Changing the Signs on the
Doors
Peter Webster
vignes@monaco.mcCopyright 2001
International Journal of Drug Policy
[for copyright reasons,
prepublication version follows]
a commentary and review of:
Resisting
12-Step Coercion: How to Fight Forced Participation
in AA,
NA, or 12-Step Treatment
Stanton Peele, PhD, JD, and Charles Bufe, with
Archie Brodsky
See Sharp Press: Tucson, Arizona, 2000 ISBN
1-884365-17-5
In the foreword to Resisting 12-Step Coercion co-author
Charles Bufe notes
that in the United States there are annually between one
and
one-and-one-half million persons forced by the courts into 12-step
treatment programs such as Alcoholics Anonymous, Narcotics Anonymous,
Marijuana Anonymous and other such carbon-copy organisations. Yet in the
introduction to the book, A. Thomas Horvath, President of the American
Psychological Association's Division on Addictions, laments that
"scientific knowledge has little impact on addiction treatment in the
United States.. [W]e have a treatment system which is almost entirely based
on an approach that has little evidence of success."
Drug War
reformers in the U.S. have nevertheless been actively campaigning
for
'treatment not incarceration', and even former Drug Czar McCaffrey and
the
U.S. Office of National Drug Control Policy have echoed the mantra in
response to increasing criticism of policies which have imprisoned millions
of non-violent drug-law offenders, strangled the justice system, and
produced widespread abuse and corruption in law-enforcement and prison
management. A major theme of Resisting 12-Step Coercion makes clear,
however, that the 'treatment' alternative being promoted is not voluntary,
informed-consent procedure such as is required by both law and ethics for
medical treatments in general, nor does this 'treatment' consist of a
scientifically-justified range of medical and/or psychiatric techniques,
but primarily a coerced diversion of those who would otherwise be destined
for prison to an alternative that may be as ethically dubious and
counterproductive as imprisonment itself.
Public opinion has also
jumped aboard the bandwagon. The November 2000
California election
referendum, Proposition 36, won a landslide victory
despite negative
editorials and dire warnings from politicians,
prosecutors, judges, prison
guards, and law-enforcement. The bill mandates
the 'treatment not
incarceration' paradigm in a state which has been
spending more on
imprisonment than higher education, (a propaganda
sound-bite widely used to
garner support for the initiative). The
strongly-supported nation-wide 'Drug
Court' system has similarly promoted
the new paradigm for dealing with drug
arrestees, providing them with the
'choice' of 'treatment' over prison.1 The
movement has grown mostly as a
response to the paralysis of justice brought
about by wildly increasing
numbers of drug cases on court dockets
everywhere.
While it may be obvious how U.S. conservatives,
arch-prohibitionists, and
the religious right can be comfortable
substituting one coercion for
another and calling it reform, and obvious as
well that public opinion can
often be stampeded in practically any direction
at all, the wisdom of the
leading reform organisations in joining this
movement is far from obvious.
In many instances it seems, reform leaders
have jumped on the treatment
bandwagon for the perception that it remains
politically out-of-bounds to
direct an attack on the core problem itself,
Substance Prohibition.
Although self-elected treatment or counselling for
drug problems should
obviously be much more widely available than at
present, and it is surely
utter folly and morally repugnant if not
criminal to imprison people
merely for their bad habits, investing the
major part of the American
public's recent willingness to reconsider drug
policy into an avenue that
retains coercion and provides an alternative that
is conspicuously lacking
in support from scientific research seems a poor if
not dangerous
strategy. For the larger reform movement the existence
of many respected
individuals who do argue for ending Prohibition such
as Governor Johnson
of New Mexico, William F. Buckley, Milton Friedman,
Thomas Szasz and many
others seems merely to provide a necessary
perceived extreme to balance
radical prohibitionism in the ongoing
propaganda and public opinion war,
supposedly legitimising the middle-ground
of 'moderate reform'.
Concerning the passage of Proposition 36 in
California, which can be seen
as the trend-setting legislation for the
treatment paradigm, Ethan
Nadelmann of The Lindesmith Center commented in
the Alameda Times-Star
(December 2, 2000):
"In California, voters
overwhelmingly endorsed Proposition 36, the
"treatment instead of
incarceration" ballot initiative that should result
in tens of thousands of
nonviolent drug-possession offenders being diverted
from jail and prison
into programs that may help them get their lives
together. The new law may
do more to reverse the unnecessary incarceration
of nonviolent citizens than
any other law enacted anywhere in the country
in decades."
Joseph D.
McNamara, retired police chief of San Jose, California, also a
leading Drug
War critic, wrote even more glowingly of Proposition 36 in the
San Jose
Mercury News, (November 26, 2000)
"Some day, I believe, the passage of
Proposition 36 may be compared to the
collapse of the Soviet Union and the
tearing down of the Berlin Wall..
Proposition 36 and other drug-ballot
initiatives passed by American voters
during recent years are signals of a
similar erosion, signs that the public
commitment to the "war on drugs" is
deteriorating.."
Many news columnists of note have also published opinion
pieces lauding the
public's wisdom for approving the 'treatment not
incarceration' measure and
congratulating the public for being way ahead of
the politicians on drug
policy reform. To what extent reform leaders see the
tactic as merely a
convenient way to get a foot in the door of the monstrous
edifice of
Substance Prohibition, or whether some or many of them genuinely
view the
new paradigm as an avenue of significant social progress is not
clear. From
the frying pan into the fire, I say. Mandating treatment rather
than prison
while failing to examine the raison d'être, the motives,
techniques, and
failure rate of the 'treatment industry', may well lead to
folly as great
and destructive as Substance Prohibition itself.
If
there are now a million or more coerced into ineffective and often
dehumanising 'treatment' yearly in the U.S., what will the figure be
when
the new paradigm takes hold nation-wide? Are we to assume that casual
users
and small-time 'dealers' of marijuana who now make up the great
majority of
drug-law arrestees will be forced into months or years of
quasi-religious
12-step programs, demanding of them admissions of
powerlessness over their
'addictions', and pledges to a 'higher power' for
eternal abstinence from
using a substance less addictive than chocolate or
coffee and far less
harmful than cigarettes? Millions smoke cannabis because
it is enjoyable,
or medically, socially or artistically useful to
them, and imprisoning
such 'criminals' is very close to being seen by world
opinion as a gross
error and injustice, if not crime against humanity.
Calling such people
'addicts' and shunting them into 12-step programs may
yet be even more
sinister, for such 'medicalisation' of the 'problem' will
surely be a
setback, allowing the drug inquisitors to appear to have the
best interests
of society at heart, yet continue with their inquisition
unimpeded.
And considering that interrupting the supply of
nonviolent drug offenders
to prisons will depopulate them significantly, how
will all the shiny new
prisons be filled? How will the powerful prison guard
unions ensure the
livelihood of their members, the police drug-squads and
SWAT teams, and the
DEA continue to enjoy their overweening power and
bloated budgets? The
title of my essay may seem a kafkaesque answer to such
questions, but
looking back over many decades of unrelenting escalation of
U.S.
Prohibitionism, optimism of any sort for U.S. federal government
leadership
toward sane drug policy, or even non-interference toward
state-initiated
effective and humane drug policy seems woefully misplaced (I
am thinking
here of the strenuous federal efforts to block implementation of
medical
marijuana provisions passed in several states). 'Treatment not
incarceration' as national policy risks yet greater justification and
public approval for stigmatising and removing from society those whose
personal choices involve politically-incorrect, 'un-American' drugs, and
doing so in a way that seems 'medical' and scientifically justified. 'Until
these sick are cured, and can accept to live in the real world of
responsibilities and duties, we will out of the good of our own hearts
ensure that they get the treatment they need, for as long as it takes,'
seems a far more dangerous collective mind-set than 'lock them up so they
will know of our disapproval.' The lack of success for treatment noted by
Dr. Horvath above will merely confirm the necessity to continue to demonise
drug users ad infinitum, as the 'treatments' will accomplish little save to
pacify the public and political conscience of the nation. 'Even with our
best and most expensive treatments, they do not become cured'. The
Therapeutic State looms ever larger in America, let us be
warned:
"The therapeutic state is a totalitarian state all the more
so for masking
its tyranny as therapy."
--Thomas
Szasz
~~~~~~~~~~~~~~~~~~~~~~~~~
In Resisting 12-Step Coercion we
have what at first seems a self-help
manual for those unfortunate U.S.
citizens taking abuse from the business
end of the treatment paradigm.
Although the book is oriented toward
'treatment' stemming from court action
related to alcohol use and abuse, it
will be of similar value to the even
greater numbers of 'treatment'
candidates created by the proliferation of
drug courts and 'treatment
legislation' such as California's Proposition 36.
While it is surely a
handbook for the coerced, and a sourcebook for legal
representatives of the
coerced as well, drug policy reformers and
researchers should not be
misled: the self-help manual format of Resisting
12-Step Coercion is in
many ways also an effective vehicle for some powerful
and penetrating
analyses of what is wrong with U.S. substance-abuse policy
today. The book
should thus also be read as a self-help manual by those in
the drug-policy
reform movement in the U.S., showing them how and why the
current
'treatment not incarceration' strategy is a big mistake. And it
should be
read by Euro-reformers as an inside view of what is going on in
the U.S.,
as a warning of what is to come world-wide if we do little or
nothing to
repudiate U.S. 'leadership' on drug policy. The book's in-depth
examination
of the U.S. treatment industry, its history, methods, and
current status,
as well as a thorough de-bunking of the research which
supposedly supports
the treatment paradigm, should open the eyes of many to
what is surely an
impending disaster. In Stanton Peele's words, "[O]ur view
in writing this
book is that compulsory treatment is wrong and ineffective.
Our goal is to
support even to encourage individuals to resist
the therapeutic state. In
no area is its emergence once a
science-fiction topic, as in A Clockwork
Orange more real than in
present-day substance abuse treatment."
The arguments and examples in
Resisting 12-Step Coercion proceed at a
furious pace: By the end of the
Introduction by Thomas Horvath, the Preface
by Stanton Peele, and the
Foreword by Charles Bufe fourteen pages of text
in total I
was already in such a state of outrage about the folly of the
present 'rush
to treatment' that I doubted I would be able to review the
book
dispassionately. Chapter 1 lays the foundation for the book's goal of
exposing and resisting the looming Therapeutic State by providing an
overview of alcoholism and substance-abuse treatment in America, revealing
the sparseness of even common sense not to mention success other than
monetary in what has become a 'big business'. The arguments are
peppered
with examples of cases of coerced treatment as hair-raising as
tales from
other famous historical instances of state or religious power
gone haywire.
Here is but one typical case (pp. 42-42):
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 [driving under
the influence
of alcohol] 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 [driving whilst
intoxicated] 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."
In
spite of near-universal public and journalistic subscription in the U.S.
to
the idea of addiction as a medical disease, and institutions full of
Ph.D.'s
insisting there can be no other explanation, Peele and his
co-authors point
out in chapter 1 an important and curious fact: The
disease model of
addiction is not only the essential ideology of the
12-step treatment
industry, but largely a historical outgrowth of it. That
a supposedly
scientific theory of addiction should have its roots deep into
the
doctrinaire soil of a quasi-religious movement should arouse much
suspicion
about its truth and applicability, to say the least. The
chapter's brief
foray into the history of AA and 'addiction science'
undermines the
legitimacy of the entire discipline, for we see the central
tenets of the
disease model of addiction relentlessly exposed for what they
are:
mythology, and a blatant misuse of the terms and concepts of medical
science
for covert religious and moral purposes. The way is thus prepared
for the
following chapters in which 12-step programs are themselves
examined with a
withering scrutiny, and compared with little-used but far
more effective
methods for assisting those with substance abuse problems.
Chapter 2
reviews the extensive research on substance abuse treatment and
the efficacy
of 12-step regimes, and it is the evidence in this chapter
that puts into
perspective the current claims for the effectiveness of
treatment over
incarceration. The widely-quoted RAND studies, for instance,
have claimed
impressive results for treatment. The 1997 RAND study by
Rydell et al.
(Rydell 1997) is frequently mentioned: "Treatment was found
to be seven
times more cost-effective than domestic law enforcement, 10
times more
effective than interdiction, and 23 times more effective than
attacking
drugs at their source." (Massing 1998) Massing goes on to say,
"Every study
of drug treatment has arrived at the same conclusion: whatever
the type of
program or the drug involved, treatment produces impressive
reductions in
both drug consumption and criminal activity, at a relatively
low cost." (p.
51) The evidence presented by Peele and co-authors reveals
that either
Massing and other treatment mavens haven't read the research,
or do not
understand it.
Firstly, note that all instances of 'effective' should
more honestly read
'cost-effective' in the above quote, and this must
tarnish somewhat the
idea that the welfare of people is what is under study.
Even so, this
sounds like a powerful argument for Drug Courts, treatment
legislation, and
the treatment paradigm in general. Here is what Peele and
his co-authors
have to say: "We agree that imprisonment for drug use and/or
drug abuse is
a ridiculous and self-defeating policy, but to rate the
effectiveness of
treatment in comparison with a nonsensical policy is
meaningless." Of note
also is that if cost-effectiveness is the goal, such
studies ignore totally
what the projected cost-effectiveness of ending
Prohibition might be. The
money being spent on Prohibition is surely many
times over what would be
needed to provide self-elected treatment of all
sorts, religious or
otherwise, to all those who believed such treatment
could help them
overcome their personal bad habits, compulsions or
'addictions' to anything
under the sun. Considering the wealth of historical
evidence for the
self-defeating nature of prohibitions, it is a curious
ignorance on the
part of supposedly scientific studies to pretend that
Substance Prohibition
is a given, a part of the landscape of human existence
rather than a quite
recent aberration of societies and power structures gone
authoritarian and
Puritanical. The lack of scientific justification for
prohibitionist
policies is even more glaring than the lack of scientific
justification for
U.S. addiction treatment noted by Dr.
Horvath.
Ironically, substance abuse treatments that have shown
significant evidence
of success exist in the U.S., and these are compared
with 12-step methods
in chapter 2. But well above 90 percent of treatment
programs approved by
Drug Courts or treatment legislation are of the 12-step
variety, and it is
not an exaggeration to say that '12-step-ism' pervades
the entire treatment
industry. Peele provides a clue to the mystery:
'treatment' is very 'big
business,' to the tune of $10-billion-a-year, and
likely to grow even
bigger. And as the research presented in the book shows,
it seems for the
most part that treatment programs having the best rate of
success are the
cheapest and simplest! A look at meta-analyses of alcoholism
treatment in
the U.S. reveals that "expensive, commonly used treatments. (in
the U.S.,
read 12-step inpatient and outpatient treatment), were among the
least
effective.and.almost all of the therapies consistently supported in
studies
as effective, such as the community reinforcement approach, marital
therapy, and social skills training, were low cost or medium-low cost." As
with so much else in America today, 'follow the money' if you want to know
what is going on.
Chapter 3 establishes that AA and other 12-step
programs are doctrinaire,
religiously-oriented programs which can have no
scientific basis to justify
their predominance over other more effective
substance abuse treatments.
Both the history of AA and the organisational
and procedural details of its
present manifestation in many guises such as
Narcotics Anonymous, Cocaine
Anonymous, Marijuana Anonymous, et al., leave
no doubt about this. Chapter
4 provides a thorough review of U.S. court
cases involving forced
attendance at AA and its clones, with the goal of
providing legal leverage
for those facing such court mandated treatment.
Interestingly, four
higher-court decisions since 1996 have ruled that forced
12-step attendance
violates the First Amendment of the U.S. Constitution,
which forbids any
government body from requiring or encouraging religious
observance of any
type. Thus there would seem adequate precedent for
resisting coerced
12-step treatment, yet, as always in legal proceedings,
especially in the
U.S., the devil is in the detail, and it remains arduous
and time-consuming
to fight the system. And with regard to employer-mandated
treatment,
rapidly becoming a major source of treatment candidates for
12-step
programs, no such Constitutional protection applies. The summary of
chapter
4 provides good advice on how best to use court precedents and
decisions.
Chapter 5 examines the issue of informed consent, "missing in
action in
addiction treatment" as the title of the chapter claims. Although
the
principle of informed consent for medical treatment has become firmly
established in law as well as clinical ethics, Peele and Brodsky note that
it is almost completely ignored in addiction treatment. On the one hand we
hear widespread claims by doctors and researchers that addiction is a
'medical disease like any other' but when it comes to applying the accepted
principles and ethics of medicine to the 'disease', suddenly the treatments
can become compulsory and court-ordered, and need not have any scientific
proof of effectiveness! Peele and Brodsky attribute this irrational
situation to
"the ideologically charged nature of drug and alcohol
abuse/dependency.
Here the legal and ethical tenets of the clinical
professions, like their
scientific foundations, are honored in the breach
rather than the
observance. The failure to implement a true medical model
across the board
has occurred in part because the prevailing model of
addiction treatment in
the U.S. is primarily rooted not in science but in
religion, or in
quasi-religious "spiritual" folklore. As such, its
practitioners promote
it and it has largely been accepted as
received wisdom, not as an issue
for empirical study."
As the
arguments and examples in Resisting 12-Step Coercion adequately
demonstrate,
the state of 'addiction science' in the U.S. is such that it
resembles not
so much a science as a cult religion, and a not very
appealing or elevating
one at that. The post WW-II position of the U.S. as
world saviour and
economic engine of plenty undoubtedly contributes
strongly to the automatic
respect paid to its institutions and endeavours,
so much so that in
instances where U.S. leadership should be severely
questioned, mistrusted,
and even repudiated, often it is not. In no other
area is the lack of
questioning by world opinion more important to the
future of humanity than
in drug policy and its associated supporting
institutional establishments,
although we would not suspect this from
coverage provided in newspapers and
TV news or documentary broadcasts.
American style Prohibitionism has over
the space of a century infected the
perceptions and institutions of an
entire civilisation and made what surely
will someday be seen as an atrocity
seem normal, a stupidity of great
magnitude seem rational and
beneficial.
The presentation of evidence in Resisting 12-Step Coercion
gives the
impression of an important legal case being argued, and indeed,
chapter 7
is a "Summary of Legal and Clinical Objections to Compulsory AA,
12-Step,
and Abstinence Treatment" addressed to the 'Decision Makers' likely
to be
involved with mandating 'treatment' for substance-abuse arrestees. In
a
larger sense, this book might be considered an important legal argument in
the court of world opinion, and the necessary and obvious verdict, that the
U.S. has led us down a very dangerous road, must be delivered, and soon. As
Joseph D. McNamara recently said of U.S. drug policy (The Sacramento Bee,
26 December 2000),
"Either we are going to become a military
dictatorship or we are going to
get over this nonsense. In the long
run this is a policy that simply cannot
survive the test of
freedom."
Footnote
1. A recent news article indicates,
however, that 'treatment' regimes have
become so onerous a choice that many
choose instead to do time in prison.
An example is given of a drug user
facing either 90 days in the county jail
or three years of treatment and
probation "doing urine tests for dope month
after month stretching into
years, people looking over [my] shoulder,
messing in [my] business, waiting
for [me] to trip up again and send [me]
back to the courthouse where the
punishment will be even worse if [I] get
'revoked'." (Houston Press,
December 14, 2000, "Tough on Drugs: Prisons are
Filled with Users who Pick
Jail over Probation and Treatment.")
References
Massing,
Michael. The Fix. New York: Simon & Schuster, 1998.
Rydell, C.P.,
Caulkins, J.P., & Everingham, S.M.S. Enforcement or
Treatment? Modeling
the relative efficacy of alternatives for controlling
cocaine. Santa Monica,
California: RAND Corporation, 1997.