A high-level delegation from the Soviet Union recently visited Quincy, Massachusetts,to learn how District Court Judge Albert L. Kramer handles drunk drivers. Kramer routinely sentences first- time driving-while-intoxicated (DWI) offenders to Right Turn, a private treatment program for alcoholism that requires participants to attend Alcoholics Anonymous meetings. The Soviet visitors enthusiastically embraced Kramer’s program, which is also a favorite of the American media.
One would think that the Soviets were ahead of us in therapeutic coercion, given their history of incarcerating political dissenters under bogus psychiatric labels. But from their perspective Kramer’s approach is innovative: A.A. treatment is a process of spiritual conversion that requires submission to a “higher power” (a.k.a. God). By adopting compulsory A.A. treatment, the Soviets would be shifting from a policy of enforced atheism to one of enforced religion.
Alcoholism treatment is today the standard sanction for DWI offenses in the United States, according to Constance Weisner of the Alcohol Research Group in Berkeley. “In fact, many states have transferred much of the handling of DWI offenses to alcohol treatment programs,” she writes. In 1984,2,55 1 public and private treatment programs in the United States reported providing DWI services for 864,000 individuals. In 1987, the 50 states devoted an average of 39 percent of their treatment units to DWI services. Some states continue to accelerate such treatment: From 1986 to 1988, Connecticut reported a 400-percent increase in the number of DWls referred to treatment programs.
The response to drunk driving is part of the widespread American practice of forcing or pressuring people into A.A.- style treatment. The courts (through sentencing, probation, and parole), government licensing and social-service agencies, and mainstream institutions such as schools and employers are pushing more than a million people into treatment each year. The use of coercion and pressure to fill the rolls of treatment programs has distorted the U S . approach to substance abuse: The A.A. model, which uses a spiritual approach to treat the “disease” of alcoholism, would not have as pervasive an influence under conditions of free choice.
Furthermore, prescribing treatment as a substitute for normal criminal, social, or workplace sanctions represents a national revision of traditional notions of individual responsibility. When called to account for misbehavior, the criminal, delinquent teenager, the malingering employee, or the abusive supervisor has an out: Alcohol (or drugs) made me do it. But in exchange for the seductive explanation that substance abuse causes antisocial behavior, we allow state intrusion in people’s private lives. When we surrender responsibility, we lose our freedom as well.
Consider some of the ways in which people end up in treatment:
- A major airline ordered a pilot into treatment after a fellow employee reported that he had twice been arrested for drunk driving a decade earlier. To keep his job and his FAA license, the pilot has to continue treatment indefinitely, despite an impeccable work record, no work-related drinking incidents, no drinking problems or DWI arrests for years, and a clean diagnosis by an independent clinician.
- Helen Terry, a city employee in Vancouver, Washington, was ostracized on the job after she testified in support of a colleague’s sexual-harassment suit. Terry never drank more than a glass of wine in the evening. Nonetheless, based on an unconfirmed report that she had drunk too much at a social event, her superiors ordered her to admit she was an alcoholic and enter a treatment center, under threat of dismissal. A court awarded her more than $200,000 in damages after she sued the city for wrongful discharge and denial of due process.
- A man seeking to adopt a child admitted he had used drugs heavily almost a decade earlier. Required to submit to diagnosis, he was labeled “chemically dependent” even though he had not used drugs for years. Still awaiting the completion of the adoption process, he now worries that he will be followed for the rest of his life by the stigma of “chemical dependence.”
- States routinely require “impaired” physicians and attorneys to enter treatment to avoid having their licenses revoked. A certified addiction counselor for the American Bar Association’s Commission on Impaired Attorneys reports: “I do an assessment and tell that person what they have to do to get well. Part of that component is A.A. They must attend A.A.”
Alcoholics Anonymous was not always tied to coercion. It began in 1935 as a voluntary association among a handful of chronic alcoholics. Its roots were in the 19th-century temperance movement, as reflected in its confessional style and sin-and-salvation spirit. A.A., and the alcoholism-as-disease movement it inspired, translated American evangelism into a medical world view.
Originally anti-medical, A.A. members often emphasized the failure of physicians to recognize alcoholism. Marty Mann, a publicist and early A.A. member, correctly saw this as a self-limiting strategy. In 1944 she organized the National Committee for Education on Alcoholism (now the National Council on Alcoholism and Drug Dependence) as the public-relations arm of the movement, enlisting well-placed scientists and physicians to promote the disease model of alcoholism. Without this medical collaboration, A.A. could not have enjoyed the enduring success that distinguishes it from earlier temperance groups.
A.A. now has been incorporated into the cultural and economic mainstream. Indeed, many view A.A.’s 12-step philosophy as a cure not only for alcoholism but for a host of other problems. Twelve-step programs have been developed for drug addicts (Narcotics Anonymous), spouses of alcoholics (Al-Anon), children of alcoholics (Alateen), and people with literally hundreds of other problems (Gamblers Anonymous, Sexaholics Anonymous, Shopaholics Anonymous). Many of these groups and “diseases,” in turn, are linked to counseling programs, some conducted in hospitals.
The medical establishment has come to recognize the financial and other advantages of piggybacking on the A.A. folk movement, as have many recovering alcoholics. A.A. members frequently make counseling careers our of their recoveries. They and the treatment centers they staff can then benefit from third-party reimbursement. In a recent survey of 15 treatment centers across the country, researcher Marie Bourbine-Twohig found that all of the centers (90 percent of which were residential) practiced the 12-step philosophy, and two-thirds of all counselors in the facilities were recovering alcoholics and addicts.
Early A.A. literature emphasized that members could succeed only if “motivated by a sincere desire.” As their institutional base widened, A.A. and the disease approach became increasingly aggressive. The proselytizing tendency, originating in the religious roots of the movement, was legitimized by the association with medicine. If alcoholism is a disease, then it must be treated – like pneumonia. Unlike people with pneumonia, however, many people identified as alcoholics don’t see themselves as sick and don’t want to be treated. According to the treatment industry, a person with a drinking or drug problem who does not recognize its nature as a disease is practicing “denial.”