Rsisting 12-step CoercionResisting 12-Step Coercion: How to Fight Forced Participation in AA, NA, or 12-Step Treatment

By Stanton Peele, Charles Bufe, with Archie Brodsky

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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

  1. Is alcoholism a disease?
    No. It's a behavior. Once you begin to call behaviors "diseases," where do you stop?
  2. What are the key beliefs in the disease concept of alcoholism?
    There are several key beliefs —
    1. The "disease" is progressive—it inevitably gets worse if it goes untreated;
    2. It's an entity unto itself, existing independently of family, social, and economic situations;
    3. Alcoholics cannot recover; all that they can hope to do is arrest the disease;
    4. Alcoholics are powerless to deal with their situation without outside help;
    5. Alcoholics lose control if they drink any amount of alcohol—"one drink, one drunk";
    6. Alcoholism is characterized by "denial."
  3. Are those beliefs supported by the available research evidence?
    No. Every single one of them is contradicted by the available scientific evidence.
  4. 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.
  5. 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."
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. 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."
  17. 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).
  18. 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.
  19. 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.
  20. 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.
  21. 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.
  22. 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