In Maia Szalavitz’s recent article in Salon.com and The Fix, she raises a valid but outdated question: “Do 12-step programs lead to cults?” By pinpointing various treatment-programs-gone-wrong, the article’s overall impact is to associate substance abuse treatment with “stockpiling weapons, forcing couples to get sterilized…[and] conspiracy to commit murder.” It’s true that virtually any lifestyle can be exploited to create a destructive cult-like environment, as eventually happened with Synanon when their unstable leader twisted the treatment process and imposed it by force. But for the vast majority of treatment programs, this couldn’t be further from the truth.
One problem with the article is that it misrepresents the 12 steps, therapeutic communities, and treatment in general. For example, the first step doesn’t force people “into a position of absolute powerlessness” as Szalavitz claims; it asks you to admit that you’re powerless over alcohol (or whatever drug). It’s not that you’re helpless no matter what; it’s that your drug of choice renders you unable to make good choices—and acknowledging this actually gives you power.
Another problem is that this article is old news. Sure, in the ‘60s, ‘70s, maybe even ‘80s, many therapeutic communities were using harsh and dehumanizing methods, but this has long been changed for the better. In fact, the entire substance abuse treatment field grew out of a somewhat erratic paraprofessional approach. There was very little drug treatment at all in the U.S. until Vietnam vets started coming home addicted to heroin. So at first this wasn’t a health care field based in science at all; it was more of a trial-and-error scenario.
In addition, substance abuse treatment hasn’t historically been funded as well as the rest of health care—and for a long time it wasn’t managed as well either. Addiction wasn’t even regarded as a disease until very recently, and addiction treatment was seen as a sort of “awkward stepchild” of medicine. As a result, remuneration for treatment and the quality level of professional programs, standards, and guidelines was significantly diminished. We have come a very long way since then.
Today, programs like Phoenix House use cognitive behavioral therapy in supportive, compassionate, and forward-thinking communities. There is no degradation of clients, no abuse of any kind, no breaking-down or “haircuts.” To focus on the therapeutic community’s past mistakes is to dredge up controversial practices that we’ve all long abandoned. Are there isolated places that still wrongly twist the steps or use the old “encounter groups” of the ‘60s? Of course there are, and they deserve to be shut down. But there’s no reason to make a blanket statement about treatment being universally exploitive.
We know treatment is not one-size-fit-all. In fact, in New York state, the Office of Alcoholism and Substance Abuse Services doesn’t allow treatment programs to mandate the 12 steps for this and other reasons. The accepted motto is that the steps are “there for people who want them”—and they’ve probably helped more people than any treatment program. It’s stated right in the second step: “All of AA’s 12 Steps are but suggestions.” It’s very clear—you take what works for you, and you leave the rest behind.
The bottom line is that any doctrine, lifestyle, set of guidelines, or religion can be steered in the wrong direction and dragged off the deep end. But in the case of substance abuse treatment, let’s not trash the 12 steps or any other modality when we really want to criticize the individuals who inappropriately apply them. And let’s not get hung up on the flaws of treatment models that are long gone.
The 12 steps are, and should continue to be, a voluntary treatment option for folks who want them. Courts don’t mandate the 12 steps, although they may require people to attend meetings. Might there be a couple of crazy zealots in that meeting? Sure. But there are a couple of crazy zealots on the street corner every day; that doesn’t mean you have to listen to them.
Deni Carise, Ph.D.
Chief Clinical Officer
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