Resisting 12-Step Coercion: How to
Fight Forced Participation in AA, NA, or 12-Step Treatment
By Stanton Peele, Charles Bufe, with
Archie Brodsky
Stanton and his colleagues respond to
the overwhelming use of coercive referrals to substance abuse
treatment (read "12-step treatment") in the United
States with a primer on the legal, ethical, and clinical
aspects of such treatment. The authors find that the empirical
basis for claims that 12-step treatment is useful is weak
at best. Important research has found no benefits — or
even negative results — from assignment to AA and related
treatments, and certainly other treatments are at least as
effective. Moreover, a personal resolution to participate
in a particular treatment is an important component in effective
therapy.
From here, the authors review legal and ethical issues surrounding
compulsion to go to 12-step groups. A number of higher courts
have made clear that government-agency or court coercion
to attend AA violates the first amendment's separation of
church and state, since AA has uniformly been found to be
religious in nature (both the legal and factual basis for
this finding are part of this book). A separate chapter evaluates
chemical dependence treatment in terms of current standards
of medical informed consent, and finds such treatment highly
deficient in this regard. The strange, sad case of G. Douglas
Talbott, the founder and past president of the American Society
of Addiction Medicine, is discussed. Talbott, who for years
has been criticized and sued for force-feeding the 12 steps
to physicians, was recently found liable for malpractice
and fraud in an unfortunately typical case of American substance
abuse treatment.
Finally, the authors summarize their material in a ready-to-digest
form for submission to policy makers who are considering
making people go to AA or related therapies. Since court
challenges are a last resort, the authors instead suggest
gently informing decision-makers that such policies are unwise
and illegal. Effective alternatives are outlined and discussed,
along with references to alternate support groups. This book
is a critical aid for combat in the emerging war over treatment
as a part of intrusive and punitive drug and alcohol laws,
which are made to seem more palatable by the inclusion of
treatment provisions, but which are actually even more coercive
and repressive than simple punishment for using drugs or
drinking in ways that AA doesn't like.
Questions about Resisting 12-Step
Coercion
Is alcoholism a disease?
No. It's a behavior. Once you begin to call behaviors "diseases," where
do you stop?
What are the key beliefs in the disease concept of
alcoholism?
There are several key beliefs —
The "disease" is progressive—it inevitably
gets worse if it goes untreated;
It's an entity unto itself, existing independently
of family, social, and economic situations;
Alcoholics cannot recover; all that they can hope
to do is arrest the disease;
Alcoholics are powerless to deal with their situation
without outside help;
Alcoholics lose control if they drink any amount
of alcohol—"one drink, one drunk";
Alcoholism is characterized by "denial."
Are those beliefs supported by the available research
evidence?
No. Every single one of them is contradicted by the available
scientific evidence.
You say that pretending alcoholism is a disease is
harmful. How so?
It's harmful in several ways. The most obvious is that
it convinces people that they have a lifelong, inbred,
progressive disease, when in reality they have a behavioral
problem which they can overcome. What would all the people
who have quit smoking — a majority of smokers — do
if they believed they could never quit smoking on their
own? In addition, by claiming that individuals are "powerless" and
that substances are "powerful," the disease concept
provides the rationale for all sorts of government intrusion
into people's lives.
What is the key element in AA's approach to alcoholism?
It's basically a religious program, and its key element
is that individuals are powerless to deal with their
drinking problems through their own efforts and that,
in order to do so, they must turn their "lives and
will over to God."
How effective is AA?
Not very. The best available research evidence, and evidence
from AA's own triennial surveys, indicates that AA's
results are no better than the rate of spontaneous remission,
that is, that it's no better than no treatment at all.
One problem is that we generally only hear about AA's
successes. And when someone, like Darryl Strawberry (who
traveled the country speaking on behalf of AA) fails,
the blame is laid on him and not the program.
How big is the 12-step treatment industry?
According to the Substance Abuse and Mental Health Services
Administration, there are about 15,000 treatment facilities
in the country, and well over 90% of them are 12-step
facilities. Both the Department of Health and Human Services
and the Institute of Medicine have estimated that treatment
is a $10-billion-dollar-a-year industry.
How many people does it treat annually?
According to the latest figures from SAMHSA (for 1997),
about two million people. This figure rose steadily in
the late 1970s and the 1980s. The number of alcoholics
treated annually has been in the two million range since
1990.
If tens of millions of people have been treated,
why hasn't the rate of alcohol abuse gone down, and even
seems to be rising?
Because 12-step treatment doesn't work. Most people refuse
to participate in it voluntarily, most people who are exposed
to it react negatively and drop out, and the small number
of people who successfully stick with "the program" and
remain abstinent is far smaller than the number of new
alcoholics and problem drinkers who crop up each year.
If it doesn't work very well, why is it so universally
employed?
The 12-step industry has been receiving rivers of government
and insurance industry cash for decades, and 12-step treatment
providers have every financial reason to keep things as
they are. In addition, a great many people within the treatment
industry are 12-step true believers, and they don't care
about the scientific evidence that their approach doesn't
work very well. Beyond this, 12-step advocates have largely
managed to suppress alternative approaches.
How effective is 12-step treatment?
The large bulk of the available scientific data indicate
that it's not very effective, and that it's in fact far
less effective than alternative approaches that are more
commonly practiced in other countries. Twelve-step treatment
is also, by the way, among the most expensive types of
treatment.
Are effective treatments available?
Yes. They're called cognitive-behavioral approaches, and
they involve people in modifying their environments,
thinking, and behaviors. They accept and build on people's
existing values and motivation to change, rather than
telling them they are powerless. They're also low in
cost in comparison with 12-step treatment as it is conducted
in medical facilities. Two therapies that I'd particularly
recommend, brief intervention
and motivational enhancement, are not only inexpensive,
but they're also very easy to apply.
How many people are coerced into AA, NA, or 12-step
treatment annually?
According to the figures from SAMHSA, at least one million
annually, and the actual number is probably somewhat above
that. It could reach one-and-a-half million a year.
What are some of the ways in which people are coerced
into 12-step groups and treatment?
Today the court system forces people into treatment in
lieu of or in addition to criminal penalties, such as for
drunk driving. In nearly all states, treatment systems
have grown to handle DUIs and a number of other lower-level
criminal activities in which a defendant has been drinking
or using drugs. Family courts also frequently force people
into treatment, for example when one spouse complains that
the other drinks too much. Parents are often forced into
treatment by state family service agencies to retain custody
of a child. Employers also coerce a lot of people into
treatment, along with state bar and medical associations.
There are other ways, too, but these probably account for
the bulk of the coercion.
Is it legal for the government to force people to
attend 12-step groups or treatment?
No. It's a violation of the First Amendment's "Establishment
Clause." Four appeal-level courts (the 2nd and 7th
Federal Circuit Courts, and the Tennessee and New York
Supreme Courts) have ruled on this, and they have uniformly
found that AA and other 12-step treatments are religious
in nature and that the state may not force individuals
into them without offering non-religious alternatives.
Doesn't AA successfully evade the designation "religious" with
statements like "it's spiritual, not religious"; "God
as we understand Him"; "whatever `higher power'
means to you"; or "take what you want and leave
the rest"?
The appeals courts have uniformly ruled that AA is religious,
and specifically Christian, in nature. Our book traces
the very much religious and Christian origins of the group.
Beyond that, forcing people to pray, even telling people
that they can conceive of God any way they like, is impermissible
under the U.S. Constitution. Think about this: no one can
force you to attend a Catholic church or Jewish synagogue
service just by saying "When they mention God, you
can think of whatever you want."
If mandatory AA violates the First Amendment, why
is virtually every court in the country continuing to
force people to attend AA and related treatments?
The U.S. Supreme Court hasn't ruled on the question, so
there's no nationally binding precedent. Beyond this, even
in places where the courts have decided coerced 12-step
treatment is illegal (such as New York State), it's business
as usual until someone challenges mandatory AA, possibly
at an appeals level. Yet, most individuals in this situation
do not feel at liberty to challenge the system (think of
a doctor who is told to enter a 12-step program or else
he or she will lose his or her medical license).
Even if mandatory AA is illegal, isn't it necessary
to force people into such programs for their own good?
Aside from the danger of deciding for someone else what
is good for them, and the problems of resistance on the
parts of clients forced into AA and 12-step treatment programs,
there is the assault on the individual's integrity and
beliefs that often occurs in these settings. Unwilling
participants in 12-step meetings are usually attacked — and
accused of an additional condition (denial). Many extremely
negative consequences result from these experiences (up
to an including suicide). A
number of people describe such experiences at Stanton Peele's
web site.
The courts routinely sentence DUI offenders to attend
AA or 12-step treatment. Is this an effective way to
reduce drunk driving?
No. The majority of those arrested for drunk driving aren't
alcoholics, so treating them makes no sense at all. And
substantial scientific evidence indicates that treatment
is ineffective in reducing recidivism — less effective,
for example, than suspension and revocation of drunk drivers'
licenses.
Do 12-step treatment centers follow standard medical
ethics?
No. They routinely violate modern medical ethical principles,
and particularly what is called informed consent. In ordinary
medical practice, physicians explain the benefits and risks
of a proposed treatment to patients. Doctors also describe
alternative treatments and the benefits and risks of each,
or the possibility of receiving no treatment at all. After
being given this information, the patient must consent
before treatment begins. In contrast, 12-step treatment
providers almost never mention potential alternative treatments
or the option of not having treatment. Providers then routinely
impose their views on patients, even against their expressed
wishes. In 1999, G. Douglas Talbott, one of the leading
medical practitioners of alcoholism treatment in the U.S.
(he founded the American Society of Addiction Medicine) was
found liable for malpractice, fraud, and false imprisonment for
forcing a physician into his treatment program by claiming
the man was alcohol dependent when he was not.
Can people beat an alcohol problem by themselves,
or do they need the help of AA or some other support
group?
Every available study of untreated alcoholics, including
a mammoth study by the National Institute on Alcohol Abuse
and Alcoholism of 45,000 Americans, shows that most people
solve alcohol problems without any kind of treatment or
support group. The things that are most important in solving
a drinking problem (often by reducing drinking, although
others abstain) are a strong desire to do so, the belief
that one can, and support and opportunity for productive,
sober activity. When people have that desire and that belief,
and a life with sufficient opportunity for growth, they'll
normally beat their drinking problems, even if these are
quite severe.
For those interested in a support group, what are
some of the alternatives to AA?
There are several, including SMART Recovery, Moderation
Management, Rational Recovery, Women for Sobriety, and
Secular Organizations for Sobriety. These are all free,
nonreligious programs. You can find where to contact them
in our book.
Published in 2000 by See Sharp Press,
Tucson, AZ
ISBN 1884365175
