Introduction

I am currently the President of the American Psychological Association's Division on Addictions (Division 50), the world's largest organization of addictive behavior psychologists. Unfortunately, even though the research conducted by the members of our Division and other psychologists forms most of the scientific foundation for addic- tion treatment, in practice scientific knowledge has little impact on addiction treatment in the United States, and psychologists typically play a small role in addiction treatment. Instead, we have a treatment system which is almost entirely based on an approach that has little evidence of success, and which attempts to treat human diversity with a one-size-fits-all approach. This approach is implemented primarily by drug and alcohol counselors who have far less training than psychologists or other mental health professionals.

Perhaps you have picked up this book because you are already familiar with how U.S. residents are coerced into 12-step groups (such as Alcoholics Anonymous) and into 12-step treatment. Even if you have not fully appreciated the irrationality and enormity of 12-step coercion, you probably have at least an intuitive sense that this coercion is wrong in several ways. If you're uncertain about this, it's understandable don't almost all addiction professionals insist that 12-step recovery is the only approach that works?

This book can help to resolve any uncertainty you may have about mandated attendance in 12-step groups and 12-step treatment. Resisting 12-Step Coercion will explain in detail (with thorough docu- mentation) how frequently 12-step coercion occurs, how and why it can be damaging, and how to prevent or resist it in practical ways. The material presented here will enable individuals faced with such coercion not only to evaluate their options, but also to understand what recourse they have in fighting imposed 12-step treatment.

This information is presented efficiently, yet with deep appreci- ation for the sufferings caused by 12-step coercion. When individuals become subject to coercive judicial or treatment systems, they are likely to be especially confused, self-doubting, and vulnerable. Great damage can be done at such times times which call for careful assessment and options.

The authors offer a number of qualifications to their argument, and these are worth introducing here. Unless adjudicated incompe- tent, individuals are and should be held fully responsible for their behavior. Individuals should be free to choose to enter 12-step groups and 12-step treatment just as they should be free to choose other self-help groups and treatments (or no treatment at all). What the U.S. needs is not to pare down existing treatment options, but to expand these options and to provide equal access to a variety of approaches, particularly those that have solid evidence of effec- tiveness. AA's spiritual approach is neither proven nor disproven by scientific study, nor is any other set of spiritual or religious beliefs; such beliefs are a separate matter from science. The central precepts of the disease concept of alcoholism have already been refuted or remain unconfirmed. In addition to its lack of scientific basis, there are also powerful public health arguments to be made for jettisoning the disease hypothesis the foundation of 12-step treatment as a basis of public policy.

I would add that whatever success does occur through 12-step attendance may be based more on the experience of social support than on "working the steps." Although for some working the steps may be the only road to success, the number of such individuals is probably very small. Most individuals would benefit from a variety of approaches, because, to simplify, success may be based more on making the decision to change than on the kind of help obtained after that decision. Nevertheless, getting help that reinforces the decision to change can be very beneficial, and can help to reduce the high relapse rates typical of all addictive behaviors. A substance- abusing individual needs careful personal (and possibly professional) assessment and information about a range of options, not dogma.

The primary responsibility for the current state of affairs in addic- tion treatment lies with present treatment providers, who continue to misinform the public about the diversity and effectiveness of treat- ment and support groups. In October, 1998, my associate Jeff Jones, CDAC, and I conducted a survey of San Diego alcohol providers (Horvath, 1999). In essence, we asked them where we could refer someone who clearly had problems from drinking, but who unequivo- cally did not want to attend AA. Forty-five percent stated that AA was the only approach, 47% stated that there were other approaches but that they were not effective, and only 8% (3 out of 38) got it right: there are alternative approaches and they can be helpful. In my own treatment center, Practical Recovery Services, estab- lished in 1985, the matching of services to clients is the highest priority. We view our role as aiding a naturally occurring recovery process, and not as providing something without which the client would end up dead or in an institution. We use empirically supported treatments, or elements of them, as described in Chapter 2 of this book, as well as other psychological change techniques. Treatment is a collaborative dialogue based on the individual's unique needs and state-of-the-science techniques for behavior change that identifies addiction (and related) problems, and practical solutions for these problems.

SMART Recovery is an alternative support group (see Appendix B) which I feel privileged to serve, currently as president. SMART's volunteer meeting leaders offer support groups which focus on teaching participants how to build and maintain motivation, identify and cope with cravings, resolve old problems in new ways (rather than relying on addictive behavior), and build a balanced lifestyle (in order to prevent relapse). Rather than tell newcomers that "we are the only thing that works," we encourage them to attend a few meet- ings, try our methods, read our publications, and return if they find them helpful. We assume that individuals are competent to determine if SMART Recovery would likely be of help to them.

Managed care has had mixed results in changing addiction treat- ment. The overemphasis on inpatient treatment that was prevalent one to two decades ago has now stopped, and has been replaced with an emphasis on outpatient treatment. This has been good for most insured persons, although saving money rather than the insureds' welfare would appear to have been the insurance companies' primary motive.

But the 12-step approach is still dominant. Even the prospect of saving money has not overcome deeply ingrained practices. I have had several clients who requested and seemed likely to benefit from a short course of individual psychotherapy sessions of the type that have been well tested in the scientific literature. However, their case managers "knew" that an individual with moderate addiction prob- lems could only benefit from an outpatient program which consisted of multiple weekly meetings for several months, and which was of course 12-step oriented. It did not matter that the program cost three times what I was proposing or that the program had little evidence of efficacy (vs. the references I provided for mine). Nor did it matter that the time requirements of the program were completely impracti- cal for these particular individuals. If attempted, the 12-step out- patient program would have required undoing much of the clients' lives, in both their positive and negative aspects, rather than undoing the negatives while building on the positives. In the end, the clients became frustrated and left treatment, and precious moments of moti- vation were lost.

Stanton Peele, Charles Bufe, and Archie Brodsky have long been advocates for truth in the addiction field. Among them they have written over 20 books on various aspects of addiction and its treat- ment, beginning with Peele and Brodsky's 1975 classic, Love and Addiction. Bufe has also built See Sharp Press, a publishing house that presents addiction works that might not otherwise be seen. Without their leadership we would be much further behind than we are today. It is exciting to see them now present the information necessary to bring about what I believe is the single most needed change in the U.S. addiction treatment system: guaranteeing informed consent and choice of treatment and support groups. As the authors point out, this freedom of choice, like so many freedoms, will likely not be granted at first request. They provide here the rationale and tools for those who are willing to fight for it.

A. Thomas Horvath, Ph.D., FAClinP

President, Practical Recovery Services, La Jolla (San Diego), CA www.practicalrecovery.com
President, 1999-2000, Division on Addictions, American Psychological Association
President, SMART Recovery
Author of Sex, Drugs, Gambling and Chocolate: A Workbook for Overcoming Addictions (1999)