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, 2,551 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."
In fact, denial of a drinking problem—or of the disease diagnosis and A.A. remedy—has come to be a defining characteristic of the disease. But indiscriminate use of the denial label obscures important distinctions among drinkers. While people sometimes do fail to recognize and acknowledge the severity of their problems, a drinking problem does not automatically prove a person is a lifelong alcoholic. Indeed, most people "mature out" of excessive, irresponsible drinking.
The disease approach uses the concept of denial not only to force people intro treatment, but to justify emotional abuse within treatment. Drug an alcohol problems typically rely on confrontational therapy (like that depicted in the film Clean and Sober) in which counselors and groups deride the inmates for their failings and their reluctance to accept the program's prescriptions. Most of the celebrities who graduate from such programs, out of either genuine belief or judicious discretion, report tough but positive experiences.
But the remarks of a critical minority are revealing. Actor Chevy Chase, for example, criticized the Betty Ford Center in Playboy and on TV talk shows after his 1986 stay there. "We called the therapy 'God squadding'" he said. "They get you to believe that you're at death's door…and that you've ruined it for everybody, that you're nothing and that you've got to start building yourself back up through your trust in the Lord…I don't care for the scare tactics being used there. I didn't think they were right."
In a 1987 New York Times article, New York Mets pitcher Dwight Gooden described the group indoctrination at the Smithers Center in New York, where he was sent for cocaine abuse. Gooden, who had used cocaine at off-season parties, was browbeaten by fellow residents: "My stories weren't as good [as theirs].…They said, 'C'mon, man, you're lying.' They didn't believe me.…I cried a lot before I went to bed at night."
For every Dwight Gooden or Chevy Chase, there are thousands of less-famous people who have bitter experiences after being roped into treatment. Marie R., for example, is a stable, married woman in her 50s. One evening she drove after drinking beyond the legal limit and was apprehended in a police spot check. Like most drunk drivers, Marie did not meet the criteria for alcoholism, which include routine loss of control. (Research by Kayle Fillmore and Dennis Kelso of the University of California has found that most people arrested for drunk driving are able to moderate their drinking.)
Marie admitted that she deserved to be penalized. Nonetheless, she was shocked when she learned that she faced a one-year license suspension. Although irresponsible, her carelessness was not as serious as the recklessness of a DWI whose driving clearly endangers others. Such disproportionate sentences push all but the most stubborn DWIs to accept "treatment" instead; indeed, this may be their purpose. Like most offenders, Marie though treatment was preferable, even though she had to pay $500 for it.
Marie's treatment consisted of weekly counseling sessions, plus weekly A.A. meetings, for more than four months. Contrary to their initial expectations, she found the experience "the most physically and emotionally draining ordeal of my life." At A.A. meetings, Marie listened to ceaseless stories of suffering and degradation, stories replete with phrases like "descent into hell" and "I got down my knees and prayed to a higher power." For Marie, A.A. was akin to a fundamentalist revival meeting.
In the counseling program provided by a private licensee to the state, Marie received the same A.A. indoctrination and met with counselors whose only qualification was membership in A.A. These true believers told all the DWIs that they had the permanent "disease" of alcoholism, the only cure for which was lifetime abstinence and A.A. membership—all this based on one drunk-driving arrest!
In keeping with the self-righteous, evangelistic spirit of the program, any objection to its requirements was treated as "denial." The program's dictates extended into Marie's private life: She was told to abstain from all alcohol during "treatment," a proscription enforced by the threat of urinalysis. As Marie found her entire life controlled by the program, she concluded that "the power these people attempt to wield is to compensate for the lack of power within themselves."
Money was a regular topic at the sessions, and counselors constantly reminded group members to keep up their payments. But the state picked up the tab for those who claimed they could not afford the $500 fee. Meanwhile, members of the group who had serious emotional problems searched vainly for competent professional counseling. One night, a woman said she felt suicidal. The group counselor instructed her, "Pray to a higher power." The woman dragged on through the meetings with no apparent improvement.
In lieu of real counseling, Marie and the others were forced to participate in a religious ritual. Marie became preoccupied by "the moral, ethical, and legal issue of coercing citizens into accepting dogma which they find offensive." Having had only a vague idea of the A.A. program, she was astonished to discover that "God" and a "higher power" are mentioned in half of A.A.'s 12 steps. For Marie, the third step said it all: "Made a decision to turn our will and our lives over to the care of God." Like many, Marie was not consoled that it was God "as we understood him."
She wrote in her diary: "I keep reminding myself that this is America. I find it unconscionable that the criminal justice system has the power to coerce American citizens to accept ideas that are anathema to them. It is as if I were a citizen of a totalitarian regime being punished for political dissent."
As Marie's story shows, court-mandated DWI referrals generate income for treatment entrepreneurs from insurance companies and state treasuries. The director of one treatment center says: "Approximately 80 percent of my clients come via the courts and deferred prosecution agreements. Many are simply taking advantage of the opportunity to avoid jail, increased insurance premiums, blemished driving record, etc. and have no intention of changing their behavior."
Although DWIs constitute the largest number of referrals from the criminal-justice system, defendants are required to enter substance-abuse treatment programs for other crimes as well. In 1988, a quarter of Connecticut's probationers were under court order to enter drug and alcohol treatment. Penal systems are opting to treat the large number of drug offenders they face, both as an alternative to treatment to sentencing and as a condition of parole. The potential flow of treatment clients is huge: New York prison authorities estimate that three-quarters of all inmates in the state have abused drugs.
Adolescents are another rich source of treatment clients. (See "What's Up to Doc?," February.) High schools and universities regularly direct students into A.A., sometimes based on isolated incidents of drunkenness. In fact, people in their teens and twenties represent the fastest-growing segment of the A.A. membership. The incarceration of adolescents in private mental institutions—primarily for substance abuse—grew by 450 percent during the 1980s. Teenagers almost always enter treatment involuntarily, whether under court order or under pressure (on them or their parents) from schools and other public agencies. In treatment, they undergo "tough love" programs, which strip children of their pretreatment identities through techniques that often border on physical abuse.
In The Drug War, Arnold Trebach documents the shocking case of 19-year-old Fred Collins, who was pressured into residential treatment in 1982 at Straight Inc. near St. Petersburg, Florida, by his parents and the organization's staff. Collins's and other inmate's parents collaborated with Straight in forcibly confining him for 135 days. Isolated from the outside world, he was subjected to 24-hour surveillance, sleep and food deprivation (he lost 25 pounds), and constant intimidation and harassment.
Collins eventually escaped through a window and, after months from hiding from his own parents, sought legal redress. In court, Straight did not contest Collins' account but instead claimed the treatment was justified because he was chemically dependent. Collins, an above-average student, presented psychiatric testimony that he had merely smoked marijuana and drunk beer occasionally. A jury found for Collins and awarded him $220,000, mostly in punitive damages. Nonetheless, Straight has never admitted its treatment program was flawed, and Nancy Reagan has continued to be a staunch advocate for the organization. Meanwhile, ABC's "Primetime Live" and "20/20" have documented similar abuses in other private treatment programs.
Another major group of treatment clients are those referred by employee-assistance programs (EAPs). While some employees seek counseling for variety of problems, the main focus of EAPs has been substance abuse. Typically the initiative for treatment comes from the EAP rather than the employee, who must undergo treatment to keep his or her job. There are now more than 100,000 EAPs in the United States, most created in the last decade, and the number continues to grow. The majority of companies with at least 750 employees had EAPs by the mid-1980s.
EAPs often used "interventions," a technique that is popular throughout the treatment industry. An intervention involves surprising the targeted individual with a phalanx of family members, friends, and co-workers who, under the supervision of treatment personnel, browbeat the person into accepting that he or she is chemically dependent and requires treatment. Interventions are often spearheaded by counselors who themselves are recovering alcoholics. And usually the agency that assists with the intervention ends up treating the accused substance abuser.
"Interventions are the greatest advance in alcoholism treatment since Alcoholics Anonymous was founded," says the director of a California treatment center that depends on such clients. In a 1990 article in Special Report on Health entitled "Drunk Until Proven Sober," journalist John Davidson offered a different assessment: "The philosophical premise behind the technique appears to be that anyone—especially a recovering alcoholic—has the right to invade another's privacy, as long as he's trying to help."
Although employees who are subjected to such interventions are not coerced, they are usually threatened with dismissal, and their experiences often parallel those of criminal defendants who are forced to undergo treatment. Companies confronting employees suspected of drug and alcohol abuse make the same mistake as courts do in handling drunk drivers. Most important, they fail to distinguish among different employees suspected of substance abuse.
As the stories of Dwight Gooden and Helen Terry indicate, employees may be identified by an EAP even through their job performance is satisfactory. Random urinalysis may find drug traces, a record search may turn up an old drunk-driving arrest, or an enemy may submit a false report. Furthermore, not every employee who screws up at work is because of drugs and alcohol. Even when an employee's performance is suffering because of drugs or alcohol use, this does not mean he or she is an addict or an alcoholic. Finally, those employees who have serious substance-abuse problems may not benefit from the 12-step approach.
For all its strong-arm tactics, mainstream drug and alcohol treatment does not seem to work very well. The few studies that have used random assignment and appropriate control groups suggest that A.A. works no better, and perhaps worse, than no treatment at all. The value of A.A., like that of any spiritual fellowship, is in the perceptions of those who choose to participate in it.
This year a study in The New England Journal of Medicine reported, for the first time, that employee substance abusers sent to private hospital programs had fewer subsequent drinking programs than employees who selected their own treatment (which generally meant either a hospital or A.A.). A third group sent to A.A. fared the worst of all.
Even in the hospital group, only 36 percent abstained throughout the two years following treatment (the figure was 16 percent for the A.A. group). Finally, although hospital treatment produced more abstinence, no differences in productivity, absenteeism, and other work-related measures were found among the groups. In other words, the employer who was footing the bill for treatment realized no greater benefit from the more expensive option.
Moreover, the study looked at private treatment centers, which cater to the sorts of clients—well-to-do, educated, employed, with intact families—who most often straighten out on their own. The results for public treatment facilities are even less encouraging. A national study of public treatment facilities by the Research Triangle Institute in North Carolina found evidence of improvement for methadone maintenance and therapeutic communities for drug addicts, but no positive changes for people entering treatment for marijuana abuse or for alcoholism. A 1985 study published in The New England Journal of Medicine reported that just 7 percent of a group of patients treated in an inner-city alcoholism ward had survived and were in remission when followed up several years later.
All of these studies suffer from the flaw of not including a nontreatment comparison group. Such comparisons have most often been carried out with DWI populations. A series of such studies has shown that treatment of drunk drivers is less effective than judicial sanctions. For example, a major study in California compared four counties where drunk drivers were referred to alcohol-rehabilitation programs with four similar counties where driver's licenses were suspended or revoked. After four years, DWIs in the counties imposing traditional legal sanctions had better driving records than those in the counties relying on treatment programs.
For nonalcoholic DWIs, programs teaching drivers the skills with which to manage or avoid risky situations have proven superior to conventional A.A. education programs. Indeed, research has shown that, even for highly alcoholic drinkers, teaching life-management skills, rather than lecturing about the disease of addiction, is the most productive form of treatment. The training covers communication (particularly with family members), job skills, and the ability to "cool out" under stressful conditions that often lead to excessive drinking.
Such training is the standard for treatment in most of the world. Given the spotty record of disease-model treatment, one would think the U.S. programs would be interested in exploring alternative therapies. Instead, these remain anathema to treatment facilities, which see no possibilities beyond the disease model. Last year, the Institute of Medicine of the prestigious National Academy of Sciences issued a report calling for a much wider range of treatments to respond to the variety of individual preferences and drinking problems.
By accepting the notion that people who have drinking or drug problems (or are merely identified by others as having such problems) suffer from a disease that forever negates their personal judgment, we have undermined the right of people to change their behavior on their own, to reject labels they find inaccurate and demeaning, and to choose a form of treatment they can be comfortable with and believe will work for them. At the same time, we have given government support to group indoctrination, coerced confessions, and massive invasions of privacy.
Fortunately, the courts have supported those seeking protection from coercive treatment. In every court challenge to mandated A.A. to date—in Wisconsin, Colorado, Alaska, and Maryland—the courts have ruled that A.A. is equivalent to a religion for First Amendment purposes. The state's power is limited to regulating people's behavior, not controlling their thoughts.
In the words of Ellen Luff, the ACLU attorney who successfully argued the Maryland case before a state appeals court, the state may not "intrude further into the probationer's mind by forcing sustained attendance in programs designed to alter…their belief in God or their self identity." Whether or not any established religion is involved, she concludes, "if the state becomes a party to attempting to precipitate a conversion experience, the First Amendment has been violated."
Decisions like the one in Maryland, issued in 1989, have not deterred the director of the court-sanctioned Right Turn program in Massachusetts, who declares: "The basic principle about entering A.A. voluntarily is debatable, because most non-Right Turn members of A.A. were forced into the program by other pressures; for instance, a spouse or an employer delivered a last ultimatum." Leaving aside the assumption that the typical drunk driver resembles the alcoholic who voluntarily goes to A.A., the equation of judicial coercion with social or economic pressure would leave us no Bill of Rights.
In place of today's confused, corrupt tangle of treatment, law enforcement and personal treatment, we propose the following guidelines:
Punish misbehavior straightforwardly. Society should hold people accountable for their conduct and penalize irresponsible, destructive behavior appropriately. For example, drunk drivers should be sentenced, irrespective of any presumed "disease state," in a manner commensurate with the frequency and severity of their reckless driving. As the lower end of DWI driving offenses (borderline intoxication), the penalties are probably too severe; at the upper end (repeat offenders, reckless drunk driving that endangers others, vehicular homicide), they are too lenient. Penalties should be uniform and realistic—for example, a one-month license suspension for a first-time drunk driver who did not otherwise drive recklessly—since they will actually be carried.
Similarly, employers should insist that workers do their jobs properly. When performance is not satisfactory, for whatever reason, it may make sense to warn, suspend, demote, or fire the employee, depending upon how short of accepted standards he or she falls. Treatment is a separate issue; in many cases—for example, when the only indication of substance abuse is a Monday-morning hangover—it's inappropriate.
Offer treatment to those who seek help, but not as an alternative to accountability. Coercive treatment has such poor results in part because offenders typically accept treatment as a way to avoid punishment. Courts and employers should provide treatment referrals for those who want help in extricating themselves from destructive habits, but not as a way of avoiding penalties.
Offer a wide range of therapeutic alternatives. Treatment should reflect individual needs and values. For treatment to have its greatest impact, people must believe in it and take responsibility for its success because they have chosen it. Americans should have access to the range of treatments used in other countries and proven effective in clinical research.
Emphasize specific behaviors, not global identities. "Denial" is often a response to the mindless insistence that people admit they are addicts or alcoholics. This resistance can be circumvented by focusing on the specific behavior that the state has a legitimate interest in modifying—for instance, driving while intoxicated. A practical, skill-oriented approach, implemented through situational and skills training, has the best chance of changing behavior.
There is no better motivation for change than the experience of real-world punishments for misbehavior. By comparison, coercive treatment on a religion model is notably ineffective. And it is one of the most blatant and pervasive violations of constitutional rights in the United States today. After all, even murders on death row are not forced to pray.
Archie Brodsky is a senior research associate at the Harvard Medical School's Prgoram in Psychiatry and the Law. Contributing Editor Stanton Peele is a psychologist and health-care researcher. They are authors, with Mary Arnold, of The Truth About Addiction and Recovery: The Life Process Program for Outgrowing Destructive Habits (Simon & Schuster).