Commentaries 17
re-integration is recovery, whatever forms of affiliation—
employment, relationship, church—that re-integration
takes. It is relevant to prevention, too; the more social roles
a person undertakes, the less likelihood of drinking
problems [3].
Unfortunately, people who might respond well to
treatment (in Sellman’s terms, those who are recruited to
clinical trials) do not often come to our services. He wants
more research into how to manage the marginalized
people who do attend, but I think services need to change
their focus. We risk being as stuck as the people we
are unable to cure, locked into our own stereotyped
responses. Recovery for specialist addiction services is
through re-integration with the health care system. If
half our primary care practitioners addressed alcohol
issues with half their patients, and replicated the out-
comes of Project COMBINE, it would make a substantial
contribution to reducing the burden of disease associated
with alcohol [4]. But they do not [5] and, as George
Vaillant has argued, nor do general hospitals [6].
Doctors do not want to be stuck managing
patients unless they feel competent to do so, and can
obtain help and advice if things get frustrating. The
role of specialist services is to support primary care
and hospitals, initiating treatment plans and managing
complex cases which cannot be managed in primary
care. Addiction medicine consultation–liaison services
need to be relevant and useful, helping primary care
and hospital staff manage complex and chronic pa-
tients efficiently and humanely, reducing the frustration
felt by generalist staff, and increasing their readiness to
ask and advise their patients about alcohol and drug
use.
Declaration of interest
James Bell has given a talk for Schering Plough (distribu-
tors of buprenorphine) and has had research and travel
funded by Reckittbenckiser, research funded by Biomed
PL and research funded by Titan Pharmaceuticals.
Keywords Addiction, addiction medicine, health
services, public health.
JAMES BELL
South London and Maudsley NHS Foundation Trust,
London, UK. E-mail: james.bell@slam.nhs.uk
References
1. Sellman D. The 10 most important things known about
addiction. Addiction 2010; 105: 6–13.
2. Miller W. Rediscovering fire: small intervention, large effects.
Psychol Addict Behav 2000; 14: 6–18.
3. Kuntsche S., Knibbe R. A., Gmel G. Social roles and alcohol
consumption: a study of 10 industrialised countries. Soc Sci
Med 2009; 68: 1263–70.
© 2010 The Authors. Journal compilation © 2010 Society for the Study of Addiction
4. Anton R. F., O’Malley S. S., Ciraulo D. A., Cisler R. A., Couper
D., Donovan D. M. et al. Combined pharmacotherapies and
behavioral interventions for alcohol dependence: the
COMBINE study: a randomized controlled trial. JAMA 2006;
295: 2003–17.
5. Abouyanni G., Stevens L. J., Harris M. F., Wickes W. A.,
Ramakrishna S. S., Ta E. et al. GP attitudes to managing
drug- and alcohol-dependent patients: a reluctant role. Drug
Alcohol Rev 2000; 19: 165–70.
6. Vaillant G. The Natural History of Alcoholism. Boston, MA:
Harvard University Press; 1984.
add_2786 17..24
MISSING THE CONTINUUM
Sellman’s provocative paper makes several excellent (e.g.
‘different psychotherapies appear to produce similar out-
comes’) and sometimes contentious (e.g. ‘compulsive
drug seeking is initiated outside of consciousness’)
points [1]. In this commentary, we offer some general
reactions to Sellman’s paper and then discuss an impor-
tant area in the addictions field about which little is
known.
One of the most important points raised by Sellman,
also discussed by Orford [2], is that rivalries between
explanatory models seem to have been more important to
practitioners and researchers than to clients. Another
important point raised by Sellman is that therapists can
play a critical role in increasing a client’s motivation for
change. We found it puzzling, however, that Sellman’s
paper focused almost exclusively on substance abusers
whose problems are severe. Such a focus raises two con-
cerns. First, the references Sellman cites about alcohol
problems are decades old, and there are no references to
the National Epidemiologic Survey on Alcohol and
Related Conditions (NESARC). Data from the NESARC
survey suggest that long-term stability of outcomes is
achieved by many alcohol abusers, with about equal pro-
portions of abstinent and low-risk drinking outcomes [3].
Secondly, Sellman’s focus on substance abusers who
present for treatment ignores the majority of individuals
with alcohol [3,4] and other drug problems [5], as they
do not seek treatment. In this regard, any comprehensive
conceptualization of substance use disorders must apply
to all cases, not just those in treatment. This point, made
repeatedly by others, including Orford & Edwards [6],
Vaillant [7], Cahalan [8] and Robins [9], is best captured
in the following statement: ‘addiction looks very different
if you study it in a general population than if you study it
in treated cases’ ([9]; p. 1051).
Reference to the well-documented process of self-
change or recovery without formal help or treatment [10]
is also absent in Sellman’s paper. The concern here is that
many substance abusers who do not enter treatment
recover on their own [10], and typically their problems are
Addiction, 105, 14–21
18 Commentaries
less severe (amount of substance used, consequences, or
both) than those in treatment. Not including such indi-
viduals in a paper on ‘things known about addiction’ pre-
sents a skewed and incomplete view of substance use
problems. From the standpoint of the health care system,
recognizing the process of self-change and targeting indi-
viduals with less severe problems is a very important
priority [11].
An important area in the addiction field where we feel
rigorous data are lacking is about the effects of psychoac-
tive substances on clinical populations. Our experimental
intoxication research in the early 1970s provided us with
an exceptional opportunity to observe and interact with
individuals who had severe alcohol problems when those
individuals were under the influence of alcohol. That
experience greatly influenced our thinking both then and
now. At that time, within a short period of time a handful
of laboratories produced a great deal of very important
information about the nature of alcohol problems (e.g.
[12–14]). Today such research is lacking. Consequently,
critical scientific information in several areas is lacking.
For example, we do not know how decision making
capacities are affected when substance abusers are under
the influence of alcohol or other drugs. Unfortunately,
our main source of knowledge about many important
effects of drugs remains subjective, retrospective reports.
Declaration of interest
None.
Keywords Addiction, intoxication studies, natural
recovery, self-change.
MARK B. SOBELL & LINDA C. SOBELL
Center for Psychological Studies, Nova Southeastern
University, 3301 College Avenue, Fort Lauderdale,
FL 33314, USA. E-mail: sobellm@nova.edu
References
1. Sellman D. The 10 most important things known about
addiction. Addiction 2010; 105: 6–13.
2. Orford J. Asking the right questions in the right way: the
need for a shift in research on psychological treatments for
addiction. Addiction 2008; 103: 875–85.
3. Dawson D. A., Grant B. F., Stinson F. S., Chou P. S., Huang B.,
Ruan W. J. Recovery from DSM-IV alcohol dependence:
United States, 2001–2002. Addiction 2005; 100: 281–92.
4. Institute of Medicine. Broadening the Base of Treatment for
Alcohol Problems. Washington, DC: National Academy
Press; 1990.
5. Compton W. M., Thomas Y. F., Stinson F. S., Grant B. F.
Prevalence, correlates, disability, and comorbidity of
DSM-IV drug abuse and dependence in the United States:
results from the national epidemiologic survey on alcohol
© 2010 The Authors. Journal compilation © 2010 Society for the Study of Addiction
and related conditions. Arch Gen Psychiatry 2007; 64: 566–
76.
6. Orford J., Edwards G. Alcoholism: A Comparison of Treatment
and Advice with a Study of the Influence of Marriage. Oxford,
UK: Oxford University Press; 1977.
7. Vaillant G. E. The longitudinal study of behavioral disor-
ders. Am J Psychiatry 1984; 1: 61–2.
8. Cahalan D. Studying drinking problems rather than alco-
holism. In: Galanter M., editor. Recent Developments in Alco-
holism, vol. 5. New York: Plenum Press; 1987, p. 363–72.
9. Robins L. N. Vietnam veterans’ rapid recovery from heroin
addiction: a fluke or normal expectation? Addiction 1993;
88: 1041–54.
10. Klingemann H. K., Sobell L. C. Promoting Self-Change from
Addictive Behaviors: Practical Implications for Policy, Preven-
tion, and Treatment. New York: Springer; 2007.
11. Sobell M. B., Sobell L. C. Treatment for problem drinkers: a
public health priority. In: Baer J. S., Marlatt G. A., McMahon
R. J., editors. Addictive Behaviors across the Lifespan: Preven-
tion, Treatment, and Policy Issues, Beverly Hills, CA: Sage;
1993, p. 138–57.
12. Mendelson J. H., LaDou J., Solomon P. Experimentally
induced chronic intoxication and withdrawal in alcoholics,
Part 3. Psychiatric findings. Q J Stud Alcohol 1964; 25:
40–52.
13. Mendelson J. H., Mello N. K. Experimental analysis of drink-
ing behavior of chronic alcoholics. Ann NY Acad Sci 1966;
133: 828–45.
14. Tamerin J. A., Weiner S., Mendelson J. H. Alcoholic’s expect-
ancies and recall of experiences during intoxication. Am J
Psychiatry 1970; 126: 1697–704.
add_2833 18..25
PERHAPS IT IS THE DODO BIRD
VERDICT THAT SHOULD BE EXTINCT
Dr Sellman’s excellent synthesis and common-sense con-
clusions regarding the addiction treatment field will
doubtless become required reading in many addiction
training centres, and deservedly so [1]. However, Profes-
sor Sellman makes one point that appears to us to mis-
represent some of the evidence and reflects a line of
thinking which, if broadly accepted, has some potential
to reverse some of the important, and very hard-won,
progress we have made in improving the quality of addic-
tion treatment. The premise that ‘Different psychothera-
pies appear to produce similar results’, reminiscent of the
‘Dodo Bird verdict’ [2], overlooks some of the recent evi-
dence and results in some misconceptions. Following Pro-
fessor Sellman’s lead, we will limit ourselves to 10 points,
as follows.
1 As our research improves, so do our treatments
While the general equivalence of effect sizes of psy-
chotherapy may have been accurate 20 years ago, this is
no longer the case. Greater methodological rigor, with
emphasis on treatment integrity and focus upon treat-
ment specificity, has led to the development of a range of
empirically validated therapies (EVTs) [3]. While we
Addiction, 105, 14–21