British Journal of Addiction, 73 (1978) 343-345. Longman. Printed in Great Britain.

Evaluating the External Validity of Ewing andRouse

Mark B. Sobell, Ph.D, and Linda C. Sobell, Ph.D.Department of Psychology, Vanderbill University

Since the publication of Davies' (1962) classic article on normal drinking by recoveredalcoholics, such reports have been subjected to rigorous methodological critiques. Thelatest example of such a reaction involved the Rand Report (Armor, Polich andStambul, 1978). Without question, when such critiques are well thought out anddefended they can only lead to greater progress in the treatment of persons with alcoholproblems. It is curious, however, that a study in this area which reported negativefindings has eluded similar scrutiny. That study, reported by Ewing and Rouse in 1976,described a 'Failure of an experimental treatment program to inculcate controlleddrinking in alcoholics'. While the Ewing and Rouse study has not been criticallyevaluated, it has definitely been infiuential. For example, spokesmen for the NationalCouncil on Alcoholism have asserted that the report is more soundly designed thanrecent reports of successful nonabstinent outcomes (The Alcoholism Report, 1976); DrSidney Cohen (1977) has cited the report as a major research finding which casts doubtupon reports of nonproblem drinking outcomes; and Dr Frank Seixas has stated:'There are those who believe the clinical wisdom of the past will be verified ifappropriate experiments are performed (certainly Ewing's work is an indication ofthis)' (Seixas, 1977, p, 282), In light of the article's reception, it is important that Ewingand Rouse's study be evaluated as a scientific venture. That is the purpose of this letter.

The internal validity ofthe Ewing and Rouse (1976) study is diminished by majormethodological problems, some of which become apparent only upon reading earlierdescriptions of this same study (Ewing, 1972; Ewing and Rouse, 1973), Mostimportantly, the study was not a controlled investigation [no control subjects or controltreatments were used). Further, it involved a highly selected group of subjects, Ewing(1972) initially described the study as a clinical trial conducted because he wasfrustrated with traditional abstinence oriented treatment methods, stating: 'The fact isthat it is a rare alcoholic who will remain abstinent indefinitely and if we can offer a rayof hope, perhaps we should' (p, 12),

Subjects were accepted for the study only if they had a history of failure withAlcoholics Anonymous and expressed an unwillingness to accept treatmentapproaches requiring total abstinence; applicants were excluded if they had a history ofprevious extended periods of abstinence or previous successful affiliation withAlcoholics Anonymous, Thus, the authors' 1976 description of their subject populationas relatively nonselective seems at considerable variance with Ewing's 1972 statementthat; 'So far I have only accepted those who have failed with Alcoholics Anonymousand with total abstinence goals, or have rejected such approaches for the time being'(Ewing, 1972, p, 9), Actually, the subjects could be described as highly recalcitrant totraditional treatment and of generally poor prognosis.

344 ^- B- Sobell and L. C. Sobell

Ewing and Rouse's treatment methods also invite criticism. Subjects, sometimesaccompanied by their spouses, attended weekly outpatient group meetings where theyhad informal discussions with the investigators while engaging in drinking. The majortherapeutic factors Ewing and Rouse (1973, 1976) described were the use of aversiveconditioning for excessive drinking (as in Lovibond and Caddy, 1970), learningdrinking skills,maintaining a drinking record, the presence of thespouse at sessions, andmodeling (the therapists sometimes drank with subjects). What occurred during groupdiscussions is unclear from published reports. For instance, in 1972 Ewing stated that'no effort is made to invoke dynamic psychotherapeutic methods, although somepatients continue in therapy with other psychiatrists while in the program' (p. 10). Ayear later, Ewing and Rouse (1973) modified this description slightly: 'No attempt wasmade to develop formal group psychotherapy in these sessions but undoubtedlycommunications of a therapeutic nature occurred' (p. 70). However, in their morerecent report the authors stated: 'We included group therapy, couples therapy,modeling and other techniques to be described, because we wanted to make ourtherapy as powerful as possible so that it might have the greatest chance of success'(Ewing and Rouse, 1976, p. 124).

Caddy (1979) has elsewhere assailed Ewing and Rouse's use of blood alcoholconcentration discrimination training in the absence of a thorough behavioralcounseling program as an inappropriate use of the Lovibond and Caddy (1970)methodology and apt to have little influence on drinking behavior. Furthermore, thenature of treatment sessions apparently changed over the course of the study: severalsuch changes were described by Ewing (1972) and Ewing and Rouse (1973).

Considering the aforementioned methodological problems, surely this study wouldqualify as an inadequate test of any treatment approach. However, the proceduresEwing and Rouse used to evaluate treatment outcome stand unmatched in theirvulnerability to critical appraisal. The authors reported treatment outcome results fora total of 35 subjects, with follow-up periods ranging from 27 to 55 months. Only 14 ofthe subjects completed as many as six treatment sessions; all of those subjects wereevaluated as total treatment failures. How this evaluation was determined is of interest.Rather than using some indication of subjects' cumulative functioning over the follow-up interval, Ewing and Rouse instead chose to categorize subjects' outcomes accordingto the poorest single day experienced by each subject at any time since the conclusion oftreatment. Thus, an individual who had been totally abstinent for 54 months butexperienced a minor drinking episode during the first month following treatmentwould have been evaluated as having the poorest possible outcome source. In thisregard, it should be noted that several studies have found that even alcoholics who arenot necessarily recalcitrant to abstinence-oriented treatment are likely, drink to excesssometime within the first year following traditional treatment, with typical abstinencerates ranging from 5 to 15 per cent at the end of one year. Applying Ewing and Rouse'scriteria, it is obvious that all programs, even abstinence oriented programs, would bejudged as colossal failures. This is especially important in view ofthe fact that Ewingand Rouse did not use a control group.

In conclusion, one can only concur with Ewing and Rouse's (1976) assertion that:'Based on our experience with these patients and a long-term follow-up, we haveconcluded that, in our hands at least, further attempts to inculcate controlled drinking by suchmethods are unjustified' (p. 134, italics added.) Their statement, it would seem, alsosuggests the appropriate limits of generalizability of their results.

Comment on Ewing and Rouse 345

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