Project MATCH, which stands for Matching Alcoholism Treatments to Client Heterogeneity, is the largest and most expensive ($27 million) multi-site clinical trial of different forms of rehab treatment to date. The idea of the study was to determine the effectiveness of matching specific forms of treatment to the individual characteristics of the patients. Three forms of treatment were studied: Twelve-Step Facilitation Therapy (TSF), Cognitive Behavioral Therapy (CBT) and Motivational Enhancement Therapy (MET). The finding of the study showed a positive result for all three groups, including TSF. Here is the original press release from the NIH. So, the study validated the hypothesis, and all was right with the world for those advocates of AA and the 12-Step approach.

Hazelden is considered the gold standard in alcohol rehab treatment, and they base their model of treatment on the 12-Step approach. They created the Minnesota Model of addiction treatment, and they are far and away the largest publishers of AA based books, as well as the largest single purchaser of AA literature; they have board members that serve on the AA board. Hazelden has more than a  vested interest in the success (or perceived success) of the 12-Step approach to recovery. AA is their life blood, so when the initial findings of Project MATCH were announced, Hazelden was understandably pleased. Here is an article published by Hazelden in The Voice (2000) titled, “Recent research offers compelling support for the effectiveness of Twelve Step-based treatment”. Here is a quote from this article:

One of the largest and most widely quoted studies to support the ‘AA works’ philosophy is Project MATCH….”

It goes on to describe the type of 12-Step treatment used in Project MATCH:

Twelve Step Facilitation Therapy, grounded in AA’s concepts of alcoholism as a disease of the mind, body, and spirit and lifelong abstinence as the only sane response. This form of treatment guides clients through AA’s first five steps. It also actively encourages people to attend AA meetings, keep a journal of their experiences at meetings, read AA literature, and practice AA principles ‘in all our affairs.’”

It goes on:

Project MATCH found few differences in outcomes among the three treatments. This means that Twelve Step Facilitation held its own, working as well as Cognitive Behavioral Therapy and Motivational Enhancement Therapy. In fact, Twelve Step Facilitation offered a statistically significant advantage when total abstinence was the desired outcome.”

Finally, they offer a qualifier:

…treatments such as Twelve Step Facilitation (TSF) are technically not the same as AA. In Project MATCH and related studies, this treatment is based on individual counseling sessions with an ultimate purpose of guiding people to join AA. But in itself, AA is not a counseling or treatment program.”

This is an example of Hazelden wanting it both ways. On the one hand, this study proves that AA works. On the other hand, if it shows any component of the study was ineffective, it is “not really AA”. It is also absolute bullshit. Not only was TSF AA, it was spoon fed AA on steroids. This is taken directly from the TSF manual for the Project MATCH study:

“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)” (Schaler, Jeffrey  “Addiction is a Choice”)

Of course it is AA. This is obvious, but even if it did not incorporate all of AA’s tenets (which it did), AA itself proclaims you can “take what you want and leave the rest”, which means that by their logic, any combination of any components of AA are fine. By their logic, a person can take only one step if that is all they need, and it would still be considered AA. This is just another example of AA, and in this case Hazelden, an AA front group, talking out of both sides of their mouth.

As it turns out, Project MATCH was fraught with problems, from selection criteria to participant selection. The initial conclusion was the victim of cherry picking the participants and misinterpreting the data. Upon peer review, it was shown that there was no difference between TSF (AA) and the two other forms of treatment. In this case, Hazelden was right. It also showed that none were more effective than no treatment at all. None of the treatments worked, and twelve stepping actually had more of a negative impact than no treatment at all. Here is a link to a peer review from the University of Miami: Are alcoholism treatments effective? The Project MATCH data. From the study:

Results

Overall, a median of only 3% of the drinking outcome at follow-up could be attributed to treatment. However this effect appeared to be present at week one before most of the treatment had been delivered. The zero treatment dropout group showed great improvement, achieving a mean of 72 percent days abstinent at follow-up. Effect size estimates showed that two-thirds to three-fourths of the improvement in the full treatment group was duplicated in the zero treatment group. Outcomes for the one session treatment group were worse than for the zero treatment group, suggesting a patient self selection effect. Nearly all the improvement in all groups had occurred by week one. The full treatment group had improved in PDA by 62% at week one, and the additional 11 therapy sessions added only another 4% improvement.

Conclusion

The results suggest that current psychosocial treatments for alcoholism are not particularly effective. Untreated alcoholics in clinical trials show significant improvement. Most of the improvement which is interpreted as treatment effect is not due to treatment. Part of the remainder appears to be due to selection effects.”

It also made this statement, which is applicable to not only inpatient rehab treatment, but for AA specifically:

Exaggerated claims of treatment effectiveness can have undesirable consequences for patients, for therapists, and for science. Patients who fail an “effective” treatment may feel even more hopeless. This increased despair may be extremely deleterious in people with such life-threatening habits. Therapists may feel inadequate or frustrated with repeated failures. For science, exaggerated claims tend to shift focus into unproductive directions, and to obscure the pertinent facts that are necessary in order to move the science forward.”

I cannot agree more, and I have seen the consequences of people failing while doing the AA program. The unrealistic expectations that come from reading the 12 promises and things such as “rarely have we seen a person fail…” exacerbates their already frail psychological state. Add to this the shame and other mind games, and you wind up with someone worse off than they were before entering AA.

One thing this report does not address, which is important, are the consequences to the family of the patient. Rehab treatment facilities are expensive, some costing tens of thousands of dollars per stay. Insurance does not always pay for these programs, and it is not unusual for families to drain their savings and mortgage their homes in order to receive treatment. This is understandable, as any person or family member of a person suffering from addiction will tell you. Most will do whatever is possible if they believe that it will properly treat their addictions. Family members of patients are encouraged to attend Ali-non meetings, where they are fed the same dogma that is given to the stepper. So, if an AAer is not yet convinced of their character flaws, their family will confirm them, and will attribute their addiction to those flaws, because they learned this from the good people in Ali-non. The financial and emotional harm tears relationships apart.

What has changed as a result of this study? Nothing, really, except Hazelden (and other AA based rehab facilities) no longer tout the results. It is business as usual. At this moment, someone is stepping into a treatment centre for the first time, and along with his or her family, they are expecting effective and proven treatment; integrity from their caregivers; and a way out of the hell of addiction in which they have found themselves. They won’t get any of that. Think about that next time some stepper tells you that we are picking on a benign and innocuous organization.

MA

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