Miller et al. noted that the treatments with the worst clinical records are almost universally employed by American alcoholism programs. Educational lectures and general alcoholism counseling in the United States are almost entirely 12-step and disease oriented, while the successful treatments Miller et al. (1995) identified are specifically non-disease oriented. Table 5 lists the differences between the disease school of thinking and what I call the Life Process approach (Peele et al., 1991). American treatment programs reject these innovations in treatment that have been shown to be considerably more effective than current practices. For example, brief interventions—by utilizing reduced drinking goals for patients and not labelling them as "alcoholics"— run afoul of the basic tenets of AA. And, as we saw above, MDs became less likely to advise heavy drinking patients to reduce their drinking as the disease ideology of treatment grew.

Thus, the standard for treatment remained the 12-step approach, which is heavily didactic, built on the concept that alcoholics are out of control and need to be compelled to enter treatment, and that all drinking problems require abstinence.

Meanwhile, drug treatment has already shifted in the 12-step direction. That is, drug treatment in the U.S. has historically offered a wider set of treatment modalities than alcohol treatment. For example, therapeutic communities, methadone maintenance, skills-oriented training, and so on—which reflect some of the modalities found most effective in alcoholism treatment—were already part and parcel of the array of available drug abuse treatments. As drug treatment has expanded, the influence of the 12-step approach has grown, and it has become part of practically every treatment program in America.

The lack of demonstrated efficacy of AA and its continued dominance in American treatment is a social phenomenon well worth analyzing on its own. AA appeals to American religious fundamentalism, as expressed in its nineteenth century revivalistic style involving public confession, contrition, and restitution. The success of AA is a tribute both to its appeal to fundamental tenets of American culture and to the skills of Marty Mann and subsequent gifted AA marketers. The morality tale of the repentant sinner who used to enjoy drinking and intoxication but who now recognizes the folly of his ways and the need for abstinence will always be a sure seller in the United States.

Likewise, this tale will market well as drug treatment expands. The marijuana smoker or cocaine user who used to enjoy the high life but who now sees the error of his ways, affirming the correctness of his sober and abstemious brethren, will soon dominate drug treatment (as it already shows signs of doing) the way it does alcohol treatment. William Bennett and succeeding drug tsars, drug education specialists, and U.S. presidents are always on the lookout for such spokespeople for the cause of treatment. An expansion in treatment is not gauged in terms of its efficacy, but in terms of how well it supports moral entrepreneurs in presenting their visions of drug use.