This chapter provides an overview of the American alcoholism field. It provides an outline of current conditions and how these conditions arose. It briefly considers the following: 1) Definitions of alcoholism, alcohol abuse, and alcohol dependence; 2) Domination of 12-step groups in the self-help field; 3) Domination of 12-step treatment in the professional field; 4) The number of treatment facili- ties and the number of those treated; 5) The expense of treatment; 6) Avenues of coercion into 12-step groups and 12-step treatment; 7) The number of coerced persons; 8) The percentage of coerced persons who are alcoholics or addicts; 9) Origins and tenets of the disease concept of alcoholism; 10) Scientific evidence regarding the disease concept; 11) The nature of 12-step treatment.
Before assessing the effectiveness of 12-step groups and 12-step treatment in dealing with alcoholism, it's first necessary to define the term. Since the word "alcoholism" was coined over 100 years ago, there has never been agreement about what it means. A great variety of definitions have been offered over the years, most dealing with level of consumption, physical dependence, and behavioral, legal, social and/or physical consequences; but all such definitions are, necessarily, arbitrary in at least some respects. One can see how imprecise such definitions are in the wildly varying estimates of the number of alcoholics in the United States given by various experts in recent years some still cite the figure common to 1970s professional journal articles of 10 million alcoholics, while other estimates have run as high as 25 million (roughly 12% of the adult population). The National Institute on Alcohol Abuse and Alcoholism (1999b) esti- mates that there were 18.4 million alcohol abusers and alcoholics in 1995. Other estimates are even higher. G. Douglas Talbott, founder and past president of the American Society of Addiction Medicine, has claimed: "The old figure was 10,000,000 alcoholics. . . . It is way beyond that now, and as far as we are concerned, 22 million people have an alcohol problem related to the disease of alcoholism" (Wholey, 1984, p. 19). These estimates indicate that in the United States, despite great efforts, the level of alcohol abuse has not de- creased, even though the rate of abstinence has increased (Stinson et al., 1998).
Because of the great, probably insurmountable, difficulties in arriving at a generally accepted definition of the term "alcoholism," addictions researchers and other professionals have largely aban doned it in favor of the somewhat more precise terms "alcohol abuse" and "alcohol dependence." These terms at least recognize that alcohol use and abuse run across a spectrum (or several spectrums, if you consider level of consumption, physical dependency, and behavioral, legal, social, and physical consequences separately) from teetotaler to physically dependent, physically damaged, heavy daily drinker. The American Psychiatric Association (APA) has, in fact, dropped the term "alcoholism" from its authoritative Diagnostic and Statistical Manual of Psychiatric Disorders (DSM) in favor of "substance dependence" and "substance abuse," thus treating alcohol depend ence and abuse as the equivalent of tobacco or heroin dependence and abuse and not as a separate disorder.1
The current (fourth) edition of the DSM notes, "The essential feature of Substance Dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems. There is a pattern of repeated self-administration that usually results in tolerance, withdrawal, and compulsive drug-taking behavior" (APA, 1994, p. 176). DSM-IV defines the Criteria for Substance Dependence as follows:
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
DSM-IV then, on the same page, goes on to refine the diagnosis, providing the distinction, "With Physiological Dependence: evidence of tolerance or withdrawal" or "Without Physiological Dependence: no evidence of tolerance or withdrawal."
It defines the Criteria for Substance Abuse as:
These are now the standard terms and definitions used by researchers, academics, and a great many practitioners. Many others, however, continue to use the outdated, less precise term, "alcoholism." These include the mass media, 12-step groups, especially Alcoholics Anonymous (AA), and a great many 12-step professionals and paraprofessionals (members of AA and Narcotics Anonymous [NA] who work in 12-step treatment centers).
The reasons for continued use of this outmoded term vary. They include: 1) simple ignorance of modern terminology, and the reasons for its use this is usually the case with reporters and other journalists; 2) habit; 3) identity maintenance members of AA (and, especially, AA treatment professionals and paraprofessionals) have often (re)constructed (in AA) their identities around alcoholism as the core of their being (Rudy, 1986), and are very protective of that identity; 4) ideology the term "alcoholic" is a binary term (one is either alcoholic or nonalcoholic), and such a black-and-white defini- tion is essential to the disease concept of alcoholism, the ideological underpinning of abstinence-demanding 12-step treatment.
Specifying the number of alcohol abusers in this country is a very complicated question, and because of the subjective nature of even many of the best-defined criteria (such as those in the DSM), any answer will necessarily be at least somewhat arbitrary. There have, however, been many attempts to provide an answer. The U.S. Department of Health and Human Services estimated in 1997 based on the 1992 Census Bureau-conducted National Longitudinal Alco- holism Epidemiological Survey (NLAES) that about 14 million Americans, roughly 7.5% of the adult population, are alcohol- dependent or abusing (USDHHS, 1997). If you believe the figures of the National Institute on Alcohol Abuse and Alcoholism, then the total is 18.4 million; that is, 11.2 million alcohol-dependent and 7.2 million alcohol abusers (NIAAA, 1999b). Just how arbitrary these figures are can be seen by comparing them with the results of similar, previous surveys. The 1988 National Health Interview Survey, for instance, found a combined rate of alcohol abuse and dependence of 6% using the same DSM-IV criteria as the NLAES, but a rate of 8.6% using the criteria of the previous edition of the DSM, the DSM III-R (USDHHS, 1997, p. 19). These figures jibe reasonably well with the Addiction Research Foundation (ARF) estimate of the number of alcohol-dependent persons in Ontario, Canada: 5.4% (ARF, 1998).
Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and the 12-step treatment derived from them are mass phenomena in the United States. They dominate and nearly monopolize the addic- tions self-help and treatment fields.
As of January 1, 1999, Alcoholics Anonymous had approximately 51,000 groups and 1,167,000 members in the United States, com- prising roughly two-thirds of all AA members in the world (AA, 1999, p. 1). AA is by far the largest of all addictions self-help groups in America. Narcotics Anonymous is the next largest, with 16,000 groups and (through extrapolation assuming that the average NA group is the same size as the average AA group) approximately 373,000 members (NA, 1998, p. 1). For the purposes of our analysis, they can be considered as one, because NA is for all practical purposes a carbon copy of AA. Its ideology, core beliefs (as codified in the 12- steps), and structure are virtually identical to AA's. For example, the NA 12 steps differ in only two words (in the first and twelfth steps) from AA's 12 steps.
Between them, AA and NA have a combined membership in excess of 1.5 million; combined AA and NA membership probably out- numbers the combined membership of the five major non-12-step self-help groups (Moderation Management, Rational Recovery, SMART Recovery, Secular Organizations for Sobriety, and Women for Sobriety) by a ratio of at least 50 to one.2
The 12-step approach is every bit as dominant in the treatment field as it is in the self-help field. A large, recent survey of alcohol treatment providers reported that 93% of the 450 facilities it surveyed utilized the 12-step approach (Roman & Blum, 1997, p. 24). Breaking this figure down, the percentage of inpatient-only facilities utilizing the 12-step approach was, unsurprisingly, 96%; the percentage of facilities offering both inpatient and outpatient treatment utilizing the 12-step approach was 95%; and the percentage of outpatient-only facilities using the 12-step approach was 90% (e-mail message, J.A. Johnson, Research Coordinator, Center for Research on Behavioral Health and Health Services Delivery, University of Georgia, Novem- ber 4, 1998).
It's worth noting that all of the 450 facilities surveyed treated both alcohol and drug abuse, but that only 2.4% of them offered segregated alcohol and drug programs (Roman & Blum, 1997, p. 6). This is powerful testimony to the integration of alcohol and drug abuse treatment programs, and to the dominance of the 12-step approach in treating all forms of substance abuse. As well, writers sympathetic to the 12-step movement confirm that the 12-step approach pervades the entire treatment industry. One such writer, Gregory B. Collins, MD, states:
In spite of some confusion about roles, boundaries, philosophies, and objectives, the relationship between AA and treatment has been clear: AA is not treatment as stated in the Traditions of AA; treatment is not AA, i.e., it accepts payment. Overlap is in principles. Nonetheless, this union has brought forth the modern alcoholism treatment industry as we know it with its hospital-based programs, free-standing residential treatment facilities, halfway houses, outpatient centers, and support groups. The unifying philosophical principle remains the Twelve Steps and Twelve Traditions of AA, bolstered further by the disease model of alcoholism . . .
(Collins, 1993, pp. 34 35)
Another professional notes that, ". . . all kinds of interconnections between professional treatment and AA exist, and the Twelve Steps have been adopted as an important component of professional treatment programs. The United States is the clearest representative of this type of hegemony of AA" (M„kel„ et al., 1996, p. 186, emphasis in original).
Still another indication of the pervasiveness of the 12-step approach to addictions treatment can be found in the journal article, "Help-seeking and recovery by problem drinkers" (Tucker & Gladjso, 1993), which compared 161 individuals members of AA who had not been formally treated and individuals who had gone through formal treatment. The researchers conducting the study ran into an interesting problem: they were unable to include a comparison group of treated subjects who had not been exposed to AA, because almost all of their treated subjects had been exposed to AA in treatment: "Few subjects had received alcohol treatment without also having participated in A.A., so a treatment-only group was not included" (Tucker & Gladsjo, 1993, p. 532).
Thus the 12-step model dominates the treatment industry. If you (or one of your clients) are sentenced to or otherwise coerced into treatment, it will almost surely be 12-step treatment.
Just as the 12-step approach is pervasive in the treatment industry, treatment is a pervasive influence in contemporary American society. There are approximately 15,000 treatment facilities (inpatient and outpatient combined) (Substance Abuse and Mental Health Services Administration [SAMHSA], 1999, p. 112) treating approximately 2,000,000 persons annually. SAMHSA's Treatment Episode Data Set (TEDS) reports 1,477,881 admissions in 1997 (SAMHSA 1999, p. 47), but those data are quite incomplete; they do not include any admissions from Arizona, Indiana, Mississippi, Puerto Rico, or West Virginia, and are not complete for, apparently, all other states. SAMHSA reports, "In general facilities reporting TEDS data are [only] those that receive State [sic] alcohol and/or drug agency funds . . . [and] TEDS also does not include data on facilities operated by Federal [sic] agencies" (SAMHSA, 1999, pp. 4 5). Taking into account such inadequacies, SAMHSA estimates that there were 2,207,375 admissions in 1997 (SAMHSA, 1999, p. 114). This is the total number of estimated admissions; but because some individuals were likely admitted to more than one substance abuse program in 1997, the total number of persons treated is almost certainly somewhat lower. In any case, given that the SAMHSA data attempt to treat transfers from one program to another as single admissions, it seems likely that at the very minimum 2,000,000 persons were treated in 1997.
Twelve-step treatment is also very expensive. The National Treatment Center Study (NTCS) placed the daily cost of adult inpatient treatment at an average of $509 among the facilities it surveyed, while the cost per day of detox treatment ran to an average of $586, and adolescent treatment to an average of $592 per day (Roman & Blum, 1997, p. 20). This adds up quickly. One study placed the average cost to a Midwestern manufacturing plant at $4665 per treated employee (in 1985 dollars, the equivalent of approximately $7100 in 1999) (Holder & Blose, 1991, p. 190). More recently, the Substance Abuse and Mental Health Services Administration reported that treatment in correctional centers costs an average of $24 per day, with an average of 75 days of treatment for a total of $1800 per client; long-term residential care costs an average of $49 per day, with an average stay of 140 days, for a total cost of $6800; and short-term residential treatment costs an average of $130 per day, with a "typical stay of 30 days" (SAMHSA, 1997c, p. 3). The large difference between average costs as reported by SAMHSA and by the National Treatment Center Study is probably due to SAMHSA's inclusion of many publicly funded facilities, while the NTCS surveyed only facilities which receive a majority of their funds from private sources (e-mail message, J.A. Johnson, November 6, 1998).
The total cost of 12-step treatment to taxpayers and insurers is staggering. Estimates range from a low of $3.6 billion annually for treatment in the late 1980s (Nace, 1993, p. 437; Huber et al., 1994, p. 1663, put the total at $3.8 billion in 1989) to a high of $10.5 billion in "direct costs" ("specialty organizations, short-stay hospitals, office- based physicians, other professional services, nursing homes, support costs") in 1990 (USDHHS, 1997, p. 388). This figure agrees with the Institute of Medicine estimate of $10 billion in treatment costs in 1990 (USDHHS, 1994, p. 15). More recently, the New York Times (Morrow, 1998, p. D1) estimated current costs at $5 billion per year. These estimates are all for alcohol treatment alone. They do not include the costs of drug treatment. Another glimpse at how ex- pensive treatment is can be gained by looking at state treatment spending alone (including channeled federal funds), which ran to $2.52 billion in 1992 (USDHHS, 1995, p. 57).
There are several common ways in which individuals are coerced into 12-step group participation or into 12-step treatment:
These practices cover a majority of cases of 12-step coercion, but hardly all cases. A great many other individuals are coerced into AA, NA, or 12-step treatment. These include liver transplant candidates, children removed from parental custody, parents in child-custody cases, members of the military with substance abuse problems . . . and the list goes on.
While it's very difficult to estimate the total number of individuals coerced annually into AA, NA, or 12-step treatment, a number of reliable sources indicate that the total is very high almost certainly above 1,000,000. One can glimpse the importance of coercion to AA and NA and its contribution to their growth in AA's membership figures. Since the late 1970s, AA has conducted periodic membership surveys, generally once every three years. (For this reason the AA surveys are normally referred to as "triennial surveys.") In these surveys, AA asks its members what factors were most important in bringing them to AA. The findings of AA's 1996 survey were quite revealing. They indicated that probably in excess of 40% of AA's current members were coerced into attendance (AA, 1997).3
In addition, given that over 1,000,000 Americans per year are coerced into alcohol treatment (which almost always means coerced into AA as well), it seems certain that a large majority of newcomers to AA are coerced into attendance (and then leave as quickly as they can through AA's "revolving door"). This conjecture fits well with AA's self-reported new member dropout rate of 95% in the first year (Alcoholics Anonymous, n.d., p. 12, Figure C-1).
It seems likely that the percentage of NA members coerced into attendance is even higher than that of AA members coerced into attendance, because of the illegality of many recreational drugs in this country. Whereas with alcohol one must sometimes demonstrate a pattern of abusive behavior or get a DUI in order to be forced into AA or treatment, those who use illegal drugs are often arrested for simply possessing small amounts of drugs. As well, no matter in what manner such persons use drugs, they are in part because of 12-step- induced abstinence hysteria automatically assumed to be drug abusers, or even drug dependent, and therefore fair game for coer- cion into NA or 12-step treatment. (According to drug war dogma, there is no such thing as, for instance, moderate marijuana use despite the experience of many millions of casual users.)
NA's own figures bear this out. They reveal that "47% of our members were introduced to Narcotics Anonymous through a treat- ment facility or while incarcerated," and that "24% were introduced by a community professional (doctors, attorneys, clergy, judges)" (NA, 1998, p. 5, emphasis added). Given the penchant of 12-step groups for the use of euphemism, one can reasonably assume that those "introduced" to NA by judges and (district?) attorneys were actually coerced into attendance through either pre-trial diversion programs or as a condition of probation. This would bring the coerced per- centage to well above 50% of NA members.
An indication of what percentage of clients are coerced into 12- step treatment is provided by the Substance Abuse and Mental Health Services Administration's Treatment Episode Data Set. A recent TEDS survey reports, "TEDS 1995 admissions show a high rate of self-referrals (69% for heroin) and a high rate of referral by the criminal justice system for marijuana (49%), PCP (47%), and alcohol-only (46%)" (SAMHSA, 1997a, p. 3, emphasis in original). To put this in further perspective, in 1995 only 20% of those treated for marijuana abuse were indi- vidually referred, and only about 33% of those treated for drug abuse of all types were individually referred (SAMHSA, 1997a, p. 46). This low percentage of individual referrals combined with the very high percentage coerced by the criminal justice system provides good evidence taking into account the many other avenues of coercion that a majority of individuals in 12-step drug treatment are coerced into it.
Moreover, given that 46% of those treated for alcohol-only abuse in 1995 were directly coerced into it by the criminal justice system, and that only 28% of those treated for alcohol-only abuse were individually referred (SAMHSA, 1997a, p. 46), it's certain given the many other types of coercion beyond the criminal justice system that a sizable majority of those in 12-step alcohol-only treatment are coerced into it. This becomes even more obvious when one realizes that "individual" referral "includes self-referral due to pending DWI/DUI" (SAMHSA, 1999, p. 103). As to relative size, those treated for "alcohol only" abuse made up 30% of total admissions in 1995 (SAMHSA, 1997a, p. 47; SAMHSA, 1997b, p. 26). As for those treated for "alcohol with secondary drug" abuse, 34% were directly coerced into attendance by the criminal justice system, while only 31% of such persons were individually referred (SAMHSA, 1997b, p. 46). (No figures were given for "drug with secondary alcohol" abuse.) Those treated for both alcohol and drug abuse made up just over 46% of those treated (SAMHSA, 1997b, p. 26).
The most recent SAMHSA data indicate a similar level of coercion. In 1997, alcohol-only and alcohol-with-secondary-drug admissions comprised 48% of all admissions, with 42% of those admitted being directly coerced by the criminal justice system, and only 27% being individually referred (derived from SAMHSA, 1999, p. 67, Table 3.4). In addition, in 1995 those admitted for marijuana use comprised 10.5% of all admissions, but by 1997 that percentage had risen to 13% (SAMHSA, 1999, p. 47, Table 2.1), with fully 52% of such admissions being directly coerced by the criminal justice system. (An indication of the increasing use of drug courts is that the percentage of admissions for marijuana use more than doubled between 1992 and 1997, from 6% of admissions to 13% of admissions, according to SAMHSA, 1999, p. 47.)
Given that approximately 2,000,000 Americans per year enter treatment, these figures mean that considering the many other avenues of coercion almost certainly over 1,000,000 of our fellow citizens are coerced into 12-step treatment annually. And the total could be considerably higher than that.
A great many other people almost certainly hundreds of thousands are coerced into AA or NA attendance (though not necessarily 12-step treatment) through judicial diversion programs or as a condition of probation or parole. So, the total number of those coerced annually into AA, NA, and 12-step treatment combined likely far exceeds 1,000,000, and could reach as high as 1,500,000.
This is, quite simply, a staggering number.
The multi-billion-dollar 12-step treatment industry treats at the very minimum one million coerced clients annually, a great many of whom do not meet the diagnostic criteria for alcohol abuse, let alone alcohol dependence. One of the largest groups of coerced clients, DUI offenders, is illustrative. The National Highway Transportation Safety Administration (NHTSA) reports that "approximately 20% of all licensed drivers drive while intoxicated . . . during any given 1-year period" (NHTSA, 1996, p. 1, citing Nichols, 1990), and that at least 50% of those arrested for DUI offenses do not meet the clinical cri- teria for alcohol abuse or alcohol dependence (NHTSA, 1996, p. 1).
Thus the application of the term "alcoholism" to everyone with any alcohol-related problem whatsoever (including the social drinker who has one too many on New Year's Eve and gets a DUI citation) is clearly inappropriate. But it helps to ensure a steady, profitable stream of coerced clients to treatment programs; it helps to reinforce the alcoholic identities of the professionals and paraprofessionals running 12-step treatment programs; and it allows (indeed, implicitly demands) the use of one-size-fits-all, abstinence-demanding 12-step treatment for everyone who steps through the doors of a treatment center. Never mind (as we'll see later) that 12-step treatment doesn't work very well. And never mind that every single one of the testable premises underlying 12-step treatment's ideological basis (the disease concept of alcoholism) is demonstrably false.
The disease concept of alcoholism is the cornerstone of 12-step treatment, and is intimately tied to AA. In fact, it is largely a product of AA. It was first propounded (in "modern" terms) in two articles by Yale researcher E.M. Jellinek published in 1946 and 1952. It was later put in what retired University of California professor Herbert Fingarette calls its "canonical" form (Fingarette, 1988, p. 20) in 1960 in Jellinek's book, The Disease Concept of Alcoholism. Jellinek's articles and book have been amazingly influential during the latter half of the 20th century. They have provided the "scientific" rationale for AA and 12-step treatment.
Jellinek's influence is amazing, however, not because of his work's supposed scientific value, but rather because it has virtually no scien- tific value. Jellinek based his writings not on experimental studies with control groups and random assignment of subjects, not on epidemio- logical studies with matched comparison groups, not on longitudinal studies, not even on retrospective studies of a random sample of the population, but, rather, on one retrospective study of a small sample of self-selected Alcoholics Anonymous members, with no comparison group.
Jellinek's data came from an AA-designed questionnaire dis- tributed through the monthly magazine, The Grapevine, which func- tions as an internal AA organ. Thus all of the replies Jellinek received came from self-selected AA members that is, members of an organi- zation with a rigid, uniform view of alcoholism. Jellinek received 158 questionnaires, of which he discarded 60 because they were either completed by women, were incomplete, or had been completed by AA members who had pooled their answers. Jellinek went on to inter- pret the answers on the remaining 98 questionnaires at great length, producing impressive looking graphs and thousands upon thousands of words of explication. His works remain a mainstay in the scientific arsenal of 12-step proponents.
But the fact remains: Jellinek's work was a retrospective study based on a small, exclusively male, self-selected sample of AA members. It's little wonder that the answers they gave Jellinek mirrored the view of alcoholism one finds at virtually every AA meeting.
The AA-generated theory (more accurately, a weak hypothesis), the disease concept of alcoholism, has several central tenets:
Almost all of these central tenets of the disease concept are demonstrably false. In regard to inevitable progressivity, the supposed powerlessness of alcoholics to recover (let alone recover unaided), and loss of control, scientists have known for decades that alcoholism disappears faster than can be explained by mortality among indi- viduals older than 40. One researcher reports, "In the statistics avail- able on alcoholics in Victoria [State, Australia] predicted prevalence and actual prevalence do approximate each other, but only until the age of 40 years is reached, after which the actual prevalence in- creasingly falls below the predicted prevalence with increasing age" (Drew, 1968, pp. 957 958). He concludes: "The reported evidence demonstrates that alcoholism tends to disappear with increasing age. Although morbidity and mortality may account for a large part, a significant proportion of this disappearance is probably due to spontaneous recovery. . . . It is interesting that this type of obser- vation has been so generally ignored while the concepts of 'irre- versibility' and 'loss of control' have generally and tenaciously been accepted . . ." (Drew, 1968, p. 965).
Scientists have also known for decades that significant numbers of alcohol abusers "spontaneously"4 recover (Cahalan, 1970; Fillmore, 1974; Fillmore, 1975; Knupfer, 1972; Saunders et al., 1979). The meta-analysis estimate of 3.7% to 7.4% per year (Smart, 1975/76, p. 284) fits reasonably well with the available longitudinal study-derived data on mortality of alcohol abusers (Finney & Moos, 1991) and with the results of the massive National Institute on Alcohol Abuse and Alcoholism (NIAAA)/Census Bureau study, the National Longitudinal Alcohol Epidemiological Survey (NLAES) (Dawson, 1996). Finney and Moos surveyed 12 longitudinal studies of alcohol abusers, and reported an average mortality rate of 2.15% per year for the treated abusers, during an average follow-up time of 11.3 years. (The single study of "generally untreated alcohol abusers," Öjesjö, 1981, reported an annual mortality rate of 1.7%, a lower percentage than reported by all but one study of treated abusers.)
The NLAES was conducted in 1992 by Census Bureau field workers who did face-to-face interviews with roughly 43,000 Americans age 18 and over, concerning the use of alcohol and other drugs over the respondents' lifetimes. The respondents included "4,585 adults with prior DSM-IV alcohol dependence" (Dawson, 1996, p. 771). That is, these individuals were serious alcohol abusers, persons who would be termed alcoholics in common parlance. "To be included in this analysis, an individual had to have satisfied the criteria for prior-to- past year DSM-IV alcohol dependence by meeting at least 3 of the 7 DSM-IV criteria for dependence" (Dawson, 1996, p. 772).
The results of this huge retrospective study lend powerful new evidence that a great many, indeed a large majority of, alcoholics and, remember, this was a study of alcohol-dependent persons, not mere alcohol abusers spontaneously recover, with the percentage steadily rising as time passes. The NLAES reported that 20 or more years after the "onset of dependence," 90% of surviving, untreated formerly alcohol-dependent persons were either abstinent (30%) or "drinking without abuse or dependence" (60%) (Dawson, 1996, p. 773). Given that there appears to be little difference in mortality rate between treated and untreated alcoholics (Finney & Moos, 1991; Vaillant, 1995), and that the mortality rate of the cohort from which the alcohol-dependent persons in this survey was sampled was probably in the 2%-per-year range, one can at least roughly calculate the percentage of untreated alcoholics who recover without under- going treatment or participating in AA.
Assuming an average mortality rate of 2.15% per annum (as derived from the Finney & Moos study),5 a straightforward calculation reveals that 57% of those who first exhibited alcohol dependence 20 years before the NLAES should still have been alive at the time of the study. Given that 90% of the untreated subjects6 were either abstinent or drinking socially without problems, one arrives at the tentative conclusion that at least 51% (.57 X .90) of the cohort from which the NLAES subjects were drawn were alive and recovered at the time of the study.7 (Given that alcohol-related mortality declines with age, the percentage could be higher.)
But even if the recovery rate were only 51%, that is still better than it sounds. The reason for this is that significant numbers of those who died did so as a result of non-alcohol-related causes. The average mortality rate in the United States is roughly 1.3% per year (spread out over all ages). Given that alcohol problems tend to be con- centrated in the younger age groups, it would be reasonable to expect that the mortality rate in a non-alcohol-abusing population in the same age range as alcohol abusers would be lower than average. If it were 1% per year, then a non-alcohol-abusing comparison group to the subjects in the NLAES would show an approximately 80% survival rate over a 20-year period. Comparing this 80% with the 51% of recovered formerly alcohol-dependent persons in the NLAES yields a spontaneous recovery rate of 64%, corrected for non-alcohol-related mortality. Of course, these numbers are tentative, but even assum- ing a mortality rate higher than the already very high 2.15% they still provide powerful evidence that the supposed inevitable pro- gression of the disease of alcoholism exists only in the minds and solemn pronouncements of 12-step true believers. It also provides powerful evidence that the supposedly inevitable loss of control experienced by alcoholics likewise exists only in the minds and pro- nouncements of 12-step proponents.
Clinical experiments further disprove the loss-of-control suppo- sition. Since the 1960s, researchers have conducted controlled experi- ments designed to discover whether inevitable loss of control and the trigger effect really exist. (The classical disease concept posits that any amount of alcohol consumption, no matter how minute, triggers loss of control in alcoholics.) The results of these experiments have been uniformly negative.
There have been a large number of studies conducted in clinical situations in which alcohol was made available to alcoholics, often with them earning it through the performance of menial tasks. Many of these studies also offered rewards either for not drinking or for moderate consumption, and/or penalties (such as being kicked out of comfortable surroundings) for excessive consumption. The results of these studies have been remarkably uniform: in such clinical settings, the vast majority of alcoholics control their drinking. One review of over 50 such studies concludes, "within a hospital or labora- tory environment, the drinking of chronic alcoholics is explicitly a function of environmental contingencies" (Pattison et al., 1977, p. 100). Such experiments have been attacked by the 12-step establish- ment as meaningless, because they did not take place in the "real world." But as Herbert Fingarette points out:
. . . if these drinkers were able to control their drinking in these special settings, one of two explanations must hold. Either (1) the careful observers in the special settings are noticing behaviors that careful observers would also detect in everyday situations or (2) the change in setting from home to hospital indeed radically affects alcoholics' self- control and drinking patterns. Either of these explanations undermines the classic loss-of-control conjecture. If the first explanation holds, then loss of control is a stereotype born of faulty observation and a misunderstanding of drinkers' behavior. If the second explanation holds, then it is the social setting, not any chemical effect of alcohol, that influences drinkers' abilities to exert control over their drinking.
(Fingarette, 1988, p. 37)
This is powerful testimony against the disease-concept precept that alcoholism is an entity unto itself, existing independently of the alcoholic's social situation.
Further confirmation that alcoholism is not an independent entity can be found in studies of the Community Reinforcement Approach to alcohol abuse (CRA). The fundamental underlying tenet of CRA is that alcoholism is not an entity unto itself, but, rather, is highly influenced by social, economic, relationship, recreational, and family situations. Proceeding from this premise, CRA programs help an alcoholic develop better ways of meeting his or her needs than by drinking. One study describes CRA as follows: "An operant rein- forcement approach was used . . . that rearranged community rein- forcers such as the job, family and social relations of the alcoholic" (Hunt & Azrin, 1973, p. 91).8
The authors continue, "The results showed that the alcoholics who received this Community-Reinforcement counseling drank less, worked more, spent more time with their families and out of institutions than did a matched control group of alcoholics who did not receive these procedures." These results were not trivial: "The mean percent of time spent (1) drinking was 14 per cent for the reinforcement group and 79 per cent for the control group; (2) unemployed was 5 per cent for the reinforcement group and 62 per cent for the control; (3) away from family . . . was 16 per cent for the reinforcement group and 36 per cent for the control group; (4) institutionalized was 2 per cent for the reinforcement and 27 per cent for the control group" (Hunt & Azrin, 1973, p. 97).
A later study combining the Community Reinforcement Approach with disulfiram (Antabuse) showed even more impressive results. At the six-month follow-up, the control group was drinking on 16.4 days per month versus 0.9 days for the CRA group; and the control group was intoxicated 10 days per month versus 0.4 days for the CRA group (Azrin et al., 1982). Significantly, the control group in both of these studies was comprised of individuals (matched to those in the Com- munity Reinforcement Approach groups) who had undergone only conventional 12-step treatment.
There have also been direct investigations of the supposed chemi- cal trigger effect (leading to loss of control) of alcohol consumption. Again, the results of these controlled experiments have been con- sistently negative. They typically involve giving alcoholics drinks either containing or not containing alcohol, and then measuring con- sumption based on expectations. One of the most famous and methodologically sound of these studies was conducted by Uni- versity of Washington researcher Alan Marlatt in the early 1970s.
In the experiment, Marlatt et al., under the guise of a taste test, gave four groups of alcoholic subjects either straight tonic water or tonic water with a small amount of vodka mixed in. (The amount was small enough that it was not detectable through taste.) One group was given tonic water and told that it was tonic water. A second group was given tonic water mixed with vodka and told that it was tonic water. A third group was given tonic water and told that it was tonic water mixed with vodka. And a fourth group was given tonic water mixed with vodka and told that it was tonic water mixed with vodka. In other words, the researchers told two of the groups the truth about what they were drinking, and they lied to the other two groups about it. The results flatly contradicted the expectations of the disease theory and its loss-of-control myth: regardless of what they were actually drinking, the groups that believed they were drinking a vodka mix drank more than the groups that believed they were drinking only tonic water. Thus expectation was the trigger not the presence (or ab- sence) of alcohol (Marlatt et al., 1973).
Thus far we've seen that the available scientific evidence negates the first six premises of the disease concept (listed above on pp. 31 32). So, we're left with the seventh, denial. This premise is unique in that it cannot be scientifically tested (or, at least, no one has devised a means of doing so).
The disease-concept assertion that denial characterizes and is a major symptom of alcoholism is just that: an assertion and a par- ticularly asinine one at that. Everyday experience will show this: a great many alcoholics go to AA and 12-step treatment for help (in itself an admission of a problem), yet many of them continue to drink abusively, often while attending AA and working the steps. Are they in denial?
Another problem with the concept of denial is that it is useless as a diagnostic symptom. For, even if everyone who is an alcoholic is in denial about their problem (which, as we've just seen, isn't true), those who are not alcoholic will also deny that they are alcoholic. Thus reliance upon denial as a diagnostic symptom undoubtedly leads to many false positives.
It's also worth noting that denial is a Catch-22 accusation: if you admit that you're an alcoholic, you're an alcoholic; if you deny that you're an alcoholic, you're in denial strong evidence that you are an alcoholic. Either way you lose. Just as many innocent people lost the last time denial of a charge was accepted as evidence of its truth at witchcraft trials in the Middle Ages.
Denial does have its uses, though. It's a very handy weapon with which to badger coerced, recalcitrant clients in 12-step treatment facilities, and with which to badger coerced, recalcitrant newcomers at AA and NA meetings.
The disease concept of alcoholism is the ideological underpinning of the $10-billion-a-year treatment industry, and the edifice erected upon it is entirely worthy of its foundation.
Twelve-step treatment is, in reality, institutional AA and NA. To put this another way, the primary goal of 12-step treatment is the intro- duction of clients to AA or NA, with the purpose being to push clients into joining AA or NA and attending their meetings for the rest of their lives. Twelve-step advocates can sometimes be surprisingly forth- right about this:
(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 self-understanding 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. (G.A. Mann, cited by Collins, 1993, p. 35)
Two other pro-12-step writers, in a journal article describing inpatient treatment, note: "Information about self-help groups such as AA specifically need[s] to be covered during treatment because they form the backbone of a successful recovery program" (Warner & Mooney, 1993, p. 99).
So, AA forms the "backbone of a successful recovery program." But what exactly goes on in 12-step treatment? One study of AA, done in collaboration with the World Health Organization, describes 12-step inpatient treatment as follows:
Institutional 12-step treatment consists of an intensive program for a period of up to four or six weeks. Patients attend lectures on AA, read AA literature, and go to AA meetings at the institution or outside. AA members visit the institution and talk about their personal ex- periences. Key positions in the treatment personnel are often held by recovering alcoholics who are doctors, psychologists, nurses, and particularly, so-called alcoholism counselors. The latter are recovering alcoholics with varying degrees of formal training. In the course of the institutional program, the patient goes through the first four to five Steps of AA. A common formulation is that institutional 12-step treatment is an introduction to AA, where the real recovery should take place. (Mäkelä et al., 1996, p. 195)
This closely jibes with descriptions by former clients of 12-step treatment. One such client described his 35-day stay in a "Minnesota Model"9 12-step treatment facility to me as follows: "We'd get up in the morning, do calisthenics, eat breakfast, and then go to group therapy, which was basically working the steps. After lunch, we'd have a lecture [in which 12-step/disease-concept ideology was presented as established fact], and then after dinner, we'd go to an AA meet- ing." This is a relatively benign description.
Another former client, a physician, describes her stay in a 12-step inpatient facility in darker terms:
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 . . . 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.10 (Bartlett, 1997, pp. 4 5)
This then is 12-step inpatient treatment. Twelve-step outpatient treatment is essentially a watered-down version of 12-step inpatient treatment: counseling sessions with 12-step professionals and para- professionals, the purpose of which is to badger clients into over- coming their "denial," accepting the disease concept, "working the steps," and participating in AA (or NA) meetings; and for some coerced clients that means "90 meetings in 90 days." The authors of a study of 12-step outpatient drug treatment describe it as follows:
Patients were counseled that cocaine addiction was a treatable but incurable disease. They were asked to attend at least one self-help meeting every week in addition to their regularly scheduled sessions. The regularly scheduled sessions consisted of both supportive and confrontative therapy, didactic lectures, and videos on cocaine dependence, AIDS, the disease model of addiction, and the self-help orientation. During the ninth week of treatment patients were asked to bring a family member to treatment to address family issues emanating from addiction. In the latter weeks of treatment, an aftercare plan was developed and counseling was provided on relapse prevention based on the 12-step model. Finally, patients were expected to identify a sponsor from a local self-help group [read CA or NA only 12-step groups have sponsors C.B.] by the final week of treatment. (Higgins et al., 1991, p. 1220)
This is a good description of normal 12-step outpatient treatment, and the 12-step treatment utilized in this study was in fact designed to be as typical as possible of what one would find at treatment facilities.
But what is the experience of 12-step treatment like for those coerced into it? Archie Brodsky and Stanton Peele describe a typical case, that of a married woman in her 50s called "Marie." She received a DUI citation after being stopped at a police checkpoint, and chose to pay $500 to attend 12-step outpatient 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 pro- gram, 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."(Brodsky & Peele, 1991, [On-line], p. 4)
Another story one of us (S.P.) recently received at his web site further illustrates the degrading effects of 12-step treatment and "aftercare" (AA or NA participation) on non-addicted alcohol and drug users:
About 3 months ago I took a hair drug test at work. The test showed positive for marijuana. I had been using marijuana for a few years and only used a small amount each night before bedtime. After having severe migraines for years I turned to it as a last resort (I had used Imitrex, Vicodin, among other painkillers almost daily and Covera HS) and it helped considerably, almost completely eliminating the mi- graines.
Upon failing the drug test I was subject to being terminated by my employer if I didn't enter an Employee Assistance Program. I had to go through a four-hours-a-day/four-days-a-week program for three weeks at a rehab facility, even though I still believe I was using the marijuana for relief of my migraines and sleeping disorders. I did not abuse the drug or use it recreationally.
After the hospital rehab program I've been forced to go to at least four AA meetings a week in order to be in compliance with my employer's EAP. People laughed at my marijuana habit at the first AA group I went to one guy told me, "In LA we used to smoke marijuana after our AA meetings." I went to another AA group and admitted I was a marijuana addict. Afterwards, a lady came up to me and said, "You should say you are an alcoholic, you will be accepted better." I told her I don't drink alcohol and never developed a taste for it because of my migraines. So now I'm going to my third group, where I just say I'm an addict so I will be accepted by the group.
After about ten meetings I became so depressed I lost all my energy and I just lay around and have gained 20 lbs. I'm single, and recently have found myself thinking that life is no longer worth living.
These descriptions of inpatient treatment, outpatient treatment, and aftercare are not unusual horror stories. Rather, they are typical of the experiences of the one million-plus Americans coerced into 12- step treatment and 12-step groups every year.
Given the nature of 12-step treatment and 12-step groups, their results aren't terribly surprising.