly,” in which I concluded that the Science piece “reflects political forces and prejudice in America that forbid a reasonable discussion of the issues,” got me into even more trouble.
I was scheduled to give the keynote address at the Texas Commission on Alcoholism’s well-known summer school, held on the campus of the University of Texas in Austin. My invitation was rescinded after my article appeared. I threatened legal action and was reinstated. (At the conference, considering it the better part of valor, I gave a keynote speech aboutaddictive love in Romeo and Juliet.)
But by then, I was blacklisted throughout the addiction and alcoholism fields and had to get regular research jobs in order to support my family in the following years.
However, as readers of The Influence may have noticed, I survived.
Mary Pendery did not. After the dispute, she engaged in a relationship with a patient at Patton State (not one of the study subjects). Here is what followed:
On April 10, 1994, Mary Pendery was murdered by an alcoholic lover. Pendery left the alcoholism treatment program at the VA Hospital in San Diego, which she headed, to move to a VA hospital in Sheridan, Wyoming in 1992.
In January 1994, Mary recontacted George Sie Rega, whom she had first known while he was being treated at the San Diego VA. Mary apparently was rekindling an old flame. By the time Sie Rega joined Mary in Wyoming in April 1994, he was deep in alcoholic relapse. Extremely intoxicated (his BAL was above 0.30), Sie Rega shot Mary dead and then turned his weapon on himself.
George Sie Rega received the standard alcoholism treatment at Patton State—indeed, in the United States. And so, America’s strange love-and-death dance with addiction as a disease—supposedly set off irreversibly, irretrievably, irremediably by any consumption of a substance to which one has ever been addicted, and only remedied by perpetual abstinence—led to the demise of yet another two victims.
*Sobell, M. B., & Sobell, L. C. (1973). Alcoholics treated by individualized behavior therapy: One year treatment outcomes.Behaviour Research and Therapy, 11, 599-618. Sobell, M. B., & Sobell, L. C. (1976). Second year treatment outcome of alcoholics treated by individualized behavior therapy: Results. Behaviour Research and Therapy, 14, 195-215.
+Pendery, M. L., Maltzman, l. M., & West, L. J. (1982). Controlled drinking by alcoholics? New findings and a reevaluation of a major affirmative study. Science, 217, 169-175. (Response) Sobell, M. B., & Sobell, L. C. (1984). The aftermath of heresy: A response to Pendery et. al.’s (1982) critique of “Individualized behavior therapy for alcoholics.” Behaviour Research and Therapy, 22, 413-440.