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re-integration is recovery, whatever forms of affiliation

employment, relationship, churchthat re-integration

takes.It isrelevantto prevention,too;the more socialroles

a person undertakes, the less likelihood of drinking

problems [3].

Unfortunately, people who might respond well to

treatment (in Sellmans 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 GeorgeVaillant 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 consultationliaison 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 toask 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: 613.

2. Miller W. Rediscovering fire: small intervention, large effects.

Psychol Addict Behav 2000; 14: 618.

3. Kuntsche S., Knibbe R. A., Gmel G. Social roles and alcohol

consumption: a study of 10 industrialised countries. Soc Sci

Med2009; 68: 126370.

4. Anton R. F., OMalley 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: 200317.

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: 16570.

6. Vaillant G. The Natural History of Alcoholism. Boston, MA:

Harvard University Press; 1984.

add_2786 17..24

MISSING THE CONTINUUM

Sellmans 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 generalreactions to Sellmans 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 havebeen 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 clients motivation for

change. We found it puzzling, however, that Sellmans

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, Sellmans 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 applyto 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 formalhelp or treatment[10]

is also absent in Sellmans paper. The concern here is that

many substance abusers who do not enter treatment

recover on theirown [10],and typically theirproblemsare

Commentaries 17

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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.[1214]). 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: 613.2. 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: 87585.

3. DawsonD. A.,GrantB. F., Stinson F. S., Chou P. S.,HuangB.,

Ruan W. J. Recovery from DSM-IV alcohol dependence:

United States, 20012002. Addiction 2005; 100: 28192.

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

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: 612.

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. 36372.

9. Robins L. N. Vietnam veterans rapid recovery from heroin

addiction: a fluke or normal expectation? Addiction 1993;

88: 104154.

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

publichealth priority.In: BaerJ. S., MarlattG. A.,McMahon

R. J., editors. Addictive Behaviors across the Lifespan: Preven-

tion, Treatment, and Policy Issues, Beverly Hills, CA: Sage;

1993, p. 13857.

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:

4052.

13. Mendelson J. H.,Mello N. K. Experimental analysis of drink-

ing behavior of chronic alcoholics. Ann NY Acad Sci 1966;

133: 82845.

14. Tamerin J. A.,Weiner S., Mendelson J. H. Alcoholics expect-

ancies and recall of experiences during intoxication. Am J

Psychiatry 1970; 126: 1697704.

add_2833 18..25

PE R HAPS IT IS THE DODO BIR D

VERDICT THAT SHOULD BE EXTINCT

Dr Sellmans 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 theDodo Bird verdict [2], overlooks some of the recent evi-

dence and results in some misconceptions.Following Pro-

fessor Sellmans 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

18 Commentaries

2010 The Authors. Journal compilation 2010 Society for the Study of Addiction Addiction, 105, 1421