I've relied upon the work of several other investigators in this chapter, and I would particularly like to acknowledge Stanton Peele, Ken Ragge, and Jack Trimpey. Many of the insights contained in this chapter are theirs. In the section, "Suppression of Dissent," I've relied heavily upon Stanton Peele's journal articles, "Denial—of Reality and Freedom—in Addiction Research and Treatment" and "Alcoholism, Politics and Bureaucracy: The Consensus Against Controlled-Drinking Therapy in America."
   
   

Most Americans would describe Alcoholics Anonymous simply as meet­ings of coffee-slurping, cigarette-smoking ex-drunks in storefront meeting halls, libraries, YMCAs, and church basements. But AA's influence and effective structure reach far beyond such community-based meetings.

At first glance this seems odd, because AA's sixth Tradition explicitly states , "An A.A. group ought never endorse, finance, or lend the A.A. name to any related facility or outside enterprise . . ."; the eighth Tradition states, "Alcoholics Anonymous should remain forever nonprofessional . . ."; and the eleventh Tradition states, "Our public relations policy is based on attrac­tion rather than promotion; . . ." But AA's Traditions do not forbid, and implicitly encourage, AA members to promote AA and its ideology while concealing their AA membership. The eleventh Tradition continues, "we need always maintain personal anonymity at the level of press, radio, and films," which certainly seems to encourage both promotion of AA and con-cealment of membership.

In fact, such promotion/concealment of identity is very far reaching. Through it, AA exerts tremendous influence in American society; and AA ideology pervades several important social institutions. Through its members and supporters, AA/12-step ideology has great influence in the mass media, legal profession, medical profession, judicial system, penal system, and, above all, in the addictions treatment system.
   

Since its earliest days, AA has assiduously courted the mass media; and that courting has paid big dividends. It's rare to see or hear a story critical of AA in the media, or to see a movie or TV show that portrays alcohol problems or alcohol-abusing characters in a manner contrary to the stereotypes prescribed by 12-step ideology. This is no accident, and it's certainly not the result of AA's supposed effectiveness. (See Chapter 7.) Rather, it's the result of well over half a century of favorable media coverage of AA produced by AA's friends and concealed AA members. Like the majority of other Americans, most writers and reporters accept AA's rosy public image as reality, and its pronouncements as truthful. This compounds the problem of writer/reporter laziness and overwork. Because of these factors—AA's well-crafted favorable image, and writer/reporter laziness and overwork—writers and reporters are predisposed to accept AA's assertions as fact, and to accept the assertions of "professional" 12-step spokesmen (often posing as medical experts) without conducting any independent investigation.

On its web site, the group that acts as AA's spokesman on matters of "public controversy," the National Council on Alcoholism and Drug Depen­dence (NCADD), proudly proclaims its influence in the television industry. (This is hardly surprising; the AA members and supporters at the NCADD almost certainly believe that they're providing expert advice.) Among the instances of NCADD influence cited, they mention that during the 1950s and 1960s, "NCADD . . . assisted the producers of the Armstrong Circle Theater and the Alfred Hitchcock show in developing early dramatic pro­grams that sympathetically explored the subject of alcoholism. These pro­grams reached vast new audiences in their living rooms and gave NCADD an incredibly influential audience for its message."ⁱ Similar "sympathetic" messages have continued to the present day on shows such as Beverly Hills 90210 and in Ad Council public service announcement campaigns.
   

AA and 12-step ideology have also had a major impact on American cinema. As in television, it's rare to see alcohol abuse and alcohol abusers portrayed in films in a manner contrary to AA stereotypes. Beginning with The Lost Weekend in 1945, and continuing through The Days of Wine and Roses (1962), Clean and Sober (1988), and Drunks (1996), American film dramas have rarely strayed from 12-step stereotypes. Alcohol and drug abuse (at least when a central issue) is uniformly portrayed as a chronic, progressive "disease" whose symptoms include loss of control and "denial," and whose only cure is lifelong abstinence; and those who provide "help"—AA and other 12-step groups—to the victims of this behavioral "disease" are uniformly portrayed in a positive light. It's difficult to know how many of these portrayals are the result of writers simply accepting common stereo­types, and how many are the result of deliberate attempts to promote AA and 12-step ideology by 12-step group members in the film industry. But some films, such as Clean and Sober and Drunks, are so blatantly propa­gandistic that it seems quite likely that their writers and/or producers are members of AA or other 12-step groups. We'll probably never know for certain, though, because it's highly unlikely that their writers and producers will ever "break anonymity."

As for the print media, for nearly half a century after AA's founding, very few critical articles appeared in national publications. In fact, according to the Reader's Guide to Periodical Literature, during entire decades (the '30s, '40s, '50s, and '70s) no article critical of AA appeared in any indexed periodical. As noted in Chapter 11, though, this situ

ation has changed somewhat over the past decade; but even during that time approximately 75% of the in-dexed articles have been favorable to AA and the 12-step movement.
   

The primary influence of AA on the legal profession (as distinct from the judicial system) is through professional diversion programs. Such programs exist in all 50 states. It's common for state bar associations, through diversion programs, to coerce "impaired" attorneys into 12-step inpatient treatment.ⁱⁱ This type of coercion is even more pervasive in the medical system, affecting doctors and nurses, than in the legal system. In all such cases, the primary purpose of treatment is the indoctrination of coerced pro­fessionals into the 12-step belief system—not to help them overcome addic-tions.

Though he wasn't coerced by a diversion program, this intent is clear in the case of Dr. Clifton Kirton, an Ohio physician who had been abstinent for several years when he applied in the mid 1990s to the Veterans Admini­stration for a liver transplant. His abstinent status mattered not a whit to the VA, and it insisted that he undergo 12-step treatment and "aftercare" (that is, attending AA meetings) as a condition of receiving a transplant.ⁱⁱⁱ Had it wished to do so, the VA could have easily and relatively inexpensively con­firmed Kirton's abstinent status through a few breathalyzer tests, blood tests, and/or urine tests; instead, it insisted on expensive 12-step inpatient treat-ment. This is far from an isolated case.
   

For well over three decades, it's been common for the court system to coerce drunk drivers and others accused or convicted of alcohol-related crimes into AA attendance and/or 12-step treatment, through both pre-trial diversion programs and through sentencing. In 1995 alone, roughly 270,000 individuals were coerced into 12-step treatment by the judicial and penal systems,^iv with DUI offenders making up slightly over one-quarter of such coerced persons.^v The number of offenders coerced into AA attendance rather than formal treatment is likely even higher. One indication that this is so is that AA's 1996 membership survey brochure reports that 16% of AA members were introduced to AA through either court order or correctional facilities. Considering that there are now roughly 1.25 million AA members, this means that approximately 200,000 of AA's current members are there because of judicial/penal system coercion. Because AA has an astronomical dropout rate—95% during the first year, according to AA's own figures^vi— it's virtually certain that literally millions of individuals have been coerced into attending AA, and that literally millions more have been coerced into attending 12-step treatment by the judicial and penal systems.

This is unfortunate in that it's very unlikely that coerced participation in AA or in 12-step treatment are effective ways of reducing instances of DUI and other criminal behavior. As discussed in the previous chapter, one of the most significant studies of coerced participation in AA and alcoholism treatment (in that it was well designed and had a no-treatment control group), Ditman et al., reported that the two groups of alcohol offenders who participated in AA and, separately, in a treatment program fared signifi­cantly worse (as measured by numbers of rearrests) than the no-treatment, no-AA controls.^vii

But perhaps the best-studied group coerced into AA participation is DUI offenders. Study after study has shown that judicial sanctions, specifically suspension and revocation of drivers licenses, are more effective than AA participation in reducing drunk-driving recidivism. To quote the intro­duction to one such study, "the best research to date has found that drivers convicted of alcohol-related offenses have fewer crashes after their licenses have been suspended or revoked than after being sent through present types of rehabilitation."^viii Another significant study by Philip Salzberg and Carl Klingberg, involving over 2000 individuals who received DUI citations, concluded that, "The DP [diversion program] group accumulated signifi­cantly more alcohol-related violations during the 3-yr post-DP time period. The DP group had an adjusted mean of 0.36 alcohol-related violations compared with 0.30 for the control group [who received normal legal sanctions]."^ix Other studies have confirmed this result—those in 12-step diversion programs have more subsequent accidents and DUI convictions than those receiving legal sanctions.^x

But prosecutors and the judiciary ignore such findings and continue to routinely sentence those convicted of DUI and other alcohol-related offenses to AA attendance and/or 12-step treatment. One can only wonder how much of this seemingly deliberate blindness is a result of 12-stepping judges and prosecutors being eager to "carry the message." An old friend from the Phoenix area recently called to tell me that, after a DUI conviction, he had been sentenced to attend 12-step treatment by a judge wearing an AA (sobriety) chip around her neck as a pendant.

And one can only wonder how many people have died needlessly, and will die needlessly, on our roads and highways because of the continuing diversion of DUI offenders into AA and ineffective 12-step treatment.
   

The rise of the 12-step treatment industry has been a direct result of the rise of "educational" and "medical" organizations founded by AA members with three purposes: to promote AA and other 12-step groups; to promote the disease concept of alcoholism; and to promote the belief that abstinence is the only legitimate goal of alcoholism and drug treatment. AA's "educa­tional" efforts date to 1944, when AA's first female member, Marty Mann, founded the National Council on Alcoholism ( now the National Council on Alcoholism and Drug Dependence, NCADD) with the help of E.M. Jellinek and the Yale Center of Alcohol Studies.^xi Since then, the NCADD has acted as AA's spokesman (without, of course, identifying itself as such) on "outside issues" and matters of "public controversy." The NCADD has tirelessly promoted both the disease concept of alcoholism and the belief that absti­nence is the only legitimate treatment goal; it has also attempted to suppress studies on controlled drinking, and has virulently attacked those who publicly disagree with its positions on abstinence and the disease concept.^xii

The NCADD also has close ties with the "medical" arm of AA. In 1954, Ruth Fox, MD founded what is now known as the American Society of Addiction Medicine (ASAM). ASAM, like the NCADD, has campaigned relentlessly for the disease concept of alcoholism and for abstinence as the only acceptable treatment goal, publicly stating that, "Abstinence from alcohol is necessary for recovery from the disease of alcoholism."^xiii ASAM also recommends that "physicians and the alcoholism treatment agencies with which they work . . . develop relationships of maximum cooperation with the self-help groups, such as Alcoholics Anonymous," because "self-help groups, particularly Alcoholics Anonymous, have been a tremendous help in recovery to many thousands of alcoholics, their friends and families."^xiv ASAM further states that "expert" physicians should have "a knowledge of self-help groups such as AA, NA, Al-Anon, etc.," as well as "a knowledge of the spectrum of this disease and the natural progression if untreated."^xv

In 1973, ASAM's membership voted to become part of the NCADD, and it remained part of the NCADD for over a decade. According to the NCADD, "Membership in ASAM, which had begun certifying physicians specializing in addiction medicine, had grown so large by 1984 that it no longer made sense to remain under NCADD's umbrella. However, the two groups continued to meet together annually until 1991 and today are represented on each other's boards [of directors]."^xvi

The NCADD maintains close ties with other "medical" advocates of abstinence, 12-step programs, and the disease concept of alcoholism. In the 1970s, NCADD reports that it "offered homes to both the National Nurses Society on Addiction and the Research Society on Alcoholism which, with ASAM, began publishing Alcoholism: Clinical and Experimental Research."^xvii

But perhaps the NCADD's greatest coup occurred during the Nixon Administration, with the passage of the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970, also known as the Hughes Act, sponsored by "recovering alcoholic" (that is, AA member) Senator Harold Hughes. The Act won Hughes "NCADD's highest honor, the Gold Key Award."^xviii It also established the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and thus opened the tap which would release rivers of federal cash to the alcoholism movement. Very early on, the NIAAA "logically began contracting with NCADD for assistance. As a result, in 1976 NCADD's budget peaked at $3.4 million, nearly five times what it had been before passage of the Hughes Act. Government funding accounted for more than 75% of the budget."^xix It's little wonder that UPI "called passage of the Hughes Act a 'signal victory' for groups such as NCADD."^xx It's equally little wonder that in the wake of the Act the NCADD opened an office in Washington.

The money that the NCADD received from the government led to huge and rapid growth of both the NCADD and the rest of the treatment industry. Under the subhead, "Federal Government Boosts Marty's Vision," the NCADD boasts that,"This [federal funds] provided seed money for state voluntary alcoholism associations which in turn helped organize local NCADD Affiliates [sic]. Marty [Mann] . . . lived long enough to see how the government had boosted her early vision: the number of Affiliates [sic] had risen to an all-time high of 223 and their advocacy efforts had helped to bring to at least 23 the number of states who [sic] mandated insurance coverage for alcoholism treatment."^xxi

The NCADD continues, "The federal government also facilitated rapid growth in the EAP movement." (EAPs, Employee Assistance Programs, funnel "impaired" employees into 12-step treatment, very often through "interventions," threats of job loss, and other coercive means.) "Eleven years of NCADD campaigning culminated in 1974 with AFL-CIO president George Meany^xxii and General Motors director James M. Roche agreeing to chair NCADD's all-star labor management [sic] committee. When NIAAA provided NCADD with funding to establish task forces in ten major cities a year later, NCADD published the first labor-approved EAP guidelines. By the end of the 70s [sic], employees had access to 5,000 EAP programs."^xxiii

Thus, by the late 1970s AA members in government and the mass media, rivers of federal cash, and AA's "educational" and "medical" arms had set the stage for the explosive growth of the 12-step alcoholism treatment industry that would occur in the late 1970s and throughout the 1980s in the United States.
   

It's difficult to pinpoint the date of origin of the 12-step treatment industry. One could make a good case that it began with the "hospital work" of "proto-AA" (while it was still part of the Oxford Groups) in Akron in 1935. One could also make a case that it began with the establishment of the first AA group in a mental institution, Rockland State Hospital, in New York in 1939, or with the establishment of the first AA "rest farm" in 1940. But perhaps the best case could be made that it began with the institution of formal AA indoctrination, using the Big Book, by Doctor Bob Smith at St. Thomas Hospital in Akron, Ohio in August 1939. Before his death, Dr. Smith "treated" over 5,000 persons at that hospital.^xxiv

In all likelihood, this early "formal" hospital treatment was little different from Dr. Bob's earlier "hospital work": isolate the patient in a private room; restrict his visitors to AA (Oxford Group) members; restrict his reading matter to the Bible and/or (after 1939) the Big Book; induce his "sur­render"; and thoroughly indoctrinate him into AA's belief system. The 1980 conference-approved AA book, Dr. Bob and the Good Oldtimers, contains a description of the experience of Bill D., the first person ever subjected to "hospital work": "There was the identification with them (Bill Wilson and Dr. Bob), followed by surrendering his will to God and making a moral inventory; then, he was told about the first drink, the 24-hour program, and the fact that alcoholism was an incurable disease—all basics of our program that have not changed to this day."^xxv

One other thing that hasn't changed to this day is the emphasis on coercive treatment: "the alcoholic himself didn't ask for help. He didn't have anything to say about it."^xxvi One thing that has changed is that the "treat­ment" Bill D. received was free.

Throughout the 1940s, 1950s, and 1960s, the treatment industry grew relatively slowly. One brief history of treatment, by Edgar P. Nace, reports that, "From the 1930s through the 1960s, hospitals either overtly rejected alcoholics or subtly deterred them . . . The exception was state hospitals. In the 1960s, about 40% of admissions to state hospitals were chronic alcoholics . . . Private psychiatric hospitals were reporting only 6% of their admissions to be alcoholics and very few had specialty units."^xxvii The author then goes on to note, "In place of hospitals, small residential treatment centers, initially located in homes, were formed. . . . Treatment was informal and followed the principles of Alcoholics Anonymous."

But all that changed in the 1970s. Like the NCADD, Nace attributes the change largely to the passage of the Hughes Act. He also attributes it to major insurers, such as Blue Cross, Aetna, and Kemper, offering coverage for alcoholism treatment. Nace states that "recovering alcoholics [that is, AA members] played major roles in starting assistance programs in industry . . ."^xxviii The result of all this—federal money, insurance money, and "recovering alcoholics" setting up programs—was explosive growth in the treatment field. Between 1973 and 1980 the number of EAP programs leaped from 500 to 4400, and would continue to grow throughout the 1980s. "By 1985 at least one-half of the Fortune 500 companies had an EAP in operation."^xxix The number of alcoholism treatment units also skyrocketed. In the 1975-1981 period, there were roughly 1800-2000 alcoholism treatment programs, treating about 200,000 persons annually.^xxx By 1982, Substance Abuse and Mental Health Services Administration (SAMHSA) data indicate that there were fully 4233 alcoholism treatment units; by 1987 the number of treatment units had increased to 5627; and by 1990 the number had hit 7766.^xxxi During these same years, the number of individuals treated rose from 289,933 in 1982 to 563,430 in 1990,^xxxii and in that year treatment had become an $865 million per year business.^xxxiii

But these numbers understate the size of the industry, because prior to 1992 these figures did not reflect "non-responding providers"; since 1992, SAMHSA has issued figures including such "non-responding providers."^xxxiv Assuming that the percentage of "non-responding providers" was similar in previous years to the percentage in 1992, calculations yield the following corrected figures: 1982, 6947 providers with 563,509 clients; 1987, 8265 providers with 746,774 clients; and 1990, 10,494 providers with 933,680 clients. It's of major interest that the number of clients apparently peaked with an estimated 987,171 in 1991, but that the number of treatment centers continued to increase into the mid 1990s. In 1992, the number of providers had increased to 11,316, but the number of clients had dropped to 944,880. By 1994, the number of providers had increased further to 11,716, but the number of clients had declined further to 943,623. In that same year, utilization rates hit a 15-year low: 74.2% for all providers, and 57.9% for privately funded providers. "Perceived capacity" had increased 27% since 1991 and was at an all-time high, 1.27 million, and the number of providers had increased by 8%, also to an all-time high, but the number of clients had declined 4% during the same period.^xxxv Thus it isn't surprising that utilization rates were at a 15-year low.

The gravy train had stopped earlier—or had at least slowed considerably —for inpatient treatment. By the late 1980s, the high cost of alcoholism inpatient treatment was coming under increasing scrutiny from insurers and managed care organizations. Because there were no demonstrable benefits of inpatient over outpatient treatment, insurers became increasingly reluc­tant to pay for inpatient treatment, and the average length of stay in inpatient facilities plummeted. Nace reports that, "at one private psychiatric hospital . . . the average length of inpatient stay in 1988 was 49 days. In 1991, the average length of stay was 16 days, and by mid-1992 the average length of stay had declined to 11 days. At the same time, contractual agree­ments with managed care companies and insurance carriers have lowered the average daily hospital payment."^xxxvi This trend toward shorter length of stay continued well into the 1990s. In 1994, a flyer I obtained from the marketing director of America's largest treatment provider, Hazelden, stated that average length of stay, nationally, had declined to five to seven days.^xxxvii

The economic pressure from insurers and managed care organizations "was held responsible for a 'barrage' of initial unit closings in the early months of 1990, with some reports that as many as 200 private programs in the United States had been closed."^xxxviii Most treatment providers, however, survived: "Many units made financial recoveries quite soon after imple­mentation of managed care by offering an altered mix of services empha­sizing less intensive forms of care such as outpatient treatment."^xxxix SAMHSA's "National Drug and Alcoholism Treatment Unit Survey" information supports this report of a shift to outpatient services: free­standing outpatient facilities rose from 37.9% of total facilities in 1990 to 43.8% of the total in 1994, while community mental health centers had dropped slightly, from 14.2% of the total in 1990 to 12.3% of the total in 1994.^xl Thus, their combined total had risen from 52.1% of total units in 1990 to 56.1% in 1994; and the percentage of clients that they treated had also increase slightly, from a combined 66.9% of clients in 1990 to a com­bined 68.2% in 1994.^xli

During this time, in addition to shifting to outpatient services, inpatient treatment providers also survived through other means. Paul Amyx, an in-take counselor for several years at a nationally known inpatient treatment facility in the Tucson area, told me that the ratio of alcoholism to other diagnoses changed radically during the period he was employed, from roughly an 80/20 ratio of alcoholism to other diagnoses in 1991, to a 20/80 ratio when he quit in 1994. The reason? Client characteristics hadn't changed, but by the mid-1990s insurers were much more likely to pay for treatment for other disorders, for example, "post-traumatic stress disorder," than they were to pay for treatment for alcoholism.

Despite such adaptations to changing market conditions, there's some indication that there has been a small decline in the number of privately funded inpatient facilities in recent years. Anecdotal accounts of closures abound, and there's some hard evidence as well. The recent "National Treatment Center Study Summary Report" states that of the 450 units it surveyed, 12.1% (55) were one to five years old at the time of the survey.^xlii Approximately one year after they were surveyed, 20 of the units (4.5% of the total) had closed.^xliii This data indicates, if the one-year closure rate is typical of previous years, that in the mid 1990s inpatient units were closing at roughly twice the rate that new ones were opening; but the apparent decline in the number of units, while significant, isn't precipitate—only about 2% per year.^xliv This apparent trend has, however, only existed for the last few years. NDATUS data indicate that the number of specialized hospital and "other residential facilities" was essentially flat in the 1992- 1994 period, rising from a combined total of 2027 units in 1992 to a com­bined total of 2069 in 1994, that is, in the period 1992-1994 the number of such units rose about 1% annually.^xlv The most recent data, however, indicates that the trend toward inpatient unit closings is real. The November 1997 update to the "National Treatment Center Study Summary Report" indicates that the percentage of inpatient treatment facility administrators who say that their facitilities have a moderate or high likelihood of closure has doubled in the year since the report was released; it's increased from approximately 9% to 18%, with the percentage of administrators reporting a high likelihood of closure increasing from .2% to 2.3%.^xlvi

Thus, the treatment industry is still a giant. Despite the apparent slight decline in privately funded for-profit inpatient units in recent years, the total number of units is at or near an all-time high. Data provided by SAMHSA indicates that by 1995 there were at least 12,000 treatment units^xlvii treating roughly 950,000 individuals for alcoholism annually.^xlviii Others place the number of treated individuals far higher. The NCADD, citing SAMHSA data, states that 1.9 million Americans were treated for alcoholism in 1992.^xlix

The treatment industry is clearly a major force in American society, and it shows no signs of going away. But what exactly does it do?
   

Abstinence is the near-universal goal in American alcoholism treatment, and the 12-step approach is standard. The recent "National Treatment Center Study" cited above reports that 98.6% of inpatient treatment facilities recommend abstinence, and that 93.1% of them utilize the 12-step approach.^l In other words, nearly 14 out of 15 inpatient treatment centers utilize the 12-step approach, and nearly 99 out of 100 have abstinence as the goal of treatment.

Because inpatient treatment is the type of treatment most preferred by 12-step treatment providers, and because in many instances 12-step out­patient treatment is just a watered-down version of inpatient treatment, this section will concentrate on inpatient treatment.^li

When insurers or individuals will pay for it, the standard stay in inpatient facilities is 28 days. The cost of inpatient treatment averages just over $500 per day, with some units charging as much as $1700 per day.^lii Thus, the average cost of a 28-day stay will be in excess of $14,000, and the cost can reach nearly $50,000. Just what do the insurers and individuals who pay for this expensive treatment get for their money?

Many people believe that alcoholism treatment consists largely of detoxification, but this is not the case. According to the NDATUS TEDS data, only about 23% of those treated for alcoholism in 1995 went through detox,^liii and many of them apparently went through it unnecessarily. One physician, Elizabeth Bartlett, MD, reports that after checking herself into a 28-day inpatient treatment facility, "I was placed on 'detox' and medicated, heavily I might add, despite the fate that I had not had a drink in a month and had no physical symptoms of withdrawal."^liv Such unnecessary "detoxi­fication" (that is, unnecessary drugging) seems to be fairly common, but there's no way to know how many patients are subjected to it.

So if detoxification isn't the primary purpose of 12-step inpatient treat-ment, what is? One 12-step advocate lists the goals of treatment as follows:
   

(1) Treatment does not "cure" the disease—the expectation is that by insti­tuting an achievable method of abstinence the disease will be put into re­mission. (2) All therapeutic efforts are directed at helping the patient reach a level of motivation that will enable him or her to commit to this abstinence program. (3) An educational program is developed to assist the patient in becoming familiar with the addictive process, insight into compulsive behaviors, medical complications, emotional insight, and maintenance of physical, mental, and spiritual health. (4) The patient's family and other significant persons are included in the therapeutic process with the understanding that the therapeutic process does not occur in a vacuum, but rather in interpersonal relationships. (5) The patient is indoctrinated into the AA program and instructed as to the content and application of the 12 steps of the program. [emphasis added] (6) Group and individual therapy are directed at self­understanding and acceptance with emphasis on how alcohol and drugs have affected their lives. (7) There is insistence on participation in a longitudinal support and follow-up program based on the belief that, as in the management of all chronic disease processes, maintenance is critically important to the ultimate outcome of any therapy. This follow-up usually consists of ongoing support provided by the treatment facility as well as participation in community self-help groups such as AA, Narcotics Anonymous (NA), Opiates Anonymous (OA), and the like.^lv
   

Put in plain English, this means that the purpose of "the treatment process" is to "indoctrinate" the patient into "the AA program" and into the disease-concept-of-alcoholism belief system. That is, the purpose of 12-step treatment is to convince the patient that he has an incurable "disease" from which he will never recover; that he is "powerless" over his alcohol con­sumption; that he will inevitably lose control if he drinks; that should he return to drinking, he will inevitably drink in a progressively more destruc­tive manner; that he is "in denial"; that he must not trust his own thoughts and perceptions; that he must abandon self-direction and turn his life and will over to God (or God's interpreter, AA); and that he must make a com­mitment to lifelong involvement in Alcoholics Anonymous, because the only alternative to such lifelong involvement is "jails, institutions, or death."

That is the purpose of 12-step "treatment." It really has very little to do with the problem of alcohol abuse. Rather, it's an indoctrination program designed to inculcate both distrust of self and learned helplessness ("power­lessness") in the patient, and to convince him that his only hope of salvation is to abandon self-direction and to plunge himself into lifelong participation in the religious program of Alcoholics Anonymous.

Never mind that every single premise upon which this indoctrination program is built is demonstrably false. As someone once pointed out, smoking is a behavior and lung cancer is a disease, just as drinking is a behavior and cirrhosis is a disease. Alcohol abuse (lifting bottles or glasses to one's lips and swallowing more alcohol than is healthy) is a behavior, not a "disease"—terming a behavior a "disease" broadens the term's definition so greatly as to render it almost meaningless. Thomas Szasz puts the matter thusly: "Excessive drinking is a habit. If we choose to call bad habits 'diseases,' there is no limit to what we may define as a disease."^lvi

As well, drinkers are not "powerless" over their alcohol consumption—it isn't Satan controlling the muscles in the arm lifting the glass to the lips —and they can learn to control it."Loss of control" tends to occur only when individuals believe that it will occur.^lvii

Progression of the "disease" is not inevitable, and a very high percentage of alcohol abusers (including those termed "alcohol dependent") eventually "mature out" and either achieve nonproblem drinking or abstinence without participation in AA or any treatment program.^lviii

"Denial" is a Catch 22 concept, and as such is essentially useless except as a bludgeon in the indoctrination process—if you admit that you're an alcoholic, you're an alcoholic; and if you deny that you're an alcoholic, you're "in denial," which is evidence that you're an alcoholic. Either way, as with denials of witchcraft in the Middle Ages, you lose.

And, finally, participation in AA is hardly a ticket to salvation; the recovery rate in AA is no higher than the rate of spontaneous remission.^lix

Because they've been thoroughly indoctrinated into the AA/disease­concept belief system, these facts matter not at all to those administering and conducting 12-step treatment programs. For them, having turned their lives and wills over to God, The Program has become a matter of religious faith; and even to question the premises of their belief system is blasphemous. They know The Truth—as revealed by Bill Wilson in the "inspired" Big Book. As well, they believe that their sobriety and their very lives depend on "carry[ing] this message" to those not yet saved, so they often carry that message with fearful zeal.

But what is inpatient treatment actually like? Many of the elements of inpatient treatment are little changed from the days of Dr. Bob's early hospital work: the patient is isolated from family and friends; outside con­tacts are greatly restricted; reading matter is restricted to approved "re­covery" materials, such as the Big Book and other 12-step literature; the patient is regarded as sick and as unable to think sanely—thus the need for indoctrination; coercion is regarded as a normal and sometimes desirable part of the recovery process; the patient is given little time alone and is kept very busy; and the patient is placed in a milieu where indoctrination is achieved largely through the pressure of a unanimous majority opinion, and where dissenting views and skeptical attitudes are viewed as sick, as "disease symptoms." In this milieu, all activities—including individual counseling and group "therapy"—are aimed at one goal: indoctrination into the AA/ disease-concept belief system, and involvement of the patient in AA.

Dr. Bartlett, quoted above, describes her experiences in treatment:
   

For anyone who has not been in a 12-step rehab, the daily program is brutal. Mine lasted from 7:30 AM to 10:00 PM. Essentially there was no time to think. If anyone was in his or her room for more than a few minutes, staff went in and announced that "isolating was just going to cause stinking thinking, so get out of your room." Every patient was expected to be at meals exactly on time, and to participate in all scheduled events. Late arrivals resulted in the loss of the minimal telephone contact we were allowed with the outside world. Almost every group, meeting and lecture began with the Serenity Prayer, and ended with the Lord's Prayer . . . I was told that "addicts do not like following rules," so many arbitrary rules were imposed to essentially break us of the bad habit of thinking independently. They wanted to break my will, so that I would "snap," and become one of them, obedient and grateful to the program. . . .

I was told from the moment that I arrived . . . [that if I] didn't complete their "simple program," there was a 100% chance I would drink again, and would lose my career and my family, and would ultimately die from drinking.

. . . I was not allowed to question anything about AA, especially the religious aspect^lx . . . They kept telling me that my thinking was stinking, that my intelligence was a liability and was causing my problems, and that I had better check my psychiatric knowledge at the door and stop thinking.^lxi
   

Other writers, most notably and eloquently Ken Ragge in The Real AA, have pointed out that the attitudes and practices common to 12-step treat­ment are also common to the indoctrination procedures of religious cults, and to the "re-education" procedures of the Chinese Communists.

What makes matters far worse than they would otherwise be is that a majority of patients in alcoholism treatment programs are coerced into attendance, and often face dire consequences if they leave before completing their programs. The TEDS data place the percentage of those coerced into "alcohol-only" treatment by the criminal justice system at 46% of total clients.^lxii And Laura Schmidt and Constance Weisner state that by the end of the 1980s, "the predominant groups found in facilities were now coerced clients, mandated to treatment through court and workplace referrals."^lxiii

The coerced status of a majority of their clients gives 12-step admini­strators, counselors, and "therapists" great power—and they often abuse it. They often use their power to force clients to violate their own consciences, to publicly confess their sins and evilness, and to verbally proclaim 12-step/ disease-concept beliefs, even if they don't really accept them. Those stub­born and/or courageous enough to resist often face serious consequences. At the very least, they'll be "confronted" in group "therapy" and verbally bludgeoned, sometimes for hours, sometimes for days on end, until they cave in. If they persist in stating their true beliefs, they won't be discharged (as long as their insurance will pay for treatment) or they may be threatened with expulsion, which often carries with it the threats of incarceration, job loss, or loss of professional certification. In extreme cases—as in the case of organ transplant patients—the threat is death.

The abusiveness and coerciveness of some 12-step treatment personnel is well illustrated by the treatment recived by Dr. Clifton Kirton, mentioned above, who was threatened with loss of his liver transplant candidacy because of his resistance to AA, 12-step treatment, and the disease concept. His description of one treatment coordinator's attitudes is instructive:
   

"If you think that's what Alcoholics Anonymous is all about, you're really missing the point. Religion has nothing to do with it. Your higher power can be anything. You are not being coerced. Your participation in AA is entirely voluntary. I must caution you, however that your failure to internalize recovery concepts will place your transplant candidacy status in great jeopardy."

This was the response, not necessarily verbatim, but most assuredly accurate in content, from the coordinator of the Chemical Dependency Unit of a major organ transplant center when confronted, by the author, with her own coercive tactics and with the idea that AA is a coercive, proselytizing, religious cult whose main purpose is to strip individuals of personal autonomy and to brainwash them into acceptance of irrational group ideology. This same individual also had the arrogance to state, "We can't always like our 'teachers' but we must accept what they have to teach us."^lxiv
   

Perhaps the most interesting thing in the above passage is the admini­strator's insistence that Kirton was not being coerced, that he was acting voluntarily by participating in AA, even though he would have "place[d] [his] transplant candidacy [and hence his life] in great jeopardy" if he didn't. One finds similar insistence upon the "voluntary" nature of coercion in other writings and statements by 12-step treatment bureaucrats. For example, the Treatment Contract for "impaired" nurses that is standard in California under the Board of Registered Nursing Diversion Program states in part, "I have voluntarily chosen to participate in the program and agree to adhere to the rules and regulations set forth in this contract." Nurses who don't "voluntarily" participate face loss of certification, possible criminal prosecution, and banishment from their profession. This sort of insistence on the "voluntary" nature of coerced-client treatment is quite common. One could just as easily argue that when an armed robber puts a gun to a person's head, the person "voluntarily" hands over his wallet. All in all, it certainly seems that the 12-step treatment industry is in serious "denial" about its coercive practices.

But while the treatment of Clifton Kirton may seem extreme, it's any­thing but. Stanton Peele cites the case of a married woman in her 50s whom he calls "Marie." She received a DUI citation after being stopped at a police checkpoint, and chose to pay $500 to attend 12-step treatment rather than lose her license for a year:
   

Marie's treatment consisted of weekly counseling sessions, plus weekly A.A. meetings, for more than four months. . . . 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 on my knees and prayed to a higher power." For Marie, A.A. was akin to a fundamentalist revival meeting.

In the counseling program . . . 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. . . . 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."^lxv
   

This, then, is 12-step treatment. Many have proclaimed its marvels and its life-transforming qualities. But, as we saw in the previous chapter, it simply doesn't work. Given the dismal failure of 12-step treatment, one would hope that 12-step "therapists," "medical experts," and "educators" would actively encourage research into and development of alternative treatment approaches. But this is not the case.
   

In the medical/scientific world (at least ideally) when a form of treatment repeatedly fails, it's normal for those administering the treatment to pursue alternative approaches, and to encourage development of such approaches. In the face of the massive, obvious failure of their treatment method, 12-step "therapists," "educators," and "medical experts" have done exactly the opposite: they've clung tightly to their beloved form of treatment, asserting, despite convincing evidence to the contrary, that it's effective, while selec­tively and desperately clinging to any research, no matter how poorly designed, that seems to support 12-step treatment; they've attempted to suppress research publications on non-12-step forms of therapy; they've blocked programs designed to deliver alternative forms of therapy; they've blackballed non-12-step therapists and psychologists from institutions, con­ferences, publications, and treatment facilities; and they've unleashed vicious personal attacks on those who have publicly disagreed with their positions or who have published research findings not to their liking.

This is a very serious problem, because AA/the 12-step approach domi­nates the treatment field, and those in AA's hidden structure (NCADD, ASAM, etc.) wield considerable power in the medical, psychiatric, and psychological fields. Through their deliberate suppression of opposing views and treatment approaches, they've largely blocked progress in American addictions treatment during the latter half of the 20th century.

The hottest button in the American addictions field is controlled-drinking treatment, and those in the treatment industry and AA's "medical" and "educational" arms have done their best to thwart its development, despite there being good evidence that it's a useful approach for many problem drinkers.^lxvi But the very idea that any alcohol abusers, let alone dependent drinkers, could return to nonproblem drinking contradicts the most sacred tenets of AA and the disease concept. And disease-concept advocates have repeatedly reacted hysterically and abusively to controlled drinking research and researchers.

Perhaps the clearest example of this occurred in the 1970s, when Mark and Linda Sobell published two scientifically sound articles demonstrating that bad-prognosis alcohol abusers given moderation training tended to fare better than a similar group given abstinence training.^lxvii As a result of these two journal articles, the Sobells were subjected to a decades-long campaign of personal vilification by disease-concept advocates, and, even though they were ultimately cleared of all charges, they were eventually forced to find employment in Canada. Their chief accuser was one Mary Pendery.

Pendery had taken the highly unusual step of contacting the moderation subjects (but not the abstinence subjects) from the Sobells' study, and, with Irving Maltzman and L.J. West, she published an article based on her findings in 1982 in the journal Science, disputing the Sobell's results. Ac­cording to Stanton Peele, "An earlier version of the Science article (which the journal rejected on the grounds that it was libelous) had been widely dis­seminated to the media. In several interviews, at least one of the article's authors repeated his claim that the Sobells had committed fraud."^lxviii (A panel convened by the Addiction Research Foundation subsequently cleared them of any wrongdoing.) It's also of interest that after being contacted by Pendery, several of the moderation subjects in the Sobells' study sued the Sobells.

Pendery's attack was furthered by the news media. In early 1983, 60 Minutes aired a report on the Sobells' study which strongly echoed Pendery's views. In one segment, Harry Reasoner asked one of the subjects about the outcome of his moderation training, and the subject laughed; in another segment, Reasoner was shown walking along the side of the grave of one of the four moderation subjects who had died in the decade following treatment. What 60 Minutes and Reasoner didn't show were the graves of the six abstinence subjects who had died in the same period. Pendery evidently loved the 60 Minutes report, as the report was continuously shown at the 1983 NCADD (then-NCA) convention, at which she delivered an emotional tirade against controlled drinking and those who advocate it.^lxix

Similar hysterical reactions greeted another study on controlled drinking, the Rand Report.^lxx Don Cahalan reports that, "After valiant year-long attempts by prominent NCA members to have the report suppressed altogether or drastically revised in its findings, it was finally released by Rand in June 1976."^lxxi The report was met with dire tales that "some alcoholics have resumed drinking as a result of . . . the Rand study,"^lxxii and with admonitions that it shouldn't have been released to the public: "After all, people's right to know does not mean the people's right to be confused —especially when it is a matter of life and death."^lxxiii Upon the release of the document, the NCA virulently criticized it. Cahalan notes, "The NCA's major press conference criticizing the report revealed a level of anxiety and anger much higher than ordinary concern about fairness and balance in scientific reporting. NCA officials charged that many alcoholics would be 'dying in the streets' as a direct result of publication of the report."^lxxiv

Given such strength of feeling, it's little wonder that abstinence advocates have attempted to prevent establishment of controlled-drinking programs. One such incident involved Peter Nathan, former head of the prestigious Rutgers Center of Alcohol Studies. In the late 1970s, the head of a hospital board approached Nathan and asked him to develop a controlled-drinking program. Nathan and a colleague, Terry Wilson carefully devised a treat­ment plan and aftercare program, which the hospital board accepted with some minor changes. It then issued a press release describing the program and soliciting clients. Stanton Peele notes that, "When this announcement produced only a small group of potential clients, Nathan and Wilson planned a more aggressive advertising effort. Before they could proceed, however, the hospital withdrew its support for the program because of threats by representatives of AA that they would stop referring patients to the hospital's profitable inpatient program."^lxxv

Given the depth of feeling against controlled drinking and its advocates, and, for that matter, against virtually all critics of AA and the disease con­cept, it's equally little wonder that AA/abstinence advocates have often en­gaged in blackballing when they've had the ability to do so. Blackballing is, in fact, routine in the treatment industry; a great many treatment facilities will simply not hire anyone for any position (even as a cook) who does not embrace the 12-step approach and the disease concept of alcoholism.

One local example is illustrative. After moving to Tucson in 1997, Emmett Velten, a well known and well respected psychologist, and co­author (with former American Psychological Association president Albert Ellis) of When AA Doesn't Work for You: Rational Steps to Quitting Alcohol, applied to an upscale local treatment facility for an advertised part-time position lecturing on the physiological effects of drugs and alcohol, a position for which he is well qualified. A few minutes after his interview began, the director of the facility entered the room, asked Emmett if he believed in the 12-step approach, and when Emmett said, "no," the director escorted him off the property as if he were a plague carrier.^lxxvi

Those who engage in "public controversy" with AA's front groups face even rougher treatment. Stanton Peele reports that after defending the Sobells in an article in Psychology Today in 1983, his column in the U.S. Journal of Drug and Alcohol Dependence was dropped; Mary Pendery attacked him in a speech at the 1983 NCA convention; an invitation to deliver the keynote speech to the Texas Commission on Alcoholism's summer school was withdrawn (and then reinstated after Peele protested); and "the number of invitations [he had] received from conferences like that in Texas [had] dropped dramatically."^lxxvii

Peele continues, "My experience with this alcoholism dispute has given me a strong idea of the political power of the alcoholism movement to suppress discordant views. What astounded me most was how academic, professional, and government associates recommended that I drop the matter with the Texas Commission, saying simply that these events were typical. Apparently, those in the field had given up expecting freedom of speech or that a range of views should be represented at conferences receiving government funding and conducted at major universities. What I had uncovered was a matter-of-fact acceptance that those who do not hold the dominant point of view will not be given a fair hearing; that even to mention that there is doubt about accepted wisdom in the field endangers one's ability to function as a professional; and that government agencies reinterpret results of which they disapprove from research they themselves have commissioned."^lxxviii
   

AA is far from being the innocent organization that most people believe it to be. The familiar gatherings of coffee-slurping, cigarette-smoking ex­drunks are only the tip of the iceberg. AA and its disease concept of alcoholism dominate the alcoholism treatment field in this country. Through its hidden members and its carefully cultivated benign image, AA has tremendous influence in the media. It has powerful "educational" and "medical" front groups, such as the NCADD and ASAM, that to a great extent determine the direction of alcoholism research, treatment, and education. (The NIAAA, for example, has funded no controlled-drinking research for a decade.) AA's front groups and hidden members vilify and blackball critics and independent researchers. AA and 12-step treatment advocates attempt to smother alternative treatment approaches. And AA's friends and hidden members in EAPs, diversion programs, the judiciary, and penal system coerce probably half-a-million Americans per year into AA attendance and/or 12-step treatment.

This comprises AA's hidden structure and hidden influence. It is, quite simply, a national disaster.
   

Twelve-step addictions "professionals" and other AA members are evidently quite concerned about the insurance industry's increasing reluc­tance to pay for ineffective 12-step "treatment," and they're determined to do something about it. Senator Paul Wellstone (D.-Minn.) and "recovering alcoholic" (that is, AA member) Representative Jim Ramstad (R.-Minn.) introduced The Substance Abuse Treatment Parity Act in 1997. The "Act would bar any inpatient day or outpatient visit limits, deductibles, copay­ments or dollar limits on substance abuse coverage that are more restrictive than those for general health care."^lxxix That is, if passed, the Act would unleash a river of insurance cash to the treatment industry, something which those in the industry want badly. Roxanne Kibben, president of the National Association of Alcoholism and Drug Abuse Counselors^lxxx states, "This [Act's introduction] makes a statement that we're not going away. We're not going to let this go."^lxxxi