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 Chapter Eleven

Controversial Treatments
for Alcohol Use Disorders

James MacKillop and Joshua C. Gray

Introduction

The modern array of treatment options and facilities for alcohol use disor-
ders (AUDs) belies the fact that formal treatment for alcohol problems is
a relatively recent endeavor. Historically, excessive drinking was typically
viewed through a moral lens as a character defect, reflecting weakened
mental capacity and a lack of self-control (Levine, 1978). As a result, soci-
etal responses were primarily in the form of legal sanctions, such as fines or
jail sentences, and intercession by religious leaders for spiritual and moral
restoration. During the 19th and early 20th centuries, grass-roots move-
ments, such as the Washingtonians and, later, Alcoholics Anonymous,
also arose to aid individuals with drinking problems (for a full review, see
White, 1998).
Over the course of the 20th century, treatment for alcohol problems
shifted into the purview of medicine, clinical psychology, and other clinical
disciplines for a number of reasons. Psychology, physiology, pharmacology,
and neuroscience burgeoned as scientific disciplines and offered new theo-
ries for the causes of alcoholism (see Miller & Hester, 1995, for a review
of 13 theoretical perspectives) and novel ways to parse the condition (e.g.,
Jellinek, 1946, 1960). Experimental methods were developed that permit-
ted the systematic study of alcohol consumption under controlled condi-
tions (Lisman, 1974; Mello & Mendelson, 1965), further strengthening the
scientific enterprise. Perhaps the single most important event in advancing
a scientific approach to AUD treatment in the United States, however, was
passage of the Comprehensive Alcohol Abuse and Alcoholism Prevention,
322
Alcohol Use Disorders 323

Treatment, and Rehabilitation Act in 1970. This act in turn created the
National Institute of Alcohol Abuse and Alcoholism (NIAAA) in 1971,
which was in large part responsible for the substantial expansion of AUD
clinical research. Furthermore, it marked the inception of the professional
treatment establishment from which inpatient and outpatient clinics subse-
quently proliferated.
The professional treatment establishment that now exists, however, is
highly heterogeneous and fractious in terms of perspectives on best-prac-
tices. This friction in part stems from the fact that the alcohol treatment
enterprise includes two broad constituencies: treatment providers who have
limited formal training but have personally experienced AUDs (or other
addictive disorders) and are now stably recovered; and treatment provid-
ers who are formally trained but have not personally suffered from these
conditions. For example, in two recent studies of treatment professionals,
approximately half of the treatment providers were successfully recovered
individuals (Curtis & Eby, 2010; Davis & Rosenberg, 2012). A heuristic
distinction that has been made between these groups is that of “craftsmen,”
the informally trained recovered individuals, and “scientists,” the formally
trained clinicians (Kalb & Propper, 1976). The craftsmen are often char-
acterized (or perhaps caricatured) as having strong and uncritical adher-
ence and advocacy of specific approaches, with relatively little interest in
systematic research, whereas the scientists are characterized as being overly
dogmatic and unwilling to consider the merits of treatments that are not
directly supported by empirical evidence. Although recent data suggest that
this distinction is increasingly less black-and-white (Davis & Rosenberg,
2012), the fact remains that professional alcohol treatment continues to
comprise two constituencies with quite different perspectives. Based on the
varying emphasis on research, a wide assortment of treatment approaches
are currently employed, with considerable controversy and highly variable
levels of empirical support.
Reviewing the controversial treatments for AUDs is the first goal of
this chapter. We define treatments as “controversial” if they have become
widely adopted or have generated popular appeal, but have been demon-
strated by controlled research to be of questionable or even nonexistent
efficacy. Equally, other controversial treatments are defined by the inverse:
approaches that have been shown to be effective but remain largely unused
due to practitioner taboos. In other words, controversial treatments are
those that are in use despite the lack of evidence for their efficacy or are
not in use despite evidence for their efficacy. Specifically, the controver-
sial approaches we discuss are confrontational Johnson Institute “inter-
ventions;” Alcoholics Anonymous, and other mutual-help groups; the
prevention program Drug Abuse Resistance Education; and interventions
designed to promote moderate drinking. The second goal of the chapter is
to review evidence-based treatments for AUDs. Increasing the use of treat-
ments that have foundations in behavioral science and are supported by
324 CONTROVERSIES IN THE TREATMENT OF ADULT DISORDERS

scientific evidence requires persistently disseminating information about

these interventions and the supporting evidence. Here, we will review
reinforcement-based approaches, cognitive-behavioral approaches, motiva-
tional interviewing, marital and family therapy, brief interventions, and
pharmacological treatment. In a concluding section, we reflect on the state
of the field and future directions for a scientifically based approach to treat-
ing AUDs.

Controversial Treatments
The Johnson Intervention
If asked, most members of the general public would almost certainly report
“an intervention” as the most effective strategy for motivating an individ-
ual to seek treatment for an AUD. This refers to a structured confronta-
tion of the individual by family and friends to convince the person to stop
drinking and seek treatment immediately. It was initially developed in the
1970s by Vernon Johnson, an Episcopal priest and founder of an alcohol
treatment facility, the Johnson Institute, giving rise to the strategy’s formal
name, the Johnson Intervention. The format of the Johnson Intervention is
relatively well known. Responding to a false pretext, targeted individuals
are lured to a meeting with the important people in their lives. There, they
are systematically confronted with the negative effects of their drinking (or
drug use) and the consequences that will follow if they elect not to imme-
diately accept the offer of treatment. The putative strategy is to overwhelm
the individuals’ denial, thereby motivating them for treatment, and then
initiate the process (Johnson, 1986; Twerski, 1983).
The Johnson Intervention is not the only form of confrontational inter-
vention used in AUD treatment (White & Miller, 2007), but it has become
the most widespread for a number of reasons. A Johnson Intervention was
the catalyst for former U.S. First Lady Betty Ford (wife of President Gerald
Ford) to seek treatment, bringing it into the popular consciousness. More-
over, because Johnson Interventions have the potential for high drama,
they have increasingly become plot lines on a wide variety of popular tele-
vision programs (e.g., The Sopranos, Party of Five, Beverly Hills 90210).
Indeed, since 2005, an eponymous reality television program, Intervention
(A&E, 2012), has followed over 200 individuals over the course of a John-
son Intervention, winning an Emmy award in 2009.
The proponents of Johnson Interventions make undocumented claims
of very high rates of successful long-term recovery (e.g., 80%; Assistance
in Recovery, 2012). From the perspective of controlled clinical research,
however, the Johnson Intervention is not robustly supported. Liepman,
Nirenberg, and Begin (1989) examined the effects of Johnson Interven-
tion on treatment initiation and reported high rates of entry, but acknowl-
edged several limitations, including very high rates of families who did
Alcohol Use Disorders 325

not undertake the Johnson Intervention, nonrandom assignment of par-

ticipants, and a small sample size. In another study, Loneck, Garrett, and
Banks (1996a) found that, compared with four other strategies, individuals
who underwent a Johnson Intervention were more likely to enter treat-
ment. However, their methodology was retrospective and only represented
the cases in which the family members followed through with the Johnson
Intervention. Furthermore, participants in the Johnson Intervention condi-
tion were more likely to relapse than those in three of the four comparison
groups (Loneck, Garrett, & Banks, 1996b). More recently, Miller, Mey-
ers, and Tonigan (1999) conducted a more methodologically rigorous study
and found that family compliance rates for participation in an interven-
tion were strikingly low (30%) compared with another intervention condi-
tion and an Alcoholics Anonymous condition. In addition to overstated
claims of efficacy, Johnson Interventions may in fact cause harm, although
research substantiating this possibility is lacking. Implicit in the preceding
findings is that if the Johnson Intervention is believed to be the only option
for motivating a person to seek treatment, most families are unwilling to
undertake the ordeal. For those that are, coercive techniques that confront
individuals with ultimata and cataclysmic consequences, such as the dis-
solution of a marriage, may elicit extremely negative reactions (Galanter,
1993). Furthermore, confrontational Johnson Interventions do not con-
sider the possibility of exacerbating commonly comorbid conditions, such
as major depression or posttraumatic stress disorder.
The last negative consequence of Johnson Interventions comes in the
form of opportunity cost. Johnson Interventions may displace the imple-
mentation of alternative strategies for which a strong evidence base exists.
The best supported is the Community Reinforcement Approach Family
Training (CRAFT; Meyers, Miller, Hill, & Tonigan, 1998; Meyers & Smith,
1997), which has foundations in operant theory and is discussed in detail
later in this chapter. The second is a more gradual three-step approach, A
Relational Sequence for Engagement (ARISE; Garrett et al., 1998), which
starts with social and emotional support from family and friends, and pro-
gresses to a typical Johnson Intervention while striving to minimize adverse
reactions from the targeted individual. During Stage 1, a family member
or friend calls all involved individuals to set up the intervention network
and a meeting. The alcohol user is informed and encouraged to attend the
meeting. In Stage 2, the family meets regardless of the attendance of the
alcohol user, and they assess the alcohol problem in the context of the fam-
ily system. If the alcohol user continues to avoid these meetings, then Stage
3 is initiated, whereby the traditional confrontational Johnson Interven-
tion approach is employed. In a within-subjects clinical trial, Landau et al.
(2004) found that the ARISE approach resulted in 83% of the participants
engaging in individual treatment or self-help. Critically, however, 80%
were successful in the nonconfrontational Stages 1 and 2 and only 3% at
Stage 3. Although this is the only controlled study on ARISE for AUDs, it
326 CONTROVERSIES IN THE TREATMENT OF ADULT DISORDERS

is a promising start and suggests the importance of actively engaging the

individual in discussing treatment.
Taken together, the Johnson Intervention is an exemplar of a pseudo-
scientific treatment for AUDs. It is in common practice, vocally advocated
by adherents who cite very positive outcomes from unverifiable and nonsci-
entific sources, and not supported in controlled research. Furthermore, as
it may potentially result in adverse consequences for its targets and at least
one evidence-based practice is available as an alternative. In sum, although
the melodrama of surprising and confronting individuals with AUDs and
other addictive disorders appears to make for good television, the evidence
suggests that it does not make for good treatment.

Alcoholics Anonymous

Founded in 1935, with a current estimated 114,000 groups worldwide and

over 2,000,000 members, Alcoholics Anonymous (AA) is almost certainly
the largest mutual-help group in the world (Alcoholics Anonymous, 2012).
Despite its size, AA is flat in structure. The governing body is only one level
above the individual chapters and cannot make decisions that affect AA as
a whole. For this reason, AA remains both ideologically and organization-
ally very close to its grass-roots origins. Like the Johnson Intervention,
the general format of AA is also familiar to the general public. Individuals
meet together for fellowship, share their past experiences with alcohol with
a nonjudgmental group of fellow sufferers, and try to follow the 12 steps
toward individual and interpersonal rehabilitation. A religious component,
though nondenominational, is central; seven of the steps refer specifically
to God, a “Higher Power,” or Him. A sponsorship system is often in place,
in which a new member is mentored by a stable senior member. Addition-
ally, newcomers are advised to immerse themselves by attending a meeting
each night for the first 90 days.
AA is perhaps the most controversial AUD treatment (Kaskutas, 2009).
Members and proponents of AA are often perceived as overly theistic and
optimistic, and as unaccepting of other perspectives (Ellis & Schoenfeld,
1990; Tournier, 1979); some have gone as far as to compare AA to a cult
(Bufe, 1991). The AA etiological model, not having been updated in over 50
years, has also been criticized as highly outdated (Kelly, 2013). The treat-
ment model has been criticized for fostering dependence on external factors
that are beyond the individual’s control (Ellis & Schoenfeld, 1990) and
for applying a one-size-fits-all approach (Kelly, 2013). Although AA is not
affiliated with any professional organization or treatment, many formal
treatment programs have nonetheless adopted its perspective (Roman &
Johnson, 1998). Conversely, research-trained clinicians have been criticized
for being myopic and discounting the potential of AA and other self-help
treatments (Chiauzzi & Liljegren, 1993).
Alcohol Use Disorders 327

The gold standard for empirical support for the efficacy of clinical
interventions is the randomized controlled trial (RCT), but relatively few
studies have examined AA in RCTs. Of those that have, the data are not
especially supportive. For example, three randomized trials of AA have
been undertaken involving populations mandated to attend AA and were
not supportive (Alford, 1980; Ditman, 1967; Walsh et al., 1991). Meta-
analyses and systematic reviews of controlled studies have also concluded
that the balance of evidence does not support the efficacy of AA (Ferri,
Amato, & Davoli, 2006; Kownacki & Shadish, 1999).
Superficially, these findings suggest that AA is indeed a pseudoscien-
tific treatment, persisting by virtue of intuitive appeal and strident adherents
despite weak empirical support. However, there are a number of reasons
that this conclusion may not be accurate, and there remains a need to con-
sider additional research evidence. First, as a consumer-led nonprofessional
mutual-help organization, a number of AA’s characteristics distinguish it
from formal psychological or medical interventions. To start, AA does not
purport to be a formal treatment per se (Kelly, 2013) and, although the
AA format is well known, the nature of AA groups and the experiences
an individual has in AA may be highly variable. All that is required for an
AA group is that two or more alcoholics meet together for the purpose of
achieving sobriety (McCrady, Horvath, & Delaney, 2003). As such, none
of the essential features of formal treatment outcome research, like treat-
ment manuals and fidelity checks, can be applied. Random assignment of
individuals to AA does not replicate the typical pathway that leads to par-
ticipation and has the potential to create a negatively predisposed group
of subjects (McCrady et al., 2003). Furthermore, random assignment to
conditions other than AA may be ethically questionable, as it involves pro-
hibiting individuals from participating in a free community resource (Kelly,
2013).
By virtue of these innate characteristics, quasi-experimental and nat-
uralistic studies may be more appropriate for understanding the clinical
utility of AA. Here, the data are persuasive that AA participation is associ-
ated with improved drinking outcomes. For example, in a large naturalis-
tic study on individuals in the Veterans Administration, Ouimette, Moos,
and Finney (1998) found that, relative to individuals who only received
outpatient treatment, patients who attended only AA meetings were more
likely to be abstinent at 1-year follow-up, although, not surprisingly, the
best outcomes were for individuals attending both treatment modalities.
Timko, Moos, Finney, and Lesar (2000) studied the outcome of 248 prob-
lem drinkers who self-selected AA, formal treatment, formal treatment plus
AA, or no treatment at all at 1-year, 3-year, and 8-year follow-up. Those
who chose no treatment fared the worst, and the AA-only and combined
AA/formal treatment groups fared better than the formal treatment group
alone at 1 and 3 years, although not at the 8-year follow-up. A follow-
up at 16 years found that the duration of AA attendance in years 1 to 3
328 CONTROVERSIES IN THE TREATMENT OF ADULT DISORDERS

independently predicted abstinence and lower drinking problems (Moos &

Moos, 2006).
Another source of data that bears on AA comes from studies that do
not focus on AA per se, but on facilitating participation in a 12-step pro-
gram. This approach, referred to as 12-step facilitation (TSF), is formal-
ized in a way that is compatible with other psychological interventions and
is more amenable to controlled study. It is conceptually grounded in the
tenets of AA and other 12-step groups and attempts to foster a commitment
to participate in AA (Project MATCH Research Group, 1997). In the large
multisite clinical trial, Matching Alcohol Treatments to Client Heterogene-
ity (Project MATCH), TSF was contrasted with cognitive-behavioral cop-
ing skills management and motivational enhancement therapy. Although
TSF intervention was not a test of AA as a treatment, the three treatments
produced comparable outcomes (Project MATCH Research Group, 1998).
The lack of significant outcome differences and retention rates among the
three treatment conditions suggests that TSF is equivalent to evidence-
based treatments. In a study comparing relapse prevention and TSF follow-
ing inpatient treatment, both interventions had equally positive impacts,
although women, polysubstance users, and individuals who were high in
psychological distress benefited more from TSF (Brown, Seraganian, Trem-
blay, & Annis, 2002). These findings converge with previous evidence that
individuals with AUDs who are able to choose treatment pathways have
better outcomes (Sanchez-Craig & Lei, 1986). Taken together, it appears
that among people who self-select into AA, there are significant short- and
long-term benefits.
The empirical literature on AA has also become considerably more
sophisticated in identifying the factors that predict whether a person is
well suited for AA and the mechanisms that underlie AA’s positive effects.
For example, in Project MATCH, patient ratings of AA’s conceptual and
spiritual underpinnings predicted meeting attendance, engagement in AA
practices, and greater abstinence (Tonigan, Miller, & Connors, 2000).
Similarly, although nonreligious individuals attend AA (Tonigan, Miller, &
Schermer, 2002), they attend less frequently (Tonigan et al., 2002) and are
more likely to drop out (Kelly & Moos, 2003). With regard to mechanisms,
a recent review of 19 studies found that several potential mechanisms,
including increased self-efficacy, increased coping skills, and the develop-
ment of a more adaptive social network, appeared to be responsible for
AA’s positive effects (Kelly, Magill, & Stout, 2009). These social network
changes include both decreasing contact with pro-drinking individuals
and increasing contact with pro-abstinence individuals. In contrast, there
was limited evidence for the spiritual mechanisms or AA-specific practices
being the mechanisms of action. This finding converges with a previous
review suggesting that social network changes are substantively respon-
sible for positive AA influences (Groh, Jason, & Keys, 2008). In a recent
study examining mechanisms of AA attendance effects in Project MATCH
Alcohol Use Disorders 329

(Kelly, Hoeppner, Stout, & Pagano, 2012), there was consistent evidence
that adaptive social network changes partially mediated the link between
AA attendance and positive drinking outcomes.
These selection and mechanism findings are important for both obvi-
ous and more subtle reasons. Clearly, knowing client characteristics asso-
ciated with positive AA outcomes can inform clinicians with regard to
which patients may be most appropriate for AA. Similarly, understanding
AA’s mechanisms is important for clinicians to anticipate probable positive
consequences from AA and to orient recommendations toward those pro-
cesses. Furthermore, understanding AA’s mechanisms of behavior change,
and especially the fact that these mechanisms do not appear to be content
specific, may also inform more formal treatments, such as the develop-
ment of interventions to foster more adaptive social networks. Although
the largest by far, it is notable that AA is not the only mutual-help group
for AUDs. Others include Secular Organizations for Sobriety, which shares
similar tenets to AA but has no spiritual dimension; SMART recovery,
which is a support group that includes elements of motivational interview-
ing, cognitive-behavioral therapy, and rational emotive behavior therapy;
and Moderation Management, which focuses on helping people achieve
nonabstinent outcomes. These mechanistic findings suggest that the indi-
viduals with AUDs may benefit from diverse types of mutual-help groups
that commonly enhance self-efficacy, increase coping skills, and nurture
the development of a nondrinking social network.
A final consideration with regard to AA in AUD treatment is logisti-
cal. In a mental health treatment environment that is highly focused on the
costs of services, AA is unarguably a highly cost-effective resource, for it is
free and self-supporting. Moreover, there is increasing evidence that par-
ticipation in AA reduces general health care costs (Humphreys & Moos,
2001, 2007; Mundt, Parthasarathy, Chi, Sterling, & Campbell, 2012). For
example, in a recent longitudinal study of 403 adolescents with AUDs,
mutual-help group attendance following formal treatment was associated
with a 4.7% health care cost reduction during a 7-year follow-up (Mundt
et al., 2012). That translated into a $145 reduction in health care costs for
each meeting attended, primarily from additional treatment costs, hospi-
talizations, and psychiatric follow-up. In addition to being free, a further
advantage is that AA and other mutual-help groups are highly accessible to
the public (e.g., no formal initiation, daily meetings).
To conclude, the role of AA in the science-based AUD treatment enter-
prise has been highly controversial, but it has been increasingly informed
by data. There is weak evidence for the clinical efficacy of AA in terms of
RCTs, but the RCT may mischaracterize the nature of AA and oversimplify
the question at hand. There is consistent evidence that AA involvement
and AA facilitation are associated with positive AUD outcomes. Moreover,
research clarifying the active ingredients of AA offers novel insights that
suggest common process factors are operative and may be applicable to
330 CONTROVERSIES IN THE TREATMENT OF ADULT DISORDERS

formal treatment. To be sure, from a scientific standpoint, there are reasons

to be critical of AA’s outmoded etiological model and to question the strong
identification of formal treatment programs with AA principles (Kelly,
2013). Participation in community mutual-help groups like AA will not be
for all patients, but, for some, AA may very well enhance formal treatment
efforts. Therefore, we propose that the most appropriate approach for clini-
cians is to leverage AA’s wide proliferation and availability, but to do so in
ways that are informed by the expanding empirical literature in the area. In
other words, keep the baby, throw out the bathwater.

Controlled Drinking as a Treatment Outcome

In contrast to the preceding controversies, the posttreatment goal of con-
trolled drinking (i.e., occasional nonharmful alcohol use) is not scientifi-
cally controversial because of limited or contradictory evidence of its effi-
cacy. To the contrary, controlled drinking has a long history of controversy,
despite having an evidence base supporting its efficacy. The pseudoscience
here is its reflexive rejection as a treatment goal and its very limited integra-
tion into most treatment programs.
Controlled drinking seeks to assist individuals with drinking prob-
lems to establish or reestablish control or moderation in drinking, typically
defined as a limit on the amount and frequency of consumption, as well as
avoidance of legal, social, and physical problems. This goal may not seem
controversial, but it is antithetical to the “one-drink, one-drunk” principles
of AA and, as most AUD treatment facilities identify with that orientation
(Roman & Johnson, 1998), it also runs counter to most treatment regi-
mens. For this reason, when clinical research first supported the prospect of
controlled drinking in the early 1970s, a fractious public debate followed.
The initial data that sparked an interest in controlled drinking came
from a long-term follow-up of a cohort of alcohol-dependent individuals
that reported approximately 8% had resumed drinking but at healthy lev-
els (Davies, 1962). This was not the only report of this finding, but it was
important because the data were framed as the basis for questioning the
assumption of permanent abstinence as the only viable treatment outcome.
Subsequently, the question of controlled drinking as an acceptable treat-
ment option erupted in controversy as a result of two studies. The first was
an investigation applying behavior therapy to alcohol dependence, with the
aim of achieving controlled drinking (Sobell & Sobell, 1973, 1976). The
second was a longitudinal assessment of almost 600 alcohol-dependent
individuals who had been treated at federally funded treatment centers
(Armor, Polich, & Stambul, 1976), finding the presence of “normal” drink-
ers in the follow-up samples. Specifically, 12% and 22% of individuals were
considered normal drinkers at 6- and 18- month follow-ups, respectively.
These data were widely publicized and attacked on scientific, politi-
cal, and ethical grounds by those advocating abstinence as the only viable