Sellman's provocative paper makes several excellent (e.g. 'different psychotherapies appear to produce similar outcomes') and sometimes contentious (e.g. 'compulsive drug seeking is initiated outside of consciousness') points In this commentary, we offer some general reactions to Sellman's paper and then discuss an important area in the addictions field about which little is known.
One of the most important points raised by Sellman, also discussed by Orford 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 concerns. 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 proportions of abstinent and low-risk drinking outcomes Secondly, Sellman's focus on substance abusers who present for treatment ignores the majority of individuals with alcohol and other drug problems, 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 , Vaillant , Cahalan and Robins, 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';
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