AA Abuse - Private Treatment Centers

Written by Stanton Peele

Moreover, this study looked at private treatment centers, which cater to the sort 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 drivers 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 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 the disease-model treatment, one would think that 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 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. attendance 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 with no Bill of Rights.

In place of today's confused, corrupt tangle of treatment, law enforcement, and personnel management, 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 severity of their reckless driving. At the lower end of DWI 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 out.

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 far 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 to avoid penalties.

Offer a 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, goal-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 religious 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 murderers on death row are not forced to pray.

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