AUTONOMY AND TWELVE STEP THERAPY:
CAN THEY CO-EXIST?
Timothy Edwards, B.A., J.D., L.L.M., S.J.D.
INTRODUCTION
Autonomy is a fundamental ethical right that allows mental health clients to make informed decisions regarding the course of their treatment. Legally speaking, autonomy is a liberty interest that is protected by the fourteenth amendment to the Federal Constitution. Ethically speaking, autonomy underscores a number of important client rights, such as informed consent, the right to refuse treatment and the right to confidentiality. Practically speaking, autonomy defines professional boundaries that separate intrusive institutional policies from the clients’ right to informed self-determination. At each level, autonomy is an indispensable ingredient in the appropriate treatment of addicted persons.
Realistically speaking, autonomy exists as a qualified right. For instance, institutional and therapeutic goals may limit the client’s right to self-determination. Obviously, clients do not have the freedom to engage in behavior that disrupts the orderly administration of treatment. For similar reasons, facilities may impose reasonable consequences in an attempt to correct self-destructive behavior. In these cases, where the claim to autonomy is outweighed by legitimate institutional goals, the resulting tension is resolved in favor of the facility.
Autonomy is influenced by other factors. Many clients enter residential treatment centers as the result of outside coercion, such as court action or employment demands. In these cases, the promise of autonomy is negated by circumstances that precede the client’s admission into the facility.
Incompetent clients, such as minors, do not enjoy wide ranging autonomy. Instead, the institution, and the therapist, have an affirmative duty to exercise reasonable supervision and control, as it is presumed that the client is incapable of making decisions for herself. These measures are legally and ethically proper.
Setting these cases aside, autonomy interests are often overlooked in the addictions treatment field. This is for a number of reasons that are unique to this profession. First, addictions treatment is the only profession where a substantial number of its workers are recovering from the very illness that they now treat. It is also the only profession where non-medical staff is encouraged to diagnose and treat an undetermined disease entity. Above all, addictions treatment is the only profession that draws heavily, if not exclusively, from spiritual and moral principles in its treatment of known medical disorders. These factors speak directly to the personal bias, competence and subjectivity of a unique professional enterprise- one that has historically given autonomy a low, and unenforced, ethical priority.
The relationship between the addictions counselor and the client is also unique. Unlike most professional relationships, addictions counselors often assume that clients are incapable of making important decisions in the most intimate areas of their lives. These counselors assume a paternalistic, active role in the client’s affairs, to the point that clients are actively discouraged from making decisions on their own. This questionable leap, from autonomy to paternalism, is justified by a common misperception among addictions counselors, namely, that addiction overrides the client’s ability to make decisions in her own best interest. According to one expert in the field: “Alcoholism and other chemical dependencies are characterized by denial and self-delusion. Initially, patients may be no more capable of making well-reasoned and informed judgments in their own behalf than small children … [T]he responsible therapist must accept that … a little bit of creative coercion and outside pressure is not entirely bad.” In other words, the unique status of addiction justifies the coercion and manipulation of persons who are otherwise legally competent.
This contention is patently false. Absent a finding of legal incompetence, addiction does not warrant intrusive intervention any more than other, comparable mental illnesses, such as depression. Thus, it is always unethical to manipulate, coerce or intimidate competent clients into complying with treatment that they find objectionable. Unfortunately, such ethical violations may be unavoidable in facilities that embrace the twelve steps, and the disease concept of addiction, as principle therapeutic tools.
A.A. IN THE INSTITUTION: A COLLISION OF VALUES
The traditions of Alcoholics Anonymous contain a strong commitment to non-professionalism and individual autonomy. Tradition six states that A.A. groups “ought never endorse, finance or lend the AA name to any related facility or outside enterprise.” Tradition eight reiterates this principle a bit differently: “Alcoholics Anonymous should remain forever non-professional…” In support of A.A.’s non-secular purpose, the second tradition states that “there is but one ultimate authority- a loving God as he may express himself in our group conscience.” By specifically rejecting the “counseling of alcoholics for fee or hire,” A.A.’s traditions incorporate autonomy, and equality, as guiding principles. Treatment centers regularly violate these principles and nothing is done because they are not enforced.
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Over the years, most residential treatment facilities have incorporated the teachings of Alcoholics Anonymous into their daily treatment plan. Most facilities host AA meetings, provide twelve step lectures and workshops and, most importantly, require their clients to complete a number of A.A.’s twelve steps as a prerequisite to graduation. The “language” of Alcoholics Anonymous is common parlance in these facilities, among both staff and clientele. It is fair to say that A.A.’s commitment to non-professionalism has been set aside in these facilities, where addicted clients are strongly encouraged to incorporate highly charged spiritual, and indeed, moral principles from AA into their daily lives. This forced marriage of A.A.’s guiding principles and professional authority is a combustible mix, one that A.A.’s founders were careful to avoid.
At the institutional level, mandatory A.A. participation raises serious questions. By definition, A.A. presents a recovery program that carries significant moral overtones. When A.A. participation is encouraged in the residential facility, these principles are fused with institutional and therapeutic authority that converts A.A. into a mandatory, rather than an elective, right of passage for the addicted client. In this process, intimate, religious-based absolutes are elevated into therapeutic standards that intrude on the client’s personal and religious autonomy. When combined with the disease concept of alcoholism, the impact on autonomy interests is prohibitive.
THE DISEASE CONCEPT AND THE ILLUSION OF METAPHOR
Many inpatient facilities rely heavily on the disease concept of addiction as a principle educational, and therapeutic, tool. The disease concept defines addiction as a medical illness that is categorized by mental obsession and a corresponding desire to use drugs despite adverse consequences. The disease model conceptualizes addiction in a simple, understandable manner- one that most addicted persons can identify with and understand. The disease concept also serves as a useful, therapeutic tool in that it places an intervening agent, the disease, between the addict and her addicted behavior. This reduces shame and guilt and, in turn, facilitates openness in the therapeutic exchange.
The disease model was designed to serve as an understandable description of the physical pathology of addiction. However, it was never intended to encompass thought processes or behavior that have no logical connection to the addictive process. Today, the disease concept has been cut far adrift from its moorings, and we see its usage everywhere; “You are in your disease.” “That is diseased thinking.” “Your disease is running circles around you.” This misuse of language attaches an undefined pathology to routine manifestations of resistance that should be expected, and indeed embraced, during the course of treatment. In this context, the disease concept serves as metaphor, and not fact, as the client is led to believe that an ever-changing disease process is in full control of his mental and emotional faculties. This questionable leap from biology to psychology minimizes the client’s self-confidence and invites questionable therapeutic intrusions into protected spheres of autonomy.
THE MANY FACES OF COERCION AND UNDUE INFLUENCE
With the backing of institutional sanctions, A.A. therapy and the disease concept provide fertile ground for systematic overreaching into important autonomy interests. Technically speaking, all autonomy violations occur through manipulation, coercion or undue influence. In each violation, a person with special knowledge and control will dominate the client’s will through various, improper means, such as deception or coercive persuasion. When this occurs, the client’s autonomy rights have been violated.
Similar practices are routinely applied in twelve step residential centers. Consider the following example:
William is a 19 year old male with a history of drinking problems. After a recent DUI, William’s probation officer told him that he would go to jail if he did not successfully complete an inpatient alcoholism program. William then admitted himself into a facility that boasted a “75% success rate” for graduating clients.
William’s attitude was poor. After failing to complete and present his “First Step,” William’s counselor confronted him in the group, informing William that his “best thinking” got him to treatment, that he was full of “self will” and that he was not “willing to go to any lengths” to get sober (all common AA sayings). When William resisted, he was told that he was “in his disease” and encouraged to “trust the process” without question. When William stated that he would not participate, his counselor threatened to contact his probation officer (an implied threat of incarceration).
The next day, William was called into the director’s office, along with two other counselors and two members of his group. The director, who had no clinical training whatsoever, reminded William that his probation officer would be contacted if he did not start “working on his recovery.” The other members of the group, and William’s counselor, told William that he was “in denial” and that he had to “surrender” by “turning his will over to the group” (all common AA sayings). William refused.
Two hours later, William was told to pack his bags and get off of the premises. The next day, the director of the facility called William’s probation officer, and a warrant was issued for his arrest. After learning that William consumed alcohol on the night of his discharge, the director informed his remaining clients that William’s “disease had got the best of him” because he was not ready to “go to any lengths” to find recovery. To make matters worse, the facility encouraged William’s parents to cut off all financial and emotional support, leaving him alone and highly vulnerable at a critical point in his recovery. (This type of manipulation serves more of a punitive than therapeutic function, and it can lead to relapse, suicide or both).
William’s story demonstrates how A.A. teachings and the disease concept are routinely misapplied in the residential treatment setting. It also illustrates how these principles create an atmosphere where the client is given no choice but to conform to the expectations of a unified group process. William’s counselor abused a position of trust and power by encouraging William to abdicate his own thought process (“your best thinking got you here”) and attacking routine manifestations of resistance (“you are in your disease”). By outnumbering William in the second “intervention,” the pressure intensified, as William’s counselor encouraged him to “surrender” his thought process and become “open and willing” to a recovery plan that was, by all accounts, mandatory. As William continued to resist, administrative pressure was brought to bear and William was literally forced to choose between treatment, jail and his family. These coercive measures so closely mirror cult indoctrination techniques that the comparison cannot be overlooked.
These dynamics play out in more subtle variations. In common treatment parlance, counselors and group members will tell a client that he is “in his disease,” “not willing to go to any lengths,” or “in denial” when routine manifestations of resistance surface. Group members employ similar language, hoping to gain the acceptance of the therapist by demonstrating the strength of their own recovery. But what does this accomplish? Doesn’t the misapplied application of these AA terms undermine the importance of autonomy and expose the professional limitations of the therapist? Again, the interplay between group therapy, where professional intervention is permitted, and an A.A. meeting, where it is not, creates a dangerous battleground where autonomy is reduced to a variable that the therapist can disregard when he subjectively determines that intervention is required.
TAKING INVENTORY IN SEARCH OF SOLUTIONS
A survey of available literature provides insight into therapeutic systems that invite impermissible intrusions into autonomy interests. Put simply, “unethical therapists minimize individuals’ competence to make decisions and encourage dependency on the therapy and the group.” As a result:
“Group dynamics are utilized to ensure that the private is made public. The leader and other group members expect total ‘openness’ or access into all parts of clients’ lives … This openness then leads to efforts to exert wide areas of control over the attitudes and behavior of members. Behavior that is not compliant is often viewed as resistant or a sign of character flaws. These behaviors are then targets of ‘therapy,’ with the goal being that the member would surrender the identified deviance and adhere to group norms.”
There are a number of common factors that present themselves in facilities that promote institutional, or therapeutic, goals over the client’s right to autonomy. Specific questions should include the following:
– Does the facility use family members to manipulate the course of treatment through “tough love” or the pretense that withholding love or affection is a way to “take care of themselves?”
This is a common problem in addictions treatment and it literally destroys families, who should be invited into a respectful, honest dialogue with the client that includes authentic boundaries that are not imposed as a measure of control. This should be obvious.
- Does the facility “take all comers” and rarely refer clients to outside facilities?
Facilities, or therapists, that fail to acknowledge the limitations of their own practice often mislead prospective clients about their professional qualifications. By applying a “one size fits all” mentality to prospective admissions, these facilities are more likely to assign blame to clients who resist the moral tenor of mandatory participation in twelve step therapy. This dynamic is especially dangerous when the facility fails to diagnose underlying psychiatric disorders that are beyond the reach of traditional twelve step therapy.
- Does the facility impose consequences against clients who resist therapy?
Rigid, twelve step facilities promote compliance over the honest expression of thought and feelings. Clients who resist are subject to group pressure and, often punishment. Often, those clients who fail to respond are blamed for their refusal to “surrender,” labeled as “toxic” and ostracized from the group.
- Does the facility hire graduates of its own program as therapists or administrative aides?This practice, which raises concerns regarding dual relationships, reinforces the dominance of the group’s philosophy by closing the system off from outside sustenance. In turn, expressions of individuality among clients is met with resistance by employees who share a common vision of recovery. Facilities that employ a disproportionate number of AA members should be inventoried carefully to insure that personal bias does not override the client’s best interests.
- Are financial relationships manipulated so as to discourage autonomy?
Many residential facilities require prepayment or otherwise bill for services that have not been delivered. Here, it is not uncommon for a client to held to a “contract,” signed on his first day at the facility, only to later learn that the facility will not return a portion, or all, of his money if he chooses to leave early. These practices prevent clients from exercising their right to refuse treatment without paying a tangible, financial price.
- How is the client treated if he leaves the facility early?
In many cases, clients that leave a facility “against medical advice” are not permitted to contact remaining clients or, in some cases, their counselor. A halfway house in Northern Arizona “terminates” clients by giving them thirty minutes to leave or face arrest by the local police. These coercive practices place insurmountable pressure on the client, who is forced to choose between inappropriate therapy or potential homelessness.
· Are non-licensed administrative staff allowed to participate in the client’s therapeutic process?
In some facilities, there are no enforceable boundaries that prohibit administrators and non-clinical staff from intruding the clinical realm. Thus, many administrators and adjunct staff provide “treatment” that is derived solely from personal experience. By blurring the line between “twelve step work” and legitimate therapy, these individuals wield considerable influence in an area that they are not qualified to act.
CONCLUSION
Understandably, many addictions counselors feel a sense of urgency when dealing with a reluctant client. As with most serious mental disorders, addiction invites us to assume that the addicted client is incapable of making decisions for himself. This assumption, which places addicted clients on the same footing as legally incompetent persons, is insulting and clinically flawed. Once embraced, the counselor is tempted, and indeed permitted, to override the client’s thought process with his own therapeutic agenda. Once this assumption is discarded, as it should be, the client is invited to discard his mask of compliance, engage in authentic discourse, and explore legitimate recovery.
In any event, coercion and manipulation is not therapy. It is, instead, a complete breakdown of the therapeutic process- one that reflects the counselor’s inability to reach the client through conventional, ethical means.
Many counselors feel that autonomy is always intact because the client has the absolute right to leave the facility at any time. This is a fallacy. As noted above, most addicted clients enter treatment involuntarily. While the client is technically allowed to terminate treatment at any time, this decision can carry severe consequences, such as jail time, the loss of a job, or the loss of a professional license. This is particularly true when the counselor tells the client that early departure will result in inevitable relapse, or even death. It is thus incumbent on the facility, and the counselor, to extract themselves from policies that undermine the client’s qualified right to think and behave as an individual. In such facilities, the successful client will receive credit for his choices and, ultimately, his own individual vision of recovery.
. See, CHARLES BUFE, ALCOHOLICS ANONYMOUS, CULT OR CURE? 7 (Sharpe Press, Tucson, Arizona, 1995)(“…coerced individuals constitute a majority of those undergoing treatment …”)(emphasis in original).
. LECLAIR BISSELL & JAMES ROYCE, ETHICS FOR ADDICTIONS PROFESSIONALS, 24 (Hazelden Press, 1994).
. PAUL ROMAN & TERRY BLUM, NATIONAL TREATMENT CENTER STUDY REPORT 10 (Institute for Behavioral Research, 1997)(noting that over 93% of all treatment centers rely heavily on the twelve steps of Alcoholics Anonymous).
. Alcoholism has been characterized as a “disease that is characterized by abnormal alcohol-seeking behavior that leads to impaired control over drinking.” NATIONAL INSTITUTE ON ALCOHOL ABUSE AND ALCOHOLISM, Alcohol and Health: Eighth Special Report to the U.S. Congress on Alcohol and Health (1993).
. Carole: I will forward you a complete citation for this proposition if you think it would be helpful. Just give me a call and I will go to the library and retrieve the source.
. KIM BOLAND & GORDON LINDLOOM, Psychotherapy Cults: An Ethical Analysis, printed in 9 Cultic Studies Journal No. 2, 137, 141 (1992). Carole: The term “9 Cultic” is proper, legal citation format for this journal, indicating that this is Volume 9 of the “Cultic Studies Journal” (that’s the name of the Journal- it’s not an abbreviation).