Two other media sensations—the 1985 broadcast of a ten-part PBS series, Bradshaw On: The Family, featuring John Bradshaw, an educator, a counselor, and a motivational speaker, and the 1987 publication of Melody Beattie’s Codependent No More: How to Stop Controlling Others and Start Caring for Yourself—lifted the self-help movement into the national limelight. Bradshaw and Beattie argued that people who suffer in destructive relationships were as sick as those causing the problem, which might be alcohol or drug addiction but could include any mental illness. Codependent No More, which was copublished by Hazelden, was enormously successful, selling more than eight million copies. It became the Big Book of a new group, Co-Dependents Anonymous, which would join so many others in adopting the twelve steps and traditions. It almost seemed that AA, just a little group of nameless drunks fifty years earlier, was remaking the world.
But the mood of the country was changing. The optimism that had led Lyndon Johnson to declare a war on poverty dissipated as the country struggled to extricate itself from the war in Vietnam. Confidence in government hit bottom as a result of the Watergate scandal, and the economy, which had been robust, was plagued by slow growth, high inflation, and increasing joblessness. Fear was growing over a violent crime wave that began in the 1960s and was still growing. In 1979, President Jimmy Carter acknowledged in a televised speech that the country faced “a crisis of confidence.” The next year, the American people replaced Carter with Ronald Reagan, a sunny Californian who promised to restore the country’s greatness. The new president said the only thing wrong with America was that government was too big. He wanted to free business of costly regulation and to give state governments control of social welfare programs. Although Reagan said he would provide strong leadership in the “war on drugs,” the only significant initiative during his first term was the launch of an educational campaign, led by his wife, Nancy, that told schoolchildren to “Just Say No” to drugs.
Then, in 1984, crack made its first appearance on city streets. A cheap form of cocaine that was smoked, it provided an intense but short-lived intoxication that quickly addicted the user. Crack addiction spread rapidly, destroying lives as well as the neighborhoods where it was sold. Homicide rates among young African American men doubled as gangs fought for control of the trade. Congress responded in 1986 by passing the Anti-Drug Abuse Act, which made possession of five grams of crack punishable by a mandatory five-year prison sentence without the possibility of parole. The law symbolized a shift in federal priorities as the nation confronted a new generation of addicts, providing almost $1.5 billion for law enforcement and only $230 million for drug treatment.
The result was soon apparent in a rapid rise in the prison population, which reached one million in 1994. Sixty-one percent of the inmates had been sentenced for drug offenses, and many of them were addicts. The number of prisoners continued to grow to more than 2.4 million in 2013, four times the prison population in 1980. Surveys of federal and state prisoners indicated that approximately half had a drug or alcohol problem.31
At the same time, there were signs that the treatment industry was on financially shaky ground. The rapid expansion of alcoholism treatment that had begun a decade before had reached its peak. There were almost three times as many alcoholism wards in hospitals—1,148—and more than twice as many beds—34,364. The number of private for-profit treatment units more than quadrupled. In many places, there was suddenly too much help available. In 1985, in the East Valley section of Phoenix, there had been only seventy-four beds for alcoholics and drug addicts serving a population of almost a half-million people. By the time the St. Luke’s Behavioral Health Center opened an eighty-bed treatment center there two years later, four other companies were making plans to open similar facilities. In 1989, there were over four hundred beds available in the area, and St. Luke’s was forced to close its East Valley unit.
The competition among treatment centers quickly turned into a struggle for survival. The leaders of these institutions realized they couldn’t sit around waiting for patients to show up. They began advertising and hiring salesmen who courted the managers of employee assistance programs and representatives of the health maintenance organizations. “I’ve got seven or eight lunches scheduled with people who could send patients here and quite frankly we’ve never done that before,” the vice president of a Milwaukee treatment center said.32
In this often desperate hunt for patients, ethical problems began to arise. The focus of many institutions shifted from providing effective treatment to financial sustainability. “There was never any doubt in my mind that my primary, if not my exclusive area of accountability, was filling beds in the hospital,” one administrator said. “In the four years I spent at the hospital, I was never asked one question by my superiors about the relative success of our efforts to treat addictions.”33
William L. White described industry abuses at the time as “widespread and severe.” They included “unethical marketing practices, financially motivated and clinically inappropriate admissions, excessive lengths of stay, inappropriate readmissions, excessive fees and the precipitous abandonment of clients when they reached the limits of their financial resources.” “In this climate, alcoholics and addicts became less people in need of treatment and more a crop to be harvested for their financial value,” he said.34
The treatment industry was also under fire for the cost of its services. Almost half of the alcoholics in treatment were enrolled in programs that followed the Minnesota model, which involved four weeks of expensive inpatient treatment. The managed care companies raised questions about the need for prolonged inpatient treatment, and not without reason. Alcoholics and addicts were being treated, were relapsing, and were readmitted repeatedly. Treatment costs ranged from $35 to $2,000 a day for what looked on paper like the same services. “People began to ask, ‘My god, what kind of professional field is this?’” recalled Dan Anderson, the former president of Hazelden.35
Private industry paid a significant proportion of the $9 billion that was spent on treatment in 1986, and companies were soon adopting measures to control their costs, including hiring managed care companies to review requests for treatment. In the early days of managed care, there was some mutual understanding between the two sides: many treatment professionals agreed that there were patients in twenty-eight-day programs who could be treated just as effectively in outpatient programs, and managed care executives acknowledged that some patients required hospitalization. But the detente between the cost cutters and the caregivers did not last long.
The representatives of the managed care companies began to scrutinize the records of every patient and made decisions that were often at odds with the recommendations of their doctors. “Pardon me if I use some four-letter words,” a treatment center administrator apologized. “We just had a patient sent here by his physician. . . . [He] had insurance . . . and some f——b—— on a phone tells us the patient is not appropriate for treatment.” Another complained:
These [patients] are actively suicidal and self-mutilating and have had outpatient treatment and failed, yet they say they don’t need inpatient care. At what point do you need inpatient? When you’re dead?
The managed care companies held the purse strings and were bound to prevail. The number of approved inpatient days dropped steadily until it reached the several days required for detoxification. The average occupancy of private inpatient programs fell 25 percent in a single year, 1988–1989. Treatment companies began to merge units and lay off staff. Many hospitals closed their addiction units, sending alcoholics and addicts who needed hospitalization back to the psychiatric ward. Most new patients were referred to outpatient programs, although it was harder to keep them sober. A new era had begun. In the future, the only people in a twenty-eight-day program were those who could afford to pay for it themselves.36
A period of consolidation in alcoholism treatment was inevitable following such rapid expansion, but many working in the field believed
that something worse was happening. They were on the receiving end of a backlash that was ideological as well as economic. A chorus of voices criticized those who had embraced the disease concept to explain the problems in their lives. Many were conservatives who had a long history of insisting that people were to blame for their failures. There was also criticism from the left. “We are a nation of sexaholics, rageholics, shopaholics and rushaholics,” Wendy Kaminer wrote in her 1991 book, I’m Dysfunctional, You’re Dysfunctional: The Recovery Movement and Other Self-Help Fashions. Kaminer had surveyed the burgeoning literature of recovery and emerged with serious concerns about its impact on politics. “Imagine the slogan of recovery—admit that you’re powerless and submit—as a political slogan, and what is wrong this movement becomes clear. That is hardly a slogan for a participatory democracy,” she wrote. Instead of focusing people on the injustices in the world, the widespread adoption of the twelve-step program was infantilizing them:
The phenomenal success of the recovery movement reflects two simple truths that emerge in adolescence: all people love to talk about themselves, and most people are mad at their parents. You don’t have to be in denial to doubt that truths like these will set us free.
Kaminer’s criticism was directed mostly at programs that addressed “codependency,” but the disease concept of alcoholism was also under heavy attack.37
One of the sharpest critics of the disease concept of alcoholism was Herbert Fingarette, a mild-mannered, semiretired professor at the University of California at Santa Barbara. In the spring of 1988, he won national attention with the publication of a slim volume, Heavy Drinking. The circumstances of its release were fortuitous. The US Supreme Court was considering a case in which two alcoholics were suing the Veterans Administration for denying them an extension of the period when they could apply for education benefits. Such extensions were granted to veterans with physical or mental problems, and the men, who had stopped drinking, argued that their alcoholism had caused them to miss the application deadline. The VA said their failure to apply was the result of “willful misconduct.” Fingarette’s views had been cited by the VA. When the Supreme Court ruled against the alcoholic veterans, it appeared to validate the thesis of his book, which Fingarette was soon repeating in magazine and newspapers articles, TV interviews, and on talk shows.
Fingarette charged those who portrayed alcoholism as a disease with perpetrating a fraud. “Almost everything that the American public believes to be the scientific truth about alcoholism is false,” he wrote in Heavy Drinking. “[I]n fact, we know that there are no decisive physical causes of alcoholism,” Fingarette asserted in an article published in the same year. He continued:
[T]he public has been kept unaware of a mass of scientific evidence accumulated over the past couple of decades, evidence familiar to researchers in the field, which radically challenges each major belief generally associated in the public mind with the phrase, “alcoholism is a disease.”
The disease concept declares that at a certain point in an alcoholic’s drinking, he loses control and continues to drink until he is so drunk that he passes out. In other words, “one drink—one drunk.” Fingarette pointed to experiments that he claimed had shown that alcoholics were capable of moderating their drinking for extended periods. In one hospital experiment, men who were accustomed to drinking a quart of whiskey a day were given a monotonous task to earn credits for liquor. It was easy to earn enough credits to get drunk, but none of them did during the one- to two-month duration of the experiments. “The consensus in the research literature is that even in their normal, everyday settings, chronic heavy drinkers often moderate their drinking or abstain voluntarily, the choice depending on their perceptions of the costs and benefits,” Fingarette wrote.38
Fingarette did not deny that biology played some role in alcoholism. He acknowledged that studies had shown that the children of alcoholics were three times as likely to become drunks than other children. This meant that as many as 14 percent of alcoholics had a genetic predisposition to heavy drinking. But Fingarette rejected claims that this evidence supported the disease theory. He pointed to the fact that the overwhelming majority of alcoholics did not have an alcoholic parent. Not even a majority of the children of alcoholics became drunks. At most, the studies had proved that genetics was one factor among many in alcoholism, he said.
Potentially more damaging than Fingarette’s criticism of the disease concept was his claim that alcoholism treatment didn’t work. He acknowledged that this contradicted what people were hearing in ads for treatment and “the heartfelt testimonials of celebrities . . . who write books and appear on talk shows to praise their newfound sobriety.” Fingarette said most people who conquer their drinking problem—as many as 30 percent—did it on their own. The majority were young men who “aged out” of their guzzling habit when they got their first job and started raising a family.39
Fingarette did not dispute the fact that some people did get sober in treatment, particularly those who were strongly motivated, possessed economic security, and had strong family support. But he asserted that there was no evidence that it was because of treatment. “The current consensus in the research community is that by scientific standards of effectiveness the therapeutic claims of disease-oriented treatment programs are unfounded,” he wrote. Fingarette also rejected the idea that AA would ever be a solution for most alcoholics. He cited one study that estimated that 82 percent of AA members relapsed in the first year and a half. This meant that AA was helping only 5 percent of the drunks in the United States and Canada.40
Fingarette’s sweeping rejection of the disease concept and the effectiveness of treatment infuriated many people, including those who worked with alcoholics and the drunks they had helped. “[H]e swings at those he sees as the enemy with the same vigor that Carry Nation used in swinging her hatchet at bottles of booze,” observed William Madsen, a colleague on the faculty of the University of California at Santa Barbara. In Defending the Disease: From Facts to Fingarette, Madsen, an anthropology professor, argued that Fingarette’s conclusions rested on “misconceptions, fallacies and examples of poor reasoning.” He accused Fingarette of an over-reliance on psychological and sociological research while failing to provide any significant biological or medical facts. Madsen said he did not even seem to understand that many of the researchers he was citing were themselves supporters of the disease concept. He concluded by considering Fingarette’s impact on people working in the alcoholism field. “Fingarette has administered a totally undeserved and a very vicious slap in the face to these sacrificing people as well as to every sufferer of the disease of alcoholism,” he wrote.41
Some of the depressing facts cited by Fingarette could not be denied even by people who were working hard to help alcoholics. Dr. George E. Vaillant was one of them. A graduate of Harvard Medical School, he became interested in alcoholism in the early 1970s when relatives of an alcoholic friend asked him for help. He was a psychiatrist who was considered knowledgeable about addiction generally, but he had to call some senior members of the Harvard faculty for advice. No one was able to help.
His curiosity piqued, Vaillant signed on as a consultant and ultimately codirector of an ambitious project to help alcoholics in the neighboring cities of Cambridge and Somerville, Massachusetts. “To me, alcoholism became a fascinating disease,” Vaillant wrote.
It seemed perfectly clear that by meeting the immediate individual needs of the alcoholic, by using multi modality therapy, by disregarding “motivation,” by turning to recovering alcoholics rather than to Ph.D.’s for lessons in breaking self-detrimental and more or less involuntary habits, and by inexorably moving patients from dependence on the general hospital into the treatment system of A.A., I was working for the most exciting alcohol program in the world.
Anxious to prove the effectiveness of their program, Vaillant and the director checked on the progress of the first one hundred patients to undergo detoxification two years aft
er their discharge. Only five of the patients had remained abstinent for the entire period, which was a success rate of just 20 percent. Since that was about the rate at which untreated alcoholics stopped on their own, it appeared they were not helping. “Not only had we failed to alter the natural history of alcoholism, but our death rate of three per cent a year was appalling,” Vaillant recalled.42
Facing layoffs, closings, a loss of public confidence, and self-doubt, the people who were lucky enough to still have jobs in the addiction field in the 1990s were severely demoralized. William L. White spoke for them in 1997 as he wrote the final words of his comprehensive study, Slaying the Dragon: The History of Addiction Treatment and Recovery. He had worked as a counselor, clinic director, and researcher since the late 1960s and had experienced the great excitement surrounding the growth of treatment. Now he wondered if he was watching its collapse. “America is moving addiction once again from the arena of public health to the arena of public morality,” he wrote. “If this trend continues, it is likely that addiction will be de-medicalized and increasingly criminalized for all but the most affluent of our citizens.”43
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