G. Douglas Talbott is a physician and recovering alcoholic. He has been one of the most forceful voices perhaps the most forceful in American medicine in advocating the recognition of alcoholism as a disease à la the AA and 12-step approach. Moreover, he has been a pioneer in educating physicians about substance abuse problems, and in offering substance abuse care to them. In particular, he has emphasized the need to confront doctors with such problems and to compel them to enter treatment.
Talbott has used several mechanisms to accomplish this. He organized and has been a prominent member of the American Society of Addiction Medicine (ASAM, 1999), "the nation's medical specialty society dedicated to educating physicians and improving the treatment of individuals suffering from alcoholism or other addictions." Addiction medicine is not a recognized specialty, so one of ASAM's goals is to "establish addiction medicine as a specialty recognized by the American Board of Medical Specialties."
Talbott was President of ASAM from 1997 to 1999, when (in April of 1999) he took office as immediate Past President. But his involvement with the organization is more fundamental than his official positions alone would indicate. After graduating from Columbia Medical School in 1949 and completing his residency program in 1953, Talbott served three years in the U.S. Air Force during the Korean War. In 1956, he returned to his hometown of Dayton, Ohio, where he entered private practice in internal medicine and cardiology. In 1969, Talbott switched into the field of addiction medicine (presumably, in good part, because of drug and alcohol problems he has admitted). In 1971, he became medical director of the Baltimore Public Inebriate Program for skid row alcoholics, following which he created an alcohol and drug program at DeKalb General Hospital for DeKalb County (Georgia) and the city of Atlanta.
Talbott was also a formative figure in the AMA's Impaired Physicians Program. This led Talbott to create the DeKalb County Impaired Physicians Committee, which became the official program for the Medical Association of Georgia. This program then became a national model for treating impaired physicians and other health professionals. In 1976, he entered the private treatment business with a program he created at Ridgeview Institute, also in metropolitan Atlanta. Talbott was central in the founding of the American Society of Addiction Medicine in 1988. Later, he was co-founder of the Talbott Recovery Campus in 1989. This campus serves as a National Impaired Health Professionals Treatment Program for physicians, nurses, dentists, pharmacists, and health therapists. In addition to his offices in ASAM, Douglas Talbott is medical director of the Talbott Recovery Campus. (Talbott's biography is available at the Talbott Recovery Campus, 1999, web site.)
From the start, Talbott and his treatment program's insistence on confrontational techniques raised questions, although rarely from within the addiction medicine field. In one four-year period, according to the Atlanta Journal and Constitution, five health care professionals committed suicide at Ridgeview (Durcanin, 1987). But this was only the tip of the iceberg; according to the paper (Durcanin & King, 1987): "At least 20 doctors, nurses and other health professionals who have gone through the Ridgeview Institute's nationally acclaimed treatment program over the past 12 years have killed themselves since leaving the hospital. . . ." In 1987, a jury awarded $1.3 million to the widow of one of the deceased physicians against Ridgeview and Dr. James W. Blevins, a staff psychiatrist, although a Superior Court judge later set aside the verdict (Ricks, 1987). Other suits initiated on behalf of the suicides were settled out of court (Durcanin, 1987).
Another article in a four-part series in the Journal and Constitution (King & Durcanin, 1987a) noted that the Ridgeview hospital had removed Talbott as director of the addiction treatment program he founded. Some questioned the tough philosophy Talbott practiced. For his part, Talbott defended his confrontational approach: "Every physician I've got here thinks he's his own doctor," said Talbott. "I tell them if that's the case they've got a fool for a patient." The article continues, "'I'm not much for the bullying that goes along with some of these programs,' said Dr. LeClair Bissell. . . ." Bissell, a psychiatrist who has written about and administered programs for impaired physicians and nurses, was one of the few who wasn't afraid to speak her mind about Talbott and his approach: "When you've got them by the license, that's pretty strong leverage. You shouldn't have to pound on them so much. You could be asking for trouble."
Another article in the series (King & Durcanin, 1987b) reported that doctors entered the treatment program because of threats that they would lose their licenses, "even when they would prefer treatment that is cheaper and closer to home. . . . Ridgeview also enjoys unparalleled connections with many local and state medical societies that work with troubled doctors to save their licenses. Their membership often includes physicians who themselves have successfully completed Ridgeview's program. Licensing boards often seek recommendations from such groups in devising an approved treatment plan for a troubled physician. And that is how many such doctors wind up at Ridgeview." The cost of a 28-day program for nonprofessionals at Ridgeview in 1987 was $10,000 (compared with $6,000 for the Betty Ford Center and $4,300 for Hazelden), while the cost was "higher for those going through impaired-health professionals programs," which lasted months rather than 28 days (Durcanin & King, 1987).
Physicians who questioned the Talbott-Ridgeview method faced serious trouble. "One South Georgia physician who decided to seek treatment elsewhere wound up in a protracted battle for his license. 'I refused to humble to Ridgeview,' said the physician. 'Back then no one had ever fought Ridgeview, but I did and it cost me four years before my license was reinstated'" (King & Durcanin, 1987b). Talbott, of course, felt there was no problem: "[W]e know more about impaired professionals than anyone else." But some experts in the field say the threat of losing licenses amounts to intimidation. "There's a lot of debate in the field over whether treatment imposed by threats is worthwhile," according to Bissell. "To a large degree a person has to seek the treatment on his own accord before it will work for him."
Another Talbott-Ridgeview method for dealing with doctors who expressed a desire to map an independent path was to expel them. "For instance, a Virginia therapist was asked to leave on the 25th day of the 28-day program after she told her physician she wanted to complete the second phase of a rehabilitation program closer to home. On the 27th day of the program, a retired Maryland physician was given 90 minutes to leave the hospital. 'If anyone was ever going to kill himself over something, it would be the shock of someone coming up to you and saying you're out now,' he said. 'If they had picked the wrong person, they could have really set someone off'" (King & Durcanin, 1987b).
Accusations against Talbott and programs in Georgia with which he was associated were not limited to patients. In an extremely serious charge, Dr. Paul G. Cohen asserted that Talbott and doctors at Northside Hospital began alleging in 1982 that he had an alcohol or drug problem. Their reason for doing so, according to a suit he brought, was that he "repeatedly found fault with doctors or the hospital over deficiencies in patient care. . . . Dr. Cohen claims in the suit, which specifies no monetary damages, that he underwent at least five psychiatric evaluations and more than 30 drug tests, and none showed any addiction to alcohol or drugs" (McIntosh, 1989).
Talbott regards doctors as overly impressed with themselves and their ability to heal themselves, a view he took special satisfaction in rooting out of his patients. "Talbott said the sessions, which are often highly emotional, are designed to force patients to admit their addiction and to talk about their problems instead of bottling them up inside. They go a long way, he said, toward destroying the 'M.D.eity' of impaired physicians the feeling that they are unique, invulnerable to addiction, and capable of curing themselves. . . . Impaired doctors must first acknowledge their addiction and overcome their 'terminal uniqueness' before they can deal with a drug or alcohol problem, he said. 'Terminal uniqueness' is the phrase Talbott's group uses to describe doctors' tendency to think they can heal themselves" (King & Durcanin, 1987a).
This attitude, according to some critics, stems from the personal histories of the treatment staff, including Talbott. One such critic was Assistant Surgeon General John C. Duffy, who was a pioneer in addressing impaired physicians. "Duffy, who has followed the Ridgeview approach for years, said the hospital suffers from a 'boot-camp mentality' when it comes to treating alcoholic and drug-addicted physicians. . . . He blames the program's attitude, in part, on the fact that former addicts are at the helm of the treatment program. . . . 'They assume every physician suffering from substance abuse is the same lying, stealing, cheating, manipulating individual they were when they had the illness. Certainly some physicians are manipulative, but it's naive to label all physicians with these problems'" (Durcanin & King, 1987).
"Talbott himself is no stranger to the problems of impaired physicians. His own addiction to alcohol and drugs led to the disintegration of a successful career as a cardiologist in Dayton, Ohio, and the near destruction of his marriage and family. After overcoming his addiction, he founded the program that to this day relies heavily on elements of the Alcoholics Anonymous philosophy. Talbott is no stranger to the dangers of suicide, either. In 1981, a Little Rock, Arkansas psychiatrist, Dr. Martha Morrison, attempted to kill herself shortly after entering the Ridgeview program. The attempt failed when the belt she was using snapped while she was trying to hang herself from a tree on the hospital grounds. Dr. Morrison went on to become the director of Ridgeview's programs for addicted adolescents. She also married Douglas Talbott Jr." (King & Durcanin, 1987a).
Obviously, key members of Talbott's staff are dedicated beyond question to his approach. And Talbott himself brooks no opposition to the AA/12-step model. In an interview on impaired physicians, in response to the question, "Is Alcoholics Anonymous essential for physicians, nurses, and other health professionals?" Talbott responded, "Of course it is" (Physicians for Prevention, 1999).
For well over a decade there have been many danger signs that Talbott and his colleagues are true believers verging on zealots who have no real respect for their patients' points of view or alternative approaches to drinking problems. They have shown themselves more than willing to rely on coercion and threats to get and keep patients in their program. Yet surprisingly little opposition has been raised within the field to Talbott, his program, or his approach. Well after the series of suicides and newspaper analyses of Talbott's single-minded treatment style, he was elected president of ASAM in 1997. There were no signs that he was ever called to task professionally for what seems to be his complete disregard for ethical and legal principles such as informed consent. This concept, which is imbedded in the ASAM's (1999) Principles of Medical Ethics, requires that a physician allow prospective patients to choose their treatment freely, other than in exceptional life-threatening emergencies (see Chapter 5 and Appendix A).
In part, Talbott was protected by the fact that it was exceedingly difficult for a physician to challenge him or his program. Given that physicians and other health professionals were referred to the program under threat of revocation of their licenses, it was rare that a doctor would challenge the treatment. Even after physicians left the program, there was little to be gained from challenging its value or its methods.
Dr. Leonard Masters of Jacksonville, Florida, and his wife sued "Talbott Recovery [which Talbott established in 1989 after leaving Ridgeview], its founder, Dr. G. Douglas Talbott, Anchor Hospital and 13 others, including doctors and counselors who treated Masters during his hospitalization and treatment center stay" (Ursery, 1999a). The elements of Masters' suit resemble complaints lodged against Talbott's program at Ridgeview, to which Talbott and colleagues claimed they had responded with adjustments in their program. Whether or not the Ridgeview suicides and Talbott's take-no-prisoners approach were related, the Masters' suit certainly challenged whether Talbott practiced in accordance with ASAM's Principles of Medical Ethics.
Masters admitted to being a fairly heavy drinker, saying that "he drank a fifth of scotch . . . plus four or five glasses of wine a week" (Ursery, 1999a). But no one ever reported him for having a drinking problem, according to his attorneys, "not his friends, not his wife, not his seven children, not his fellow doctors, not his employees, not his employers. No one." Talbott and the other defendants did not contradict this testimony. Rather, both sides agreed, Masters wound up in treatment after a physician who had attended the Talbott program, and who headed the Florida Physicians Recovery Network, referred Masters for an evaluation. Masters was told "he'd been accused of prescribing too many narcotics to his chronic pain patients." The physician "told Masters that he could either surrender his medical license until he could disprove the allegations or go to Anchor in Atlanta for a 96-hour evaluation."
However, once at the Anchor Hospital, Masters was quickly assessed as being alcohol dependent and was immersed in four months of treatment in the Talbott Recovery System. Masters described how he told inmates at Anchor Hospital he was only there for an evaluation: "Two patients laughed when Masters mentioned he'd be going home soon," according to his attorney (Sibley, 1999). Furthermore, "family members, employees and longtime friends, including his first wife, testified they were stunned at the diagnosis" (Sibley, 1999). Masters' attorney said he "was afraid to leave the program because 'if any doctor dared to dispute the team's diagnosis, if they wanted to leave and go home, or even consent to get treatment in their home state,' Talbott Recovery personnel 'would threaten to report that doctor to his or her state board of medicine . . . as being an impaired physician, leaving necessary treatment against medical advice'" (Ursery, 1999a).
In other words, Masters experienced exactly the same coercive techniques that Talbott's Ridgeview program had been accused of years earlier. Other physician patients in Talbott's program testified on behalf of Masters. The transcripts of Masters v. Talbott (1994) were sealed. This could have been due to the terms of the settlement, but it probably also was in part to protect witnesses who testified that their medical licenses were threatened or suspended by Talbott and his organization.
On his release, Masters was forced to sign a five-year continuing care contract, which included attendance at AA. Masters actually attended these meetings and "admitted" he was an alcoholic. This and other evidence was used by the defense to show that, initially, Masters bought into his own diagnosis. A key witness for Masters was Dr. Anne Geller, former director of the Smithers Institute in New York City and president of ASAM prior to Talbott! Geller testified that the Talbott program's diagnosis of alcohol dependence against Masters deviated from the professional standard of care. While Masters was a heavy drinker, he showed no signs of withdrawal, loss of control, or other life detriments from his drinking required for a diagnosis of alcohol dependence (Ursery, 1999a).
In May 1999, the jury awarded Masters $1.3 million in actual, or compensatory, damages. (He had asked for $930,000 before trial.) Before the jury could reach a figure for punitive damages, however, the defendants settled on this aspect of the judgment. The punitive figure might easily have exceeded the compensatory damages. The jurors found Drs. G. Douglas Talbott and his daughter-in-law, Martha A. Morrison, liable for fraud in the form of breach of fiduciary duty. A finding of fraud obligated the jurors to decide that the defendants had acted intentionally. The jury also found "that at least one of three doctors . . . Talbott, Dr. James W. Blevins [a recovering alcoholic whom a jury had earlier found liable in a Talbott patient's suicide] and Dr. John P. Keppler misdiagnosed Masters as an alcoholic," which amounted to malpractice. Talbott and Keppler were also liable for a novel claim for false imprisonment. No specific charges were related to the defendants' failure to provide informed consent, although potentially this could have contributed to the malpractice finding (see Chapter 5). Since the jury found that Talbott and Morrison were agents of Anchor Hospital and Talbott Recovery Systems, these two institutional defendants were liable for damages as well (Ursery, 1999b).
Talbott and His Followers Are True Believers
Notwithstanding the jury's finding of fraud in Masters v. Talbott, and that Talbott and his colleagues, as well as associated programs and institutions, profited greatly from these practices, their actions are best understood as expressions of a genuine belief system. In a sense, this makes Talbott and his associates much more frightening.
They could strike out at physicians, like Dr. Cohen, who question any aspect of the care they provide. More directly, Talbott, Morrison, Blevins, et al. felt that patients had to follow the 12-step precepts of confession and contrition in order to get better, because they themselves had succeeded by using this method. If the targeted person doesn't own up, professionals like these believe, they are justified in applying indeed obligated to apply a range of coercive techniques, from peer group pressure to the threat of licensure action. In this way, Talbott and his co-defendants were not acting as health care professionals; they were too emotionally involved to exercise sound and objective clinical judgment.
Patients Themselves Often Take On the Addict Identity
Masters admitted attending AA and standing up in front of others to say he was an alcoholic. Indeed, at the Anchor Hospital, Masters reported that, in alcoholism treatment groups, he broke down. "I was no longer me," he testified (Ursery, 1999b). This type of response is to be expected when individuals are isolated, separated from their families, and subjected to repeated group and therapist pressure to identify themselves as alcoholics. (Masters eventually resumed drinking, but at a much reduced level.)
Talbott's Practices Are Widely Accepted in the Field
Talbott and his program are certainly not alone in their insistence that patients admit that they are alcoholics or addicts against their own better judgment and that they enter a 12-step program; this is standard practice in the field. Nor is Talbott likely to be alone in his excesses. Sharkey (1994) described rampant hard-selling techniques up to and including physical force to recruit patients. Among others, he related the case of resident anesthesiologist Ronald L. Hedderich, who was reported for drug abuse based on his irascible personality in the operating room. (Missing morphine played a part in the accusation, but the missing drug was soon located.) Hedderich was "repeatedly confronted" with the demand that he either admit his drug addiction or lose his residency. He was then driven directly to an inpatient treatment facility for an assessment. Although all drug tests were negative, Hedderich could not escape the hospital and a vague diagnosis of "opioid abuse unspec." Hedderich left the hospital later against advice and sued; the defendants denied his allegations, and the case was settled out of court. Like laws allowing police to confiscate property of suspected drug dealers, the treatment system requires innocent people to prove that they are not guilty. Although reformers look to treatment as a humane way to ameliorate the effects of unjust drug laws, it is among the most individuality- and freedom-denying mechanisms in our society.
The Deck Is Stacked Against Licensed Professionals Charged with Substance Abuse
Masters' damages occurred because he lost his job while he was in treatment in 1992; but he retired in 1994. Most doctors accused of substance abuse problems are obviously earlier in their careers and have more to lose. For these and other health care professionals, the costs of challenging a treatment program and the consequences likely to be imposed by their medical board or licensing body are typically prohibitive. Thus most such individuals simply bite the bullet and play the role of recovering alcoholic, as demanded of them. Likewise, airline and ship pilots whose careers and livelihoods can be destroyed by the action of a licensing body have little leeway to challenge the decisions of treatment providers, no matter how irrational these are (see Appendix A). Nonetheless, this book is based on the idea that reason, law, and science can and do make a difference, and that it is worth standing up for oneself and making a case for reasonable therapeutic and professional treatment.
Addiction Medicine Providers Do Not Care About Issues of Informed Consent, Ethics, and Individual Choice
ASAM's volume, Principles of Addiction Medicine (Graham & Schultz, 1998), while including a chapter on recovery for health professionals by Talbott and others (Angres et al., 1998), devotes no space to informed consent or other ethical principles that are commonly violated by addiction professionals. And, while it remains to be seen how ASAM and related professionals respond to this latest revelation about addiction treatment Enoch Gordis, director of the National Institute on Alcohol Abuse and Alcoholism, and Alan Leshner, Director of the National Institute on Drug Abuse, wrote introductions to the ASAM volume such leading figures have never yet come forward to criticize member misconduct or ethical deficiencies in their field. We should note, however, such courageous exceptions as Drs. Anne Geller and the irrepressible LeClair Bissell.
ASAM's (1992) Principles of Medical Ethics Are Meaningless
A thoroughgoing review of physician conduct with respect to ASAM's (1992) ethical principles is outlined in Appendix A. These principles state: "Addictionists should treat individuals only with their consent, except in emergency and extraordinary circumstances in which the patient cannot give consent and in which the withholding of treatment would have permanent and significant consequences for life and health." But how has ASAM maintained these principles in regard to the actions of its own president, even as he openly denies their validity in his treatment philosophy and his program's actions? Similarly, other violations of ASAM's stated principles such as that the patient is to be treated with respect, "regardless of possible conflicts in values between patient and physician" are the rule in addiction treatment. What's more, the principles note that the physician has a duty to uphold patient rights while working in an inter-disciplinary team and "should not delegate to any nonmedical person any matter requiring the exercise of professional medical judgment," but ASAM physicians typically hand off patients to recovering alcoholism counselors (that is, to AA or NA members with little if any medical training).
The answer to these abuses may be that, as demonstrated in Masters v. Talbott, juries can respond to the blatant violations of individual rights, medical principles, and therapeutic responsibility that pervade American addiction practice. Multimillion-dollar judgments may be the only argument that true-believing, coercive "addictionists" will understand.
ASAM has not yet (as of November, 1999) communicated to its members any concerns about or changes in the practice of addiction medicine based on the Talbott case judgment. It may be that, just as occurred after the Ridgeview Institute suicides were revealed, Talbott and the entire addictions field will proceed as usual.