Selling Water by the River, The Project Match Cover Up

_____________________________________________________________________

VOLUME 1, ISSUE 5 PSYCHNEWS INTERNATIONAL August/September 1996

SELLING 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 addict-l@listserv.kent.edu (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

(mm@sjuvm.stjohns.edu), 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 dpf@dpf.org.

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. <jschale@american.edu>

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