‘Dangerous data’: drinking after dependence part 4. The Sobells decisively crack the consensus
Vitriolic arguments over a small US study conducted in 1970 found their way to the US Congress and the nation’s TV screens. This episode the study; next, the tussle. Mike Ashton of Drug and Alcohol Findings continues his serialisation of the project’s essay on the most controversial issue in alcohol treatment: whether dependent drinkers should always aim for abstinence.
Linda and Mark Sobell: controversy peaked over their groundbreaking trial.
In the previous episode we saw how the 1976 Rand report’s findings on post-treatment controlled drinking triggered a storm of protest targeted more at the ‘undermining’ impact of disseminating such ‘dangerous’ data to the public than at the findings themselves. One reason why Rand’s researchers would have known their findings might be controversial was the reaction to a US trial conducted in 1970 by husband and wife team Mark and Linda Sobell, the key results from which had been published in 1973. There was also a direct connection: Linda Sobell had supplied data for an appendix to the Rand report.
Rand’s report came from a respected mainstream source, but in 1970 the Sobells were at or towards the start of their careers in psychology research (1 2). The young couple devised an audacious and for the time methodologically advanced experiment which, unlike the studies from D.L. Davies and Rand, tested controlled drinking using the gold-standard methodology of a randomised trial – the format which most reliably isolates an intervention as the cause of the findings rather than differences between participants assigned to it versus a comparator.
At Patton State Hospital in California they recruited 70 men voluntarily admitted for the treatment of alcohol dependence, all classified as “Gamma alcoholics”, meaning they suffered physical withdrawal symptoms when they stopped drinking and had lost control over their consumption. These 70 were the test bed for a therapy programme which in suitable patients aimed for controlled drinking, in the context of a study capable of detecting with a high degree of certainty whether – as alleged for Davies’ patients – they were ‘pulling the wool’ over researchers’ eyes. It was perhaps these strengths which helped propel the Sobells episode to the peak of the controversy and generate its enduring status as the most telling of the initial challenges to abstinence-only orthodoxy.
Promising first-year follow-up findings
The first step in the study was to divide the 70 patients into 30 considered suitable to aim for abstinence and 40 for controlled drinking, the latter chosen principally on the basis that patients had sought this objective, shown in the past they could manage it, and had a supportive environment to return to on discharge. Half of each set were then allocated at random to the hospital’s normal abstinence-oriented treatment, forming control groups against whom to benchmark the impact of a radical programme (free source at time of writing) the other half were assigned to.
The new programme was geared to the goal – abstinence or controlled drinking – for which the patients had been considered most suitable. It entailed allowing them to drink during treatment in a mocked-up bar, electric shocks when they drank at all or exceeded controlled-drinking standards, showing videos of how they looked when drunk, and training in how to manage or avoid what for the patient were situations conducive to drinking or over-consumption. Of the resulting four groups of patients, the key group were the 20 considered suitable to aim for controlled drinking and whose treatment was geared to this objective, represented bottom left in the figure above. Compared to the rest, their progress would show whether allowing ‘alcoholics’ to pursue treatment goals which involved continuing to drink would prove to be the disaster orthodoxy predicted.
Published in 1973 in the journal Behaviour Research and Therapy, first-year follow-up results turned any expectation of disaster on its head. Over the year after discharge from hospital, on 70% of days the 20 patients considered suitable for and trained in controlled drinking neither drank heavily nor were consigned to hospital or prison due to their drinking – the best results of all the patients, and achieved despite controlled drinking on around a quarter of days. The 70% ‘good days’ figure was halved to 35% among patients who though similarly suitable to try for controlled drinking, had been left to the clinic’s conventional abstinence-oriented treatment; instead they spent half their days “drunk”, defined as “any day during which 10 or more oz of 86-proof liquor or its equivalent in alcohol content were consumed, or any sequence longer than 2 consecutive days when between 7 and 9 oz were consumed on each day”.
Neither was there any sign of a fading in effect. Over the second half of the follow-up year, at 73% v. 32% the gap between controlled-drinking patients and their controls was slightly greater than the 68% v. 39% registered during the first six months, and this at a time when all the most successful set of patients drank at some stage. Patients also allocated to the new programme, but aimed at the abstinence goal for which they were considered suitable, did almost as well (during the second half of the year, 67% not drinking heavily and not in hospital or prison due to their drinking) as those trained in controlled drinking, but nearly always by not drinking at all.
These results were not due to extremes dominating the averages; the disparities were similar when expressed as proportions of patients (rather than of days) who spent most of their time not drinking heavily – 85% of those trained in controlled drinking versus 32% of their controls. At 87%, patients allocated to the new programme but geared to abstinence also outperformed their controls, of whom barely more than a quarter (27%) managed mostly to avoid heavy drinking.
How did the Sobells see their findings? Of “major importance” they said was that the patients “trained in and encouraged to practice controlled drinking” had demonstrated “their successful capacity to acquire and sustain such behavior”. Significantly in the light of later developments (next episode), the researchers relied for this judgement not on the success of these patients in approximating societal drinking norms, but their success relative to others in the same study:1 no matter how limited it might have been, if their progress was greater than that of their comparators, the programme was at least a step in the right direction.
The results seemed a clear vindication of an intervention based on seeing addiction as a learnt behaviour and of the judicious allocation of even physically dependent patients to learn how to control and moderate their drinking. Controlled-drinking patients had been selected partly because of their “sincere dissatisfaction with [Alcoholics Anonymous] and with traditional treatment modalities”; the study showed this rejection of US orthodoxy need not condemn them to the progressive deterioration predicted for untreated ‘alcoholics’.
There were, however, gaps in the design of the research. No set of patients considered suitable for abstinence was instead offered training in moderation – perhaps an ethically impossible conjunction. Neither was any patient considered suitable for a controlled-drinking objective instead trained in abstinence using the Sobells’ radical programme. It left open the possibility that patients who wanted to go for controlled drinking, and seemed as if they could manage this, would have done better if trained instead in abstinence. The greatest methodological concern (acknowledged by the authors) was that the interviewer who gathered the follow-up data knew which group the interviewee had been allocated to, so was in a position to deliberately or inadvertently steer their responses to advantage the new treatment programme. But perhaps the biggest gap was that a follow-up limited to a year left critics free to reassure themselves that no matter how promising in the short-term, the performance of the controlled-drinking patients could not be sustained. Subsequent follow-ups addressed this uncertainty.
Promise sustained into second and third years
In 1976 and 1978 results were published for the second and third years after the patients had been discharged from hospital, enabling an assessment of whether what orthodoxy predicted would be a disaster had simply been delayed. If anything, the reverse was the case. The controlled-drinking trainees whom abstinence-only advocates would have considered most at risk continued on key measures to do best, and even better than during the first year.
During the second year the same data-gathering methodology as in the first yielded similar results. Up from 70% the year before, on 85% of days patients considered suitable for and trained in controlled drinking neither drank heavily nor were in hospital or prison due to their drinking – still the best results of all the patients, achieved while they drank in a controlled manner on nearly a quarter of days, and significantly superior to the 42% among their controls. As an attempt to assess holistic recovery, a new outcome measure combined (with equal weightings) drinking status, how informants saw the patients’ adjustment to relationships and stressful situations, and patients’ satisfaction with their occupational/vocational status. Patients trained in controlled drinking also excelled on this measure, suggesting their recovery was the most broad-based of the four sets of patients and significantly broader than among their controls.
For the third year the methodology changed, as did the researchers. Addressing accusations of bias on the part of the Sobells, a new set of researchers not associated with their work conducted the study,2 and their interviewers and the team who rated the interviews were not told which group patients belonged to, correcting the main methodological weakness of the Sobells’ follow-ups. Led by Glenn Caddy, two of the three new researchers had also effectively checked the Sobells’ second-year findings, again with assessors ‘blind’ to which set patients belonged to.3
Of the 70 original participants, 62 were located and 49 of the surviving 58 were interviewed. The controlled-drinking patients had continued to show improved outcomes, though participants missing from the data4 may have somewhat altered the picture. Though just three of the 20 had abstained throughout the third year, the 13 patients5 who could be assessed had avoided heavy drinking on 95% of days, including 29% in the form of controlled drinking. Corresponding figures for their controls offered conventional abstinence-oriented treatment were 75% and 35%. Days of heavy drinking (“drunk days”) were 5% versus 25%. The controls too seemed to have improved relative to previous years, but the gap in heavy-drinking days between them and patients trained in controlled drinking remained substantial and statistically significant.
Next episode: “Sobells in the firing line.” Extending way beyond academic debate, character and honesty became the issues as accusations of intentional fabrication of evidence were adjudicated in repeated investigations.
1. “These conclusions are evidenced not only in differences between groups in the target behavior of drinking, but also supported by a number of adjunctive measures of life functioning. Unfortunately, daily drinking baseline data are not available for normal drinkers in the general population, and thus it is difficult to determine how well the subjects in this experiment approximated societal drinking norms, much less those of a sub-sample of the general population selected to constitute an appropriate matched normal drinker control group.”
2. How independent they were may be questioned. The third-year study report says the study was organised with the “enthusiastic support” of the Sobells and under the auspices of the County of Orange in California, which at the time of their second-year study had also employed the Sobells. In 1982 in the New York Times the Sobells were quoted as describing the researchers as “associates of ours”.
3. Caddy G.R., Addington H. and Perkins D. Individualized behavior therapy for alcoholics: a second year independent double-blind follow-up. Unpublished manuscript, 1977. Old Dominion University, USA. No available copy found.
4. Three of the 20 refused to be interviewed and another three could not be contacted.
5. Another one was imprisoned seemingly not due to drinking.
Full essay available on the Effectiveness Bank.
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