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Robert Todd Carroll

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substance abuse treatment

"The now tenacious attachment of the disease model and 12-step philosophy to caring behavior, commonly known as codependency, represents to me the most confusing, and iatrogenic ideas in the realm of clinical psychology." ----Robert Westermeyer, Ph.D.

Drug and alcohol abuse are evils often cited by law enforcement officials, politicians and religious leaders as so great as to threaten the survival of our society. Countless individuals worry continuously about their own and others' drinking or drug behaviors. Waiting to help all those with substance abuse "problems" are thousands of professionals in the "helping" professions. But are they really helping substance abusers? Or is substance abuse treatment (SAT) a racket designed primarily to make money or to promote some other selfish goal, with little regard for the health or well-being of patients? Or is it possible that SAT is a mixture of good and evil, much like the people it avers to help?

Criticizing those who profess to help substance abusers is unlikely to be welcomed either by those who see substance abuse as a subversive activity or by those who believe their own lives or the lives of loved ones are being destroyed by drugs or alcohol. Certainly, neither the psychologists, psychiatrists, interventionists and aids who work in treatment facilities, nor the owners and managers of such places, are likely to welcome criticism. Nevertheless, it is unconscionable to allow an industry to go unchecked simply because they claim to have good intentions. Remember Charles Dederich, who died recently, and his SAT, Synanon. In a little over twenty years, from the late '50s to 1980, Synanon grew to an authoritarian cult with perhaps between $30 million and $50 million in assets. His obituary in the Sacramento Bee reports that Dederich reportedly went way beyond SAT, destroying families instead of saving them. His empire collapsed when he pleaded no contest to a charge of conspiracy to commit murder. How do the Dederichs of the world get away with it? In his case, he was doing society's dirty business of helping drug addicts. To attack a person or an organization which is helping people is to show bad form and will generally be unrewarded. Unfortunately, this fact often gives the unscrupulous carte blanche to abuse the rest of us.


The road to Hell is paved with good intentions.



The goals of SAT may be noble, but that does not justify using any means necessary to achieve those goals. To allow treatment which denies a person his or her human as well as civil rights should not be tolerated. To treat people for questionable diseases should not be tolerated. To use therapeutic techniques with little or no substantive evidence for their effectiveness should not be tolerated. And while there may be many SAT programs which respect the basic humanity of their patients and which do a good and decent job of helping substance abusers, there are too many programs which are not being monitored by anyone and which, if exposed as going on in certain foreign countries, would probably count as human rights violations. Let me cite just one example.

In February of 1994, Tim Scanlon experienced an "intervention." A group of people, including his wife, a neighbor, his brother from another state, his sister-in-law from out of town, two of his wife's colleagues, a nun, a nephew and an interventionist greeted him in his neighbor's house where he thought he was going to celebrate a child's birthday. These people were not there to celebrate anything, however. They were there to convince Tim that he was an out-of-control alcoholic and needed to get professional help for his "problem." As Tim saw it, he had two choices: leave his wife and walk out or agree to check into a substance abuse treatment facility. He chose the latter, though he did not believe he had a drinking problem. Of course, he was "in denial." He would have to overcome that before he could get into "recovery."

Whether Tim drank too much or not, I can't say. But he did not get a chance to plead his case, whatever it might have been. There would be no hearing of his side of the story. In fact, there would be no time for him to even determine what his side of the story might be. The intervention was sprung on him out of the blue and he was given no time to prepare a defense. Not that it would have mattered; for, had he provided a defense, that would have been taken as proof of his being in "denial." The shock of the intervention, its humiliating aspects, the intimidation of numbers, all combine to prevent any sort of rational exploration of the situation. Those who have been called together to intervene are all prepped to make the case against Tim. If he had a case to argue, he would have been outnumbered and coerced into submission. His only alternative would be to walk out and not come back. He "chose" to go to a SAT facility, but his was a Hobson's choice.

While Tim was in treatment he met others who were there because they were trying to save their own marriages. He also met others who were less than impressed with their "interventionist." The interventionist is a paid professional. He or she is paid not for caring for the person they get admitted but for getting the person admitted. They take on the role of Grand Inquisitor and deliverer, rather than that of counselor. But what justifies such a position? Why are there interventionists at all? They're needed to assist families in convincing a loved one to seek treatment. They are there to offer professional support to those who want their loved one treated. But why do people need an outsider, a stranger, to help convince their loved one to seek treatment? Is it because the interventionist plays the role of the independent facilitator, professional and disinterested? If so, then the position is a fraud. For the interventionist is not independent, put paid for delivery of a live customer to the treatment facility.

The treatment facility which Tim went to was an upscale place: a mansion in Maryland, once owned by a politician and now owned by the wealthy co-founders of "Happy Valley," as Tim calls the place (after Wilfred Sheed's In Love with Daylight). Like many other SAT programs this one is based on the notion that alcoholism is a disease from which each of the patients is suffering. The cure is Alcoholic's Anonymous 12-step program. Those familiar with AA will recognize that the "disease" model of substance abuse contradicts the AA model of the weak-willed sinner who needs God's power to conquer the mighty forces of satanic booze. Of course, these clashing metaphors of the victim and the sinner are basically contradictory: the one makes the victim passive and not responsible for being an abuser; the other puts the burden of responsibility on the alcoholic. But it is a meager responsibility, since all the sinner must do to be redeemed is admit he or she is a sinner and turn oneself over to God. Contradictions apparently do not matter when your goal is noble, however. There are even some AA programs which give the nod to the "genetic disease" model of alcoholism. Now that would be an interesting job for theodicy: explain why God plants genes which cause some people to be hopeless alcoholics? So He can come to the rescue in a 12-step program?

If alcoholism is a disease, it is the strangest disease there is. What other disease is there which requires coercive teamwork to convince the sick person that he or she is ill? If I have kidney disease, for example, I expect a certain kind of evidence to be produced to verify that I have such a disease. A few bits of medical evidence ought to suffice. I sure wouldn't need a team of interventionists to coerce me into seeing that I have kidney disease.

So what are the signs of this so-called disease? The first symptom of this disease is quantity of alcohol consumed. If you drink no more than the average American, then you probably do not have this disease. If you drink more than that, then you are probably an alcoholic. (In case you are wondering, if you drink 3 or more drinks a week you are in the minority: only 27% have that many drinks. [Self-scoring Alcohol Check-up] )

Another symptom of this disease is when you drink. If you drink when stressed or depressed, lonely or bored, to get motivated or amorous, to test yourself or to feel good, then you are very likely an alcoholic. Like I said, this is a very strange disease. It depends on how much and when you drink. Is there any other disease that is comparable to this one? The quantity of alcohol and the situations in which one drinks are not really symptoms of the disease; these are the disease of alcoholism.

Another interesting thing about this disease is that the effects of the disease are usually first felt by people other than the one suffering from the disease. What other disease is like that? For most diseases, the sick person feels bad. And if the sick person doesn't feel bad, nobody else feels bad. This disease is unique in that its first identification as a disease is when it starts to annoy others. Now, I'm willing to say that an alcoholic is a pain in the ass and a bother, perhaps even a danger, but I do not believe I am witnessing a person suffering from the disease alcoholism when I witness an alcoholic. I can understand why treatment facilities want alcoholism to be a disease: they profit by it.

Alcoholism as a disease is not a matter of discovery, but of definition. It is a disease because it has been declared to be so by the very ones who profess to have the cure for the disease. How fortunate for the world that those who define the disease also define the cure! Actually, they don't have a "cure." They have a remedy. The inventors of the disease also declare that no one can be cured of this disease. Once an alcoholic, always an alcoholic. You haven't had a drink in fifty years, you say. That is not evidence that you are no longer an alcoholic. A cure would mean an end to treatment. A remedy means a lifelong income for the SAT provider.

In Tim's case the remedy cost him nearly $14,000 for a three week treatment, plus $880 for the interventionist, not to mention what it cost his ego. As a patient, he was repeatedly told that the first step to his getting better would be his declaration: I am an alcoholic. For the sinner to be saved, the sinner must first admit he is a sinner.To refuse to do so is proof the sick one is "in denial" and without grace. The only way to prove you are not in denial is to admit you are an alcoholic. Does this remind anyone of the tactics of witchhunters? This is only phase one. The next phase, public confession, is reminiscent of a totalitarian gulag: each inmate must declare before the others how they degraded themselves and betrayed their humanity through substance abuse. The point, I suppose, is to get the substance abuser to believe he or she is hopelessly addicted or diabolically possessed (or both) and can be helped only by abandoning oneself to God and other medical divinities. On what scientific basis is this hogwash based?

Neither A.A. nor many other SATs are based on science, nor do they seem interested in doing any scientific studies which might test whether the treatment they give is effective. In Tim's case, he would probably be considered a "success" even if he returned several times for treatments. And A.A. members know A.A. works, so they don't need studies to verify the effectiveness of the program. But others might like to know how many don't stay and go through the program? How many go through it, but leave? We'll only hear about the successes, not the failures, because the failures aren't counted and they aren't around to be counted. And we won't read about any comparisons with non-AA programs, nor will we hear about those substance abusers who quit drinking or drugs without any treatment at all. They didn't need God's power, or the group's pressure to quit; they did it on their own. How is that possible? If alcoholism is a disease for which there is no cure, and which requires the substance abuser to give oneself over to God, how do some people quit abusing alcohol or drugs on their own? This should not be possible if either the AA philosophy or the disease theory is correct.

If alcoholism isn't a disease, then it is foolish to seek a "cure" for it. And it is foolish to have treatment centers with patients who are "suffering from alcoholism." Many SAT programs consider the substance abuser to be a "victim." Either this characterization is false or trivial. It is false if it means that the "victim" isn't responsible for abusing drugs or alcohol but is also not suffering from some other illness such as mental illness. In that case, it is the mental illness which should be treated, and alcoholism or drug abuse recognized as the behavioral effect of a neurochemical dysfuntion not likely to go away with prayer or talk therapy. It is trivial if it means that alcoholics and drug abusers are "victims of their own bad choices." Why are they making those bad choices? In either case, it seems that calling an abuser a "victim" is a way to get others to feel sorry for him or her and agree that the "victim" needs treatment, rather than needs to change his or her behavior. That would be fine if the treatment were not for alcoholism or drug abuse but for mental illness which manifets itself by these and other self-destructive behaviors. Such people need psychiatric care and medication, not prayer and lectures on how more will power will save them.

Even if alcoholism is not a disease but a sin, I maintain that even if there is a God, it is especially foolish to treat all alcoholics with the AA 12-step program. According to AA, alcoholics are powerless and they need to get power from God to get some control back in their lives. How do the powerless get power from God? By giving up. Quit fighting. Quit struggling. Resign yourself. Make a total act of faith. Let God have possession of your mind and body. Trust in God. Admit your worthlessness. Tell the world what a weak, miserable creature you are. Ask God to erase your weaknesses and trust God to do so. Ask others to forgive you for all your trespasses. Make amends with others. Pray to God to help you. Wake up!

Giving oneself over to God is the means to redemption, and many people probably go along with it because they want to reach the goal of sobriety, i.e., of independence and control over their lives. The contradiction in giving up one form of dependency for another should be obvious. Being God-addicted may be less harmful to your body than being drug-addicted, but it isn't necessarily less harmful to your spirit. Not that all the goals of the 12-step plan require abandonment of the self to God. Some of the steps are things all of us should probably do from time to time: make a moral inventory and list all the people we've wronged; make amends and vow to harm no more. No one should quarrel with those steps. But to assume that to abuse alcohol or drugs is a disease of the soul and that the cure is the healing power of God is to claim something which no one has ever proved and no one could ever prove. The only evidence for these claims is in the form of the philosophical beliefs of those promoting these notions, as well as the anecdotes and testimonials of people who have found God and given up booze or drugs.

On the other hand, there is substantial evidence to support the notion that many who suffer mental illnesses such as depression or manic depression often turn to alcohol or drugs to ease their suffering or enhance their mania. Such people truly are ill but they need treatment for their mental disease, not for their alcholism or drug abuse. Try talk therapy or prayer with someone who thinks dead people have invaded her brain and are commanding her to kill herself. It won't work. Try prayer or talk therapy with the severely depressed old lady living in a cardboard box who drinks herself into a constant stupor. You'll be wasting your time. If there is any hope for her it will not come from joining AA but from getting proper medical treatment for her mental illness.

Now, I don't deny that there are substance abusers who have ruined and wasted their own and others' lives. Nor do I deny that there are many such abusers who deny they have a problem. But it does not follow that everyone who denies they have a problem with alcohol really does have a problem with alcohol. I don't deny that many, perhaps most, substance abusers can't quit or modify their abusive behavior without help from others. Nor do I deny that many people have been greatly helped by AA and other SAT programs. But I do deny that there is much validity to the metaphysical and pseudo-medical baggage that substance abusers and their counselors use to explain abusive behavior and the methods needed to get such behavior under control. And I reject the notion that the subjective impressions of friends or professionals should suffice to establish this metaphysical and pseudo-medical baggage.

I also reject the notion that all alcoholics come from the same mold. They are not all physically addicted. They are not all psychologically addicted. They are not all addicted. They are not all victims. They are not all diseased. They are not all hopelessly without any will-power. They are not all completely irrational and incompetent. They are not all mentally ill. They don't all need therapy or medication. And there are probably many different, good programs besides those based on the "disease" or the "sinner" models of the alcoholic. Some of them are probably not very expensive but just as effective as "Happy Valley." Substance abusers who want to get back some control in their lives might check out some of these other programs and not feel it's either AA or a "chemical dependency" program or nothing. And those who offer these programs should recognize that many of the people who come to them or are brought to them should see a medical doctor, perhaps a psychiatrist, and should be examined to rule out a neurochemical dysfunction as the cause of their abusive and self-destructive behavior.

See related entry on copendency.


further reading

reader comments

Fingarette, Herbert. (1988). Heavy Drinking: The Myth of Alcoholism as a Disease Berkeley: University of California Press.

Torrey, E. Fuller (1992). Freudian fraud : the malignant effect of Freud's theory on American thought and culture. New York, NY : HarperCollins.

Peele, Stanton. (1989). Diseasing of America. Boston: Houghton Mifflin.

Sykes, C.J. (1992). A Nation of Victims: The Decay of the American Character. New York: Saint Martin's Press.

ęcopyright 1998
Robert Todd Carroll

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Last updated 11/23/98

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