Journal of Studies on Alcohol, Vol. 38, No. 11, 1977
COMMENTS
Comment
on "Alcoholism:
of 'Treatment'
a Controlled
Trial
and 'Advice'"
RalphHingsonand NancyDay• Edwardsandhiscolleagues (1) havepresented a provocative, thoughtful studywhichraisesseriousquestions for the field of alcoholism treatment. They comparedthe effectsof two markedlydifferenttreatments given to separategroupsof men alcoholicswho were married or living in a common-lawmarriage.All the men were initially interviewedby
a psychiatristand a psychologist, and their wivesby a socialworker, and all were advisedto (a) abstainfrom alcohol,(b) continueor return to work and (c) maintaina viable marital relationship.One group was then treatedwith the conventionalcomprehensive alcoholism-treatment packagewhile the other groupwas merely advisedthat "responsibility for attainmentof the statedgoalslay in their own hands rather than it beinganythingwhich couldbe takenoverby others"(p. 1006) and that someonewould periodicallyvisit their wives to learn of their progress.The finding that I year later there were no intergroupdifferenceson a variety of outcomemeasuresclearly calls into question both the nature and the amount of servicescurrentlyoffered to alcoholics.
Although Edwards and his colleaguesindicated that their purpose was to determinethe value of a therapeuticregimenrepresentingthe "averagepackageof help" offered by alcoholismtreatmentcenters,compared with a regimenof markedlylessintensity,they actuallybroached a questionwith more importantimplications.Ever sinceJellinek'searly formulations(2), lossof controlover drinkinghas been a widely recognized key to the diagnosis of alcoholism. If alcoholicsare peoplewho have lost controlover drinking,the problemfor treatmentprofessionals is how best to help them regain it. While there has been much recent debateconcerningwhat type of controlis reasonablefor alcoholicsto pursue(3-5), much lessattentionhas been directedat the amountof responsibility that shouldbe assignedto the drinker. xDepartmentof Socio-MedicalSciences,BostonUniversity School of Medicine, 80 East Concord Street, Boston, MA 02118. 2206
COMME•rrs
2207
Alcoholism therapistsfind themselves in the difficult positionof offeringtreatmentto peoplewho have exhibiteda lossof controlover their drinkingand often over other areasof their lives as well. Even thoughno uniformlyeffectivetreatmenthasbeendeveloped,the temptation for thoseprovidinghelp, when confrontedwith someonewho haslostsuchcontrol,is to takeoverfor the personand provideit. Whether a treatmentproviderwho takesoverin thisfashionfostersunnecessary dependence on treatmentprogramsand whetherthe patientis relieved of responsibility for his own behaviorare issuesmeritingattention.They are particularlyimportantissuesbecausemany problemdrinkersclaim to have regainedcontrolon their own (6). Some(7, 8) believethat when alcoholismis consideredas a diseasebest treated with professional
help, the alcoholicmay be providedwith an alibi for not assuming personalresponsibility for his behaviorand for not attemptingto control his drinking on his own.
Because the studyby Edwardset al. constitutes the first attemptto usea sophisticated experimental designto exploresuchquestions, and becauseits findingsare so provocative, any limitationsin the studydesignshouldbe carefullyconsidered beforethe findingsare accepted. We are not suggesting that their studycompares unfavorablywith other studies of the treatment of alcoholism. In its stratified random allotment
of subiects to studygroups,in its attemptto assess the comparability of the groupsprior to treatment,in its small,carefullyexaminedloss to follow-up,and in the authors'effort to evaluateits methodological strengths andweaknesses, it is probablysuperiorto moststudies.Nevertheless, we haveseveralquestions aboutthe validityof the study,and are especially concerned with the possibility that intergroupdifferences in treatmentoutcomewere inadvertentlyobscured.
The small size of the samplestudiedby Edwardset al. militates
againstfindingstatistically significant differences betweengroupsif the differencesare subtle. The possibilityof spontaneousremissionin
patientsin both groupsfurtherreducesthe likelihoodof findingsignificant intergroupdifferences. In mostclinicaltrials,all improvement is generallyinterpretedas evidenceof therapeuticsuccess; hence,ratesof spontaneous remissionare
seldommeasured. Generalpopulation studieshaveshown,however,that
approximately 50• of the persons whowereonceproblemdrinkersdid not drinkasmuch4 yearslater?Althougha clinicalpopulation is less likelythanthe generalpopulation of heavydrinkersto experience spontaneousremission,somefractionof a clinical populationsurelydoes. Armoret al. (4) reportedabstinence at a 6-monthfollow-upin 11•
of the patientswho had contacted an alcoholism treatmentcenterbut remained untreated and in 155 of those who received only minimal
treatment.Further,the studyby Edwardset al. examineda subgroup 2CAllALAN, D. andROIZEN, R. Changes in drinkingproblemsin a nationalsam-
pieof men.Presented at theNorthAmerican Congress onAlcohol andDrugProblems, San Francisco, 1975.
2208
JOURNALOF STUDIESON ALCOHOL
of the clinical populationthat is probably most able to changespontaneously:healthy married men in relatively stable environments. To the extentthat spontaneous remissionoccurred,greaterintergroup differenceson the dependent variable are needed to attain statistical significance.For example,if no remissionoccurred (and to make the calculationseasier we assumeno improvementin the advice group), improvementin only five patients,or 105 of the treatmentgroup,would yield a significantintergroupdifferenceat the .05 level. If we assumea remissionrate of 205 in addition to those who changedspontaneously, an improvementin at least eight patients (or 225 of the remainder) would be necessary to reachthe samelevel of significance. Thus the small samplesize and the possibilityof spontaneous remission in both groupsmean that sizable differencesare needed to achieve statisticalsignificance.Someof the proceduresusedby Edwardset al. may have led them to observeand recordsmallerintergroupdifferences than thoseactually present. First, the characteristicsof the follow-up interviewersmay have influencedthe amountof drinkingreported.One year after intake the men in both groupswere interviewedabout their drinking by a project psychiatrist.If the samepsychiatristhad originally told a respondenthe wasan alcoholic,it is probablethat he, and manyof the otherrespondents interviewedtwice by the same psychiatrist,underreportedtheir drinking. This probabilitywould be strongestamong thosewho drank the most. If this underreportingoccurredin both groupsit would diminish the observedintergroup differences. Similarly, the wives of men in both groups were queried monthly about their husbands'drinking by social workers; the husbandshad been told that these interviewswould take place. We wonder whether the men'sknowledgethat their behaviorwas being monitoredby their wivesand reportedto socialworkersled them to concealtheir drinking. The absenceof data on the concurrenceof husbands'and wives'reports of drinkingstatusat the beginningof the studymakesit impossible to determinewhether suchan effect occurred.Underreportingof drinking by both groupswould tend to obscureintergroupdifferences. Second,it is not clear how the authorsobtained the data on a key
dependentvariable-thegreatestamountof patient-reported drinkingon any given day during each of the 52 weeksin the follow-upyear. If, as the authorssuggest,they relied on a singleinterviewwith the patient at the end of the follow-upyear, the possibilityof poor recall is extremelyhigh. Nonrandomvariationof the reportedconsumption from the actual consumption would again concealintergroupdifferences. Third, the authorsmade an unfortunatedecisionin not using the samedrinkingmeasures at intakeand the 12-month follow-up.It would have been desirableto examinechangesbetweenintake and follow-up in the reportedquantity,frequencyand variabilityof drinkingby individualpatientsin eachgroup.The authors'useof differentmeasures at eachstageof the studymade this impossible. The only measures
COMME•Vrs
2209
of individualchangeare the patients'reportsand their spouses' evaluations at follow-up, both subjectto the variousbiasesdiscussedabove. Fourth, although the measuresemployedshow consistentlysimilar outcomesin the two groups,the use of groupmeansdoesnot allow one to examinethe shapeof the distributionsof group outcomes,and perhaps obscuresimportant intergroup differences.The standard errors were large enoughfor differentdistributions.One examplecan be found in Table 3 (pp. 1014-1015),where the distributionof patientson the compositeoutcomescaleis very different for the two groups.Although 3270of the patientsin both groupswere rated as bad on the composite outcome,29•oof the advicegroup and 42• of the treatmentgroup were rated as equivocal,and 13%more among the advice group than the treatmentgroup (3970versus2670)were rated as good.This scale,which the authorsdescribeas more valid than the singlemeasures,showsa better outcomeamongthe advice group. Though that particular difference does not reach statisticalsignificance,it indicatesthat the effectsof the two treatmentsmay not have been as similar as the authors conclude.
In short, the methodsused in the study may have contributedto the lack of reporteddifferencesbetweenthe groupsat follow-up,making it difficult to determinewhether advice or conventionaltreatment achievedsuperiorresults. In addition to the factorswhich seem to have obscuredintergroup differences,we have severalother concernsabout the methodsused by Edwards
et al. Whether
these indicate
biases that decrease or increase
group differencesis lessclear. It is worth askingwhether the patientsassignedto the two groups were comparablein all characteristics which might influencetreatment outcome.According to the authors, patients were stratified by occupational status and severity of drinking and then randomly allocated within each stratum to the advice and treatment groups.Recognizing that randomizationdoes not always ensurecomparability,the authors compareda number of characteristics in the two groups (Table 1, p. 1008). While the groupswere nearly identical on most measures,other measuressuggestthat somepatientsin the treatmentgrouphad a more seriousdrinkingproblemat intake.Comparedwith the averagemember of the advicegroup,the averagememberof the treatmentgroupmissed 4 moreweeksof work duringthe previousyear due to illnessor unemployment;10g•more of the patientsin the treatment group had previouslyreceivedinpatienttreatmentfor alcoholism.Thoughsmall,these differencesraisequestionsaboutthe similarityof the drinkinghistories of patientsin the two groups. The measuresof drinkingusedto comparethe groupsat intakeseem inadequate.Two of them,patients'and wives'reportsof the numberof weeks of heavy drinking during the previousyear, depend on their subjectiveimpressions of what constitutesheavy drinking.The other measuresreflect only the reportedlength of abstinence. It would have
2210
JOURNALOF STUDIESON ALCOHOL
beenpreferableto comparethe groupson the basisof reportsof quantity, frequencyand variabilityover a specifiedperiod of time prior to intake. Severalothervariables•vhichmighthave affectedthe dependentvariables, such as previous outpatient treatment, source of referral, and motivationto abstainfrom alcohol,were not comparedin the two groups. If, as the authorsstate,xnanypatientswere obviouslypressuredto obtain treatment,someattempt shouldhave been made to comparethe amount of coercionto which each group was subjected. The possibilityof observerbias needsto be consideredmore carefully. The studywas not double-blind,leavingopen the possibilityof systematic bias in patient reportingas well as in observerrecording.Although Edwardset al. argue that patientsin the advice group may have perceived their treatment as second-rate,thereby adverselyaffecting reportedoutcome,one could argue,conversely, that sincethey were not offeredtreatmentsomeof them may have been led to believethat they neededit less,had a lessseriousproblem,or could exert more control over their drinking.
Althoughthe authorsthoughtthat there was no observerb{asbecause the people who gathered data used "structured"inquiry and there was no obviousconsensus of expectation,neither eliminatesthe potentialfor systematic reportingbias.If, for example,interviewerswho expectedthe studyto find that treatmentis not helpfulwere morelikely to interview patientsin one of the groups,the possibilityof such bias is clearly present.Further, we do not know whether somestaff were more involved in the treatmentor advice regimen. If so, were the expectationsand skillsof thoseofferingthe two treatmentssystematically different?
A final analyticalproblemlies in the authors'argumentthat if more treatment is better, then within each of the groupsthosewho received more treatment
should do better than those who received less. While
this is a logicallytemptingargument,the data as they are presented do not supportit. The difficultylies in determiningwho receivedmore treatmentand why. We know that in the treatmentgroup thosewho were thought to need more treatmentwere offered more, resultingin the selectionof a group of peoplewho, in the judgmentof the staff, were more in need. Similarly in the advice group, patients who were
more seriouslyill might have soughtmore treatment.The groupsreceivingdifferent amountsof treatmentthereforewere not comparable, and the differencesmight have affected the measuresof outcome.The authorshave concludedthat the similarityof outcomedemonstrates the lack of correlation between outcome and level of treatment. One could
argue equally well that the similarityin improvementdemonstrates a positiveeffectof intensivetreatment.The moreintensivetreatmentmay have allowed thosewho had more problemsto achievethe samerate
of improvement as the groupthat had fervorproblems. For all the reasonsdiscussed above,thesefindingscannotbe accepted as definitive. The small samplesize, the possibilityof spontaneous re-
COMME•rs
2211
missionamongsomeof the patientsin both groups,the testing effect of the treatmentstaff collectingdata,and the time at which self-reported drinkingwasmeasuredall work to reducethe possibilityof a statistically significantdifferencebetween the groups.Other factors-such as the possibilitythat the groupsdid not have comparabledrinkinghistories and levelsof motivationto quit or reduce drinking, the possibilitythat each group was treated by different individuals,and the opinion of the advice group about their condition and the quality of care they were receiving-couldreveal differencesnot presentin the analysisby Edwards et al. or decreasethe differenceswhich were present. In describingtheseconcernswe are by no meanssuggestingthat the questionsaddressedby the study shouldbe put aside.If anything,we are suggesting that thosewho providethe more expensiveconventional packageof servicesshouldfeel obligatedbecauseof this study to attempt to answerthesequestionswith a data set large enoughto allow a more valid and detailed analysis.
REFERENCES
1. E•)wAat)s,G., ORFOm),J., EGERT,S., GUTHRIE,S., HAWrO;R, A., HENSMAN,C., MITCHESON, M., OPPENHEIMER, E. and TAYLOR,C. Alcoholism:a controlled trial of "treatment" and "advice." J. Stud. Alc. 38: 1004-1031, 1977.
2. JELLINEK, E. M. The diseaseconceptof alcoholisdn. HighlandPark, NJ; Hillhouse Press; 1960.
3. PATTISON, E. M. Nonabstinentdrinking goalsin the treatmentof alcoholism;a clinical typology. Arch. gen. Psychiat. 33: 923-930, 1976. 4. ARMOR,D. J., POLICH,J. M. and STAMBUL, H. B. Alcoholismand treatment. [Preparedfor the U.S. NationalInstituteon AlcoholAbuseand Alcoholism.] Santa Monica, CA; Rand Corp.; 1976. 5. SOBELL,M. B. and SOBELL,L. C. Alcoholicstreated by individualized behavior therapy; one year treatmentoutcome.Behav. Res. Ther., Oxford 11: 599-618, 1973.
6. BOGUE,D. Skid Row in A•nerican cities. Chicago; Community and Family Study Center, Universityof Chicago;1963. 7. CAHALAN,D. Problem drinkers; a national survey. San Francisco; Jossey-Bass; 1970.
8. WISEMAN,J.P. Stationsof the lost; the treatment of Skid Row alcoholics. EnglewoodCliffs, NJ; Prentice-Hall;1970.
COMMENTS
Comment
on "Alcoholism:
of 'Treatment'
a Controlled
Trial
and 'Advice'"
RalphHingsonand NancyDay• Edwardsandhiscolleagues (1) havepresented a provocative, thoughtful studywhichraisesseriousquestions for the field of alcoholism treatment. They comparedthe effectsof two markedlydifferenttreatments given to separategroupsof men alcoholicswho were married or living in a common-lawmarriage.All the men were initially interviewedby
a psychiatristand a psychologist, and their wivesby a socialworker, and all were advisedto (a) abstainfrom alcohol,(b) continueor return to work and (c) maintaina viable marital relationship.One group was then treatedwith the conventionalcomprehensive alcoholism-treatment packagewhile the other groupwas merely advisedthat "responsibility for attainmentof the statedgoalslay in their own hands rather than it beinganythingwhich couldbe takenoverby others"(p. 1006) and that someonewould periodicallyvisit their wives to learn of their progress.The finding that I year later there were no intergroupdifferenceson a variety of outcomemeasuresclearly calls into question both the nature and the amount of servicescurrentlyoffered to alcoholics.
Although Edwards and his colleaguesindicated that their purpose was to determinethe value of a therapeuticregimenrepresentingthe "averagepackageof help" offered by alcoholismtreatmentcenters,compared with a regimenof markedlylessintensity,they actuallybroached a questionwith more importantimplications.Ever sinceJellinek'searly formulations(2), lossof controlover drinkinghas been a widely recognized key to the diagnosis of alcoholism. If alcoholicsare peoplewho have lost controlover drinking,the problemfor treatmentprofessionals is how best to help them regain it. While there has been much recent debateconcerningwhat type of controlis reasonablefor alcoholicsto pursue(3-5), much lessattentionhas been directedat the amountof responsibility that shouldbe assignedto the drinker. xDepartmentof Socio-MedicalSciences,BostonUniversity School of Medicine, 80 East Concord Street, Boston, MA 02118. 2206
COMME•rrs
2207
Alcoholism therapistsfind themselves in the difficult positionof offeringtreatmentto peoplewho have exhibiteda lossof controlover their drinkingand often over other areasof their lives as well. Even thoughno uniformlyeffectivetreatmenthasbeendeveloped,the temptation for thoseprovidinghelp, when confrontedwith someonewho haslostsuchcontrol,is to takeoverfor the personand provideit. Whether a treatmentproviderwho takesoverin thisfashionfostersunnecessary dependence on treatmentprogramsand whetherthe patientis relieved of responsibility for his own behaviorare issuesmeritingattention.They are particularlyimportantissuesbecausemany problemdrinkersclaim to have regainedcontrolon their own (6). Some(7, 8) believethat when alcoholismis consideredas a diseasebest treated with professional
help, the alcoholicmay be providedwith an alibi for not assuming personalresponsibility for his behaviorand for not attemptingto control his drinking on his own.
Because the studyby Edwardset al. constitutes the first attemptto usea sophisticated experimental designto exploresuchquestions, and becauseits findingsare so provocative, any limitationsin the studydesignshouldbe carefullyconsidered beforethe findingsare accepted. We are not suggesting that their studycompares unfavorablywith other studies of the treatment of alcoholism. In its stratified random allotment
of subiects to studygroups,in its attemptto assess the comparability of the groupsprior to treatment,in its small,carefullyexaminedloss to follow-up,and in the authors'effort to evaluateits methodological strengths andweaknesses, it is probablysuperiorto moststudies.Nevertheless, we haveseveralquestions aboutthe validityof the study,and are especially concerned with the possibility that intergroupdifferences in treatmentoutcomewere inadvertentlyobscured.
The small size of the samplestudiedby Edwardset al. militates
againstfindingstatistically significant differences betweengroupsif the differencesare subtle. The possibilityof spontaneousremissionin
patientsin both groupsfurtherreducesthe likelihoodof findingsignificant intergroupdifferences. In mostclinicaltrials,all improvement is generallyinterpretedas evidenceof therapeuticsuccess; hence,ratesof spontaneous remissionare
seldommeasured. Generalpopulation studieshaveshown,however,that
approximately 50• of the persons whowereonceproblemdrinkersdid not drinkasmuch4 yearslater?Althougha clinicalpopulation is less likelythanthe generalpopulation of heavydrinkersto experience spontaneousremission,somefractionof a clinical populationsurelydoes. Armoret al. (4) reportedabstinence at a 6-monthfollow-upin 11•
of the patientswho had contacted an alcoholism treatmentcenterbut remained untreated and in 155 of those who received only minimal
treatment.Further,the studyby Edwardset al. examineda subgroup 2CAllALAN, D. andROIZEN, R. Changes in drinkingproblemsin a nationalsam-
pieof men.Presented at theNorthAmerican Congress onAlcohol andDrugProblems, San Francisco, 1975.
2208
JOURNALOF STUDIESON ALCOHOL
of the clinical populationthat is probably most able to changespontaneously:healthy married men in relatively stable environments. To the extentthat spontaneous remissionoccurred,greaterintergroup differenceson the dependent variable are needed to attain statistical significance.For example,if no remissionoccurred (and to make the calculationseasier we assumeno improvementin the advice group), improvementin only five patients,or 105 of the treatmentgroup,would yield a significantintergroupdifferenceat the .05 level. If we assumea remissionrate of 205 in addition to those who changedspontaneously, an improvementin at least eight patients (or 225 of the remainder) would be necessary to reachthe samelevel of significance. Thus the small samplesize and the possibilityof spontaneous remission in both groupsmean that sizable differencesare needed to achieve statisticalsignificance.Someof the proceduresusedby Edwardset al. may have led them to observeand recordsmallerintergroupdifferences than thoseactually present. First, the characteristicsof the follow-up interviewersmay have influencedthe amountof drinkingreported.One year after intake the men in both groupswere interviewedabout their drinking by a project psychiatrist.If the samepsychiatristhad originally told a respondenthe wasan alcoholic,it is probablethat he, and manyof the otherrespondents interviewedtwice by the same psychiatrist,underreportedtheir drinking. This probabilitywould be strongestamong thosewho drank the most. If this underreportingoccurredin both groupsit would diminish the observedintergroup differences. Similarly, the wives of men in both groups were queried monthly about their husbands'drinking by social workers; the husbandshad been told that these interviewswould take place. We wonder whether the men'sknowledgethat their behaviorwas being monitoredby their wivesand reportedto socialworkersled them to concealtheir drinking. The absenceof data on the concurrenceof husbands'and wives'reports of drinkingstatusat the beginningof the studymakesit impossible to determinewhether suchan effect occurred.Underreportingof drinking by both groupswould tend to obscureintergroupdifferences. Second,it is not clear how the authorsobtained the data on a key
dependentvariable-thegreatestamountof patient-reported drinkingon any given day during each of the 52 weeksin the follow-upyear. If, as the authorssuggest,they relied on a singleinterviewwith the patient at the end of the follow-upyear, the possibilityof poor recall is extremelyhigh. Nonrandomvariationof the reportedconsumption from the actual consumption would again concealintergroupdifferences. Third, the authorsmade an unfortunatedecisionin not using the samedrinkingmeasures at intakeand the 12-month follow-up.It would have been desirableto examinechangesbetweenintake and follow-up in the reportedquantity,frequencyand variabilityof drinkingby individualpatientsin eachgroup.The authors'useof differentmeasures at eachstageof the studymade this impossible. The only measures
COMME•Vrs
2209
of individualchangeare the patients'reportsand their spouses' evaluations at follow-up, both subjectto the variousbiasesdiscussedabove. Fourth, although the measuresemployedshow consistentlysimilar outcomesin the two groups,the use of groupmeansdoesnot allow one to examinethe shapeof the distributionsof group outcomes,and perhaps obscuresimportant intergroup differences.The standard errors were large enoughfor differentdistributions.One examplecan be found in Table 3 (pp. 1014-1015),where the distributionof patientson the compositeoutcomescaleis very different for the two groups.Although 3270of the patientsin both groupswere rated as bad on the composite outcome,29•oof the advicegroup and 42• of the treatmentgroup were rated as equivocal,and 13%more among the advice group than the treatmentgroup (3970versus2670)were rated as good.This scale,which the authorsdescribeas more valid than the singlemeasures,showsa better outcomeamongthe advice group. Though that particular difference does not reach statisticalsignificance,it indicatesthat the effectsof the two treatmentsmay not have been as similar as the authors conclude.
In short, the methodsused in the study may have contributedto the lack of reporteddifferencesbetweenthe groupsat follow-up,making it difficult to determinewhether advice or conventionaltreatment achievedsuperiorresults. In addition to the factorswhich seem to have obscuredintergroup differences,we have severalother concernsabout the methodsused by Edwards
et al. Whether
these indicate
biases that decrease or increase
group differencesis lessclear. It is worth askingwhether the patientsassignedto the two groups were comparablein all characteristics which might influencetreatment outcome.According to the authors, patients were stratified by occupational status and severity of drinking and then randomly allocated within each stratum to the advice and treatment groups.Recognizing that randomizationdoes not always ensurecomparability,the authors compareda number of characteristics in the two groups (Table 1, p. 1008). While the groupswere nearly identical on most measures,other measuressuggestthat somepatientsin the treatmentgrouphad a more seriousdrinkingproblemat intake.Comparedwith the averagemember of the advicegroup,the averagememberof the treatmentgroupmissed 4 moreweeksof work duringthe previousyear due to illnessor unemployment;10g•more of the patientsin the treatment group had previouslyreceivedinpatienttreatmentfor alcoholism.Thoughsmall,these differencesraisequestionsaboutthe similarityof the drinkinghistories of patientsin the two groups. The measuresof drinkingusedto comparethe groupsat intakeseem inadequate.Two of them,patients'and wives'reportsof the numberof weeks of heavy drinking during the previousyear, depend on their subjectiveimpressions of what constitutesheavy drinking.The other measuresreflect only the reportedlength of abstinence. It would have
2210
JOURNALOF STUDIESON ALCOHOL
beenpreferableto comparethe groupson the basisof reportsof quantity, frequencyand variabilityover a specifiedperiod of time prior to intake. Severalothervariables•vhichmighthave affectedthe dependentvariables, such as previous outpatient treatment, source of referral, and motivationto abstainfrom alcohol,were not comparedin the two groups. If, as the authorsstate,xnanypatientswere obviouslypressuredto obtain treatment,someattempt shouldhave been made to comparethe amount of coercionto which each group was subjected. The possibilityof observerbias needsto be consideredmore carefully. The studywas not double-blind,leavingopen the possibilityof systematic bias in patient reportingas well as in observerrecording.Although Edwardset al. argue that patientsin the advice group may have perceived their treatment as second-rate,thereby adverselyaffecting reportedoutcome,one could argue,conversely, that sincethey were not offeredtreatmentsomeof them may have been led to believethat they neededit less,had a lessseriousproblem,or could exert more control over their drinking.
Althoughthe authorsthoughtthat there was no observerb{asbecause the people who gathered data used "structured"inquiry and there was no obviousconsensus of expectation,neither eliminatesthe potentialfor systematic reportingbias.If, for example,interviewerswho expectedthe studyto find that treatmentis not helpfulwere morelikely to interview patientsin one of the groups,the possibilityof such bias is clearly present.Further, we do not know whether somestaff were more involved in the treatmentor advice regimen. If so, were the expectationsand skillsof thoseofferingthe two treatmentssystematically different?
A final analyticalproblemlies in the authors'argumentthat if more treatment is better, then within each of the groupsthosewho received more treatment
should do better than those who received less. While
this is a logicallytemptingargument,the data as they are presented do not supportit. The difficultylies in determiningwho receivedmore treatmentand why. We know that in the treatmentgroup thosewho were thought to need more treatmentwere offered more, resultingin the selectionof a group of peoplewho, in the judgmentof the staff, were more in need. Similarly in the advice group, patients who were
more seriouslyill might have soughtmore treatment.The groupsreceivingdifferent amountsof treatmentthereforewere not comparable, and the differencesmight have affected the measuresof outcome.The authorshave concludedthat the similarityof outcomedemonstrates the lack of correlation between outcome and level of treatment. One could
argue equally well that the similarityin improvementdemonstrates a positiveeffectof intensivetreatment.The moreintensivetreatmentmay have allowed thosewho had more problemsto achievethe samerate
of improvement as the groupthat had fervorproblems. For all the reasonsdiscussed above,thesefindingscannotbe accepted as definitive. The small samplesize, the possibilityof spontaneous re-
COMME•rs
2211
missionamongsomeof the patientsin both groups,the testing effect of the treatmentstaff collectingdata,and the time at which self-reported drinkingwasmeasuredall work to reducethe possibilityof a statistically significantdifferencebetween the groups.Other factors-such as the possibilitythat the groupsdid not have comparabledrinkinghistories and levelsof motivationto quit or reduce drinking, the possibilitythat each group was treated by different individuals,and the opinion of the advice group about their condition and the quality of care they were receiving-couldreveal differencesnot presentin the analysisby Edwards et al. or decreasethe differenceswhich were present. In describingtheseconcernswe are by no meanssuggestingthat the questionsaddressedby the study shouldbe put aside.If anything,we are suggesting that thosewho providethe more expensiveconventional packageof servicesshouldfeel obligatedbecauseof this study to attempt to answerthesequestionswith a data set large enoughto allow a more valid and detailed analysis.
REFERENCES
1. E•)wAat)s,G., ORFOm),J., EGERT,S., GUTHRIE,S., HAWrO;R, A., HENSMAN,C., MITCHESON, M., OPPENHEIMER, E. and TAYLOR,C. Alcoholism:a controlled trial of "treatment" and "advice." J. Stud. Alc. 38: 1004-1031, 1977.
2. JELLINEK, E. M. The diseaseconceptof alcoholisdn. HighlandPark, NJ; Hillhouse Press; 1960.
3. PATTISON, E. M. Nonabstinentdrinking goalsin the treatmentof alcoholism;a clinical typology. Arch. gen. Psychiat. 33: 923-930, 1976. 4. ARMOR,D. J., POLICH,J. M. and STAMBUL, H. B. Alcoholismand treatment. [Preparedfor the U.S. NationalInstituteon AlcoholAbuseand Alcoholism.] Santa Monica, CA; Rand Corp.; 1976. 5. SOBELL,M. B. and SOBELL,L. C. Alcoholicstreated by individualized behavior therapy; one year treatmentoutcome.Behav. Res. Ther., Oxford 11: 599-618, 1973.
6. BOGUE,D. Skid Row in A•nerican cities. Chicago; Community and Family Study Center, Universityof Chicago;1963. 7. CAHALAN,D. Problem drinkers; a national survey. San Francisco; Jossey-Bass; 1970.
8. WISEMAN,J.P. Stationsof the lost; the treatment of Skid Row alcoholics. EnglewoodCliffs, NJ; Prentice-Hall;1970.
