One Nation Under the Influence


“An alcoholic is someone you don’t like who drinks as much as you do.” —Dylan Thomas
I loathe the term “alcoholic.” I do not like being called an alcoholic, announcing myself as an alcoholic leaves me feeling dirty, and I cringe when people get cute in throwing the term around as though it is both some sign of accomplishment and superficial shame: Brittany, you’re such an alcoholic. Yet, anyone in America seeking a solution for a drinking problem also has to carry with them the odd connotation of this silly word. Alcoholic has become to drinking what “shopaholic” is to pre-Christmas Black Friday bargain hunters. I hate it. (And for what it’s worth, I can’t say that I particularly care for Brittany, either.) Formal explanations deeming alcoholism “a primary, chronic disease with genetic, psychosocial and environmental factors influencing its development and manifestations,” only contribute further confusion to what the word might actually mean.

“Alcohol dependency,” however, is a clinically-defined condition that incorporates such criteria as cravings, uncontrolled behavior, physical dependence, and abnormal tolerance into the diagnosis. Alcohol dependency is not interchangeable with “alcohol abuse,” as those who abuse alcohol will not all become dependent, yet both terms fall under the blanket of alcoholism. The majority of people, including both those dependent on alcohol and those who are prone to abusing it, move in and out of drinking patterns throughout their lives, further contributing to the ambiguity surrounding how addictive behavior is diagnosed. Should a habitual wine sipper be classified similarly to those who wash away morning withdrawal symptoms by downing a few shots of Jameson? Drinking behaviors exist along a continuum that includes everything from severely dependent hazard drinking to problem-free use that is only occasionally interrupted by having “one too many.” Depending on the term’s insubstantial definition though, "alcoholic" remains an interchangeable slang phrase often used to draw lazy similarities between each distinct group of people.

While the term remains widely used to describe those who abuse alcohol, the act of figuratively branding oneself an alcoholic remains a caustic process, inviting with it a harmful and disruptive connotation, leaving individuals’ lives continually punctuated by a reminder of some unshakable chemical perversion. I cannot personally admit myself as an alcoholic without feeling some shame, but what I can all-too-easily admit is that my constant abuse of alcohol has taken an immeasurable toll on my life; and in America, as is true in many nations around the world, I am not alone.

The 2011 National Survey on Drug Use and Health reported slightly more than half of Americans (ages 12 and older) as current drinkers, consuming at least one alcoholic drink in the 30 days prior to the survey. Nearly one quarter of respondents participated in binge-drinking (consuming five or more drinks during a single occasion) at least once in the 30 days prior to the survey. Binge-drinking among American youth has rapidly increased in recent decades, with over a third of the nation’s high school seniors now claiming to have drank to physical extremes. A report sampling 17,000 college students found that about 40% had participated in binge-drinking. The survey also reported that over 6% of respondents participated in heavy use of alcohol, consisting of five or more drinks on the same occasion on five or more days during the month prior to the survey.

Furthermore, 12% of adults claim an alcohol dependency at some point in their lives, while an alarming 13% of American men who drink meet the criteria of “heavy episodic drinkers.” Raye Litten, chief of medications development for the National Institute on Alcohol Abuse and Alcoholism, claims the U.S. has “at least 18 million adults who suffer from alcohol use disorder, and probably twice that many who are high-risk drinkers who don’t have a diagnosis.” The point is that we Americans drink a lot of alcohol, and do so with great frequency. While definitions and drinking statistics would not seem to have much immediate impact on recovery and treatment, as long as the term alcoholic remains the prevailing phrase used to define such a wide swath of individuals, underlying dependency issues will remain tied to another more detrimental association, further complicating problematic drinking patterns by linking them to the disease-concept of alcoholism.

Since alcoholism is commonly associated with a prevailing correlation between hazardous drinking behavior and physical disease, such twisted causality can dismiss actual healing as a legitimate option. And just as it obscures alcohol dependency under the pretense of religious and spiritual neglect, Alcoholics Anonymous remains a leading proponent of the disease-concept within the field of alcohol recovery. While A.A. implicitly denies the definition of alcoholism as a foundational matter (the 10th of its Twelve Traditions states: “Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never be drawn into public controversy,” implying that A.A. has no formal opinion on the subject), The Big Book recognizes alcoholism as “an illness which only a spiritual experience will conquer.” Not only does this definition perpetuate the aforementioned necessity for individuals seeking recovery to pursue their spiritual selves, but it undermines the well-being of those seeking treatment for alcoholism. In the decades that followed The Big Book’s release, this would become increasingly important as America’s burgeoning treatment industry began to take shape.

Bill Wilson was not shy in speaking to the disease-concept, notably presenting at the National Catholic Clergy Conference on Alcoholism in 1961, where he said, “We have never called alcoholism a disease because, technically speaking, it is not a disease entity.” “For example,” he continued, “there is no such thing as heart disease. Instead there are many separate heart ailments, or combinations of them. It is something like that with alcoholism. Therefore we did not wish to get in wrong with the medical profession by pronouncing alcoholism a disease entity. Therefore we always called it an illness, or a malady – a far safer term for us to use.” This vague assessment of alcoholism as some sort of pathological “malady” presents itself as an illness which cannot simply be remedied or cured, leaving those affected perpetually in a state of limbo. Abstinence might seem the cure for alcoholism, but under this thinking the disease remains a densely layered ailment that A.A. calls a progressive illness which can never be cured: The “phenomenon of craving” can never be overcome by an individual’s willpower alone. Misconceptions continue to abound due to the dual nature implicit within A.A.’s diagnosis, only further contributing confusion through static threats that alcoholics have but three options if they do not follow The Program: death, incarceration, or insanity.

Valued as a pioneering female member of A.A., Marty Mann (who, with the help of Bill Wilson, became the first woman to achieve recovery through the male-dominated fellowship) founded the National Council on Alcoholism (which would become the National Council on Alcoholism and Drug Dependence, or N.C.A.D.D.) in the mid-1940s. The organization continues its advocacy of treatment for drug and alcohol-related problems by “provid[ing] support to those who need assistance confronting the disease of alcoholism and drug dependence.” The importance of the council goes well beyond its casual transformation of what The Big Book claimed of alcoholism however as it has deemed “addiction as an illness, not a character flaw,” which opened up the addiction-model of illness for revision. This becomes increasingly vital to the conversation through the council’s formal directive firmly recognizing that “alcohol is addictive and the state of addiction to alcohol is known as the disease of alcoholism.”

From its outset, Mann’s organization looked to champion the cause of changing people’s attitudes toward alcoholism, embarking on a mission to de-stigmatize the word and help those affected receive any necessary professional help they might need throughout their recovery. By the organization’s own historical account though, “for [the] N.C.A.D.D. to be a credible agent for changing people’s attitude and understanding of alcoholism, it would need the involvement and support of the medical scientific community.” In order to gain broader support for alcoholism as a disease-concept, they developed and published a formal “criteria for the diagnosis of alcoholism” in 1972. This criteria led to “Operation Understanding” in 1976, which represented “the first large scale, historic public celebration of recovery,” that included the likes of Buzz Aldrin and Dick Van Dyke among fifty-three public figures who “stood up and spoke openly about their recovery in an effort to reduce stigma and increase public understanding and support for alcoholism as a treatable disease.” Extensive press following Operation Understanding – which Newsweek called “one of the most important news stories of the ’70s” – gave the disease-concept of alcoholism further credibility, but also helped Mann’s council gain the trust of regulators in the council’s creation of a formally accepted model for alcoholism treatment.

The N.C.A.D.D. has remained a catalyst for such semantic confusion surrounding alcoholism’s medical definition, leaving the term to represent both a symptom of spiritual conflict and a progressive illness that remains just as dependent on cultural trends and lifestyle promotion as it does on genetic vulnerability. Findings presented in 1997 by Andrew C. Heath, for example, revealed that genetic factors accounted for as much as two-thirds of an individual’s predisposition toward alcohol dependency (“environmental factors” accounted for the remaining third), but what remains is a muddy understanding of why individuals fail to stop drinking when they start on their own accord. While proponents of the disease-concept of alcoholism are quick to assign genetics a pronounced role in support of the disease definition, to further support dependency as something other than a complex maladaptive behavior diminishes the significant role that numerous other physical factors play in sustaining addiction. The lines of what constitutes alcoholism are no better defined after inspection as they were before.

Due to its nature as a diuretic, moderate alcohol consumption often leads to dehydration and headaches, but depending on the extent of consumption habits, heavy drinkers are prone to experiencing numerous withdrawal symptoms including nausea, shakiness (delirium tremens), sweating, anxiety, increased blood pressure, rapid heart beat, cravings, and insomnia. Beyond the basics however, the extensive cellular damage caused by various levels of alcohol abuse behold some of the most revealing aspects of the substance’s damaging physical effects. Plenty of people grow up under the exact same circumstances, yet evolve differently based on environmental input and individual physical chemistry. Dopamine, for example, controls the brain’s pleasure and reward centers while mediating addictive and impulsive behavior, also enabling people to feel the most enjoyment from pleasurable experiences. But how the brain reacts to external stimuli, such as alcohol, on an individual basis is somewhat unpredictable. When we drink, alcohol is broken down into ethanol, water, carbon dioxide, and acetic acid or acetaldehyde (a toxic product which damages D.N.A., no less) before the liver and the stomach (as well as other tissues such as the brain) begin to metabolize the alcohol. While alcohol initially increases the release of dopamine, chronic alcohol exposure to the brain hijacks this reward reinforcement by decreasing the release of dopamine, leading to anxiety and craving. All of this plays a significant role, beyond that of genetics or “disease,” in shaping individual reaction to alcohol.

The fallout and feelings of emptiness that follow a hearty bender can be extreme, leading to full-body withdrawal and severe depression, but sustained alcohol abuse can also have lasting ramifications on the body. High levels of consumption can lead to degradation of white matter, which connects neurons and allows for communication between different areas of the brain, compromising how the brain learns and functions, potentially leading to atrophy. Even moderate drinking can play a pronounced role in aiding the development of cancers (estrogen receptor-positive breast cancer in women, for example), and can lead to excessive production of insulin prompting Adult Onset Diabetes, as well as the development of a fatty liver, better known as Alcoholic Liver Disease. Alcohol not only leads to dehydration, but also depletes minerals in the body including zinc and calcium which then contributes to such diseases as osteoporosis. Depending on intake, individuals also experience severe nutritional deficiencies, poor absorption of vitamins, and significantly depleted levels of glutamine, magnesium, and Omega 3 fatty acids. If any conclusion were to be made when considering the physical effects of heavy alcohol consumption on the human body, it might be that “recovery” is not simply overcoming a physical addiction, but that it is a method of attempting to re-establish normal brain chemistry and physical health. “Disease” is a very important word when considering the effects of prolonged alcohol abuse on the body for a number of reasons, none of which have to do with spiritual neglect.

As with the A.A./religion debate, some individuals’ intentions are clearer than others regarding alcoholism as a disease. But when challenging the concept, the tendency to rally around ambiguous slogan-jockeying remains high, many defenders claiming alcoholism a disease of despair, a disease of relapse, or that it simply leaves individuals in a state of dis-ease. “I’m allergic to alcohol,” some joke, “When I drink it, I break out in handcuffs.” Some disease. The true impact of the disease smokescreen begins with personal responsibility though, something individuals are often relieved of by the very nature of the disease-concept.

In 2011 social anthropologist Kate Fox released the findings of her assessment on binge-drinking, revealing a dramatic conclusion that speaks far beyond the realm of simple addiction or dependency. As she explained, “[we] believe that alcohol has magical powers – that it causes us to shed our inhibitions and become aggressive, promiscuous, disorderly and even violent. But we are wrong.” Uncompromising in her position, she continued by addressing “ambivalent” drinking-cultures. “In high doses, alcohol impairs our reaction times, muscle control, coordination, short-term memory, perceptual field, cognitive abilities and ability to speak clearly. But it does not cause us selectively to break specific social rules.” Alcohol, itself, she argued, does not lead to disinhibition, aggression, promiscuity, violence, or anti-social behavior, all of which are cornerstones for drunken folklore. Instead, the effects of alcohol are determined more by cultural rules and norms. “There are other societies (such as Latin and Mediterranean cultures in particular, but in fact the vast majority of cultures), where drinking is not associated with these undesirable behaviors – cultures where alcohol is just a morally neutral, normal, integral part of ordinary, everyday life – about on a par with, say, coffee or tea.”

The disease-concept of alcoholism is dangerous in that it promotes tendency in the name of victimhood, forgiving consequences through a misunderstood acceptance that problem drinkers are stricken with an illness that strips them of choice, preventing them from thinking for themselves under the slimy guise that there is something fundamentally wrong with them that stops them from doing so. Further, asserting that any problem drinker cannot stop if they want to allows the disease-concept to support relapse by upholding the belief that personal choice and voluntary actions play an insignificant role in reinforcing addiction. Yes, alcohol affects individuals who drink it, and yes, heavy consumption on a regular basis has consequences on the mind and body which are still not entirely known, but genetic susceptibility, a chemical imbalance, or habitual over-consumption should not dismiss personal accountability. To deny alcoholism as a disease might seem a dispute of semantics, but it has a lot to do with how problem drinking is handled in America, and through the involvement of such organizations as Mann’s N.C.A.D.D. the disease-concept has been manipulated in order to reconfigure a nation’s legal process, also inspiring the creation of a multi-billion dollar industry.

The United States stands alone in terms of its widespread acceptance of Alcoholics Anonymous as the leading model for recovery from alcohol dependency. The results of the Pew Forum’s 2008 U.S. Religious Landscape Survey revealed that nearly 80% of Americans affiliate themselves with a Christian religious tradition, so it’s not entirely surprising that a spiritual treatment program would hold the largest market share in what has developed as a vastly puritanical society. But what is curious is how this program has infiltrated numerous federal bodies through the widespread dissemination of the disease-concept of alcoholism.

The bulk of the events that impacted the development of America’s treatment industry can be traced back to legislation introduced by President Lyndon B. Johnson aimed at tackling the nation’s skyrocketing poverty rate. One of the main organizations established in response to the “War on Poverty,” as it was called, was the Office of Economic Opportunity (O.E.O.). Established in 1964, the O.E.O. helped smooth out the local application of federal funds, aimed directly at benefiting sub-poverty line citizens. Fast forward a bit to 1968 in Austin, Texas where the defendant Leroy Powell was charged with public intoxication and fined $20. Though initially insignificant, the case would be crucial in reshaping the entire face of alcoholism treatment in the country.

Initially found guilty, Powell appealed his case, arguing that he suffered from the disease of alcoholism and the punishment was not only cruel and unusual, but that it violated the Eighth and Fourteenth Amendments. Powell’s plea to the Travis County Court was considered, but the ruling was upheld. With no other option for appeal within the state, he took his case up with the United States Supreme Court. Peter Hutt, a veteran attorney who specialized in food and drug law, and worked on numerous cases of a similar nature for nearly a decade prior, took up Powell’s case and filed the brief on behalf of a variety of alcohol, medical, religious, and legal organizations and associations.

The case did not challenge whether or not Powell was drunk in public, but that he was incarcerated and fined because he was sick from his illness in public. Using the 1962 Robinson v. State of California case, which determined that the criminal justice system could punish acts but not status, the Supreme Court concluded that chronic alcoholism is a disease which destroys the afflicted person’s willpower to resist the constant, excessive consumption of alcohol; that a chronic alcoholic does not appear in public by his own volition but under a compulsion symptomatic of the disease of chronic alcoholism; and that Leroy Powell was such a chronic alcoholic who was afflicted with the disease of chronic alcoholism. In a vote of five to four, judges ruled in Powell’s favor, declaring that alcoholism was a disease in the eye of the law.

Hutt continued his work by further redefining public drinking laws, later acting as a key proponent behind legislation that spurred a comprehensive revision of the District of Columbia’s intoxication and alcoholism laws (where public intoxication was redefined as a public health problem rather than a criminal offense). This led to new provisions which prohibited “disorderly” public intoxication, paving the way for court-mandated detox centers as well as inpatient and outpatient alcohol treatment through legislation that redefined rights under the prevailing disease-concept of alcoholism. Such rulings stated that “a chronic alcoholic is a sick person who needs, is entitled to, and shall be provided adequate medical, psychiatric, institutional, advisory, and rehabilitative treatment services of the highest caliber for his illness.” As all of this change was building momentum, in 1969 the Senate’s Labor and Public Welfare Committee held a related series of landmark hearings in Washington, D.C.

Under the guidance of Senator Harold Hughes (himself an A.A. member), the hearings used numerous respected voices in addition to a small army of A.A. members, who all testified in defense of the need for the government to increase its efforts in dealing with alcoholism and drug abuse; sensitive issues made that much more pronounced at the time by troops returning from Vietnam with violent drug and alcohol addictions. Referencing then-credible scientific evidence while leveraging her own well-publicized story of triumph, Marty Mann testified, as did Bill Wilson, who spoke to the dire need for federal funding to help guide research and treatment. (While speaking for himself, such public displays conflicted with the Twelve Traditions‘ sixth tradition that Alcoholics Anonymous “ought never endorse, finance, or lend the A.A. name to any related facility or outside enterprise, lest problems of money, property, and prestige divert us from our primary purpose.”)

Mercedes McCambridge, who won the 1949 Academy Award for Best Supporting Actress for her work in All the King’s Men, also contributed her name to the cause by adding her own testimony, appealing to the everyman nature of alcoholics. “Nobody need die of this disease,” she said. “We are eminently salvageable. We are well worth the trouble. We are eminently equipped to enrich this world. We write poetry, we paint pictures, we compose music, we build bridges, we head corporations, we win the coveted prizes for the world’s great literature, and too often too many of us die from our disease… not our sin… not our weakness.” In response to her speech, Senator Ralph Yarborough replied, “Miss McCambridge, I vote you another Oscar, this time for your public service.” The hearings resulted in the formation of the Senate Special Subcommittee on Alcoholism and Narcotics, which was intended to be a temporary subcommittee that would study the issue and recommend further legislation. Chaired by Senator Hughes, this would later became a permanent panel, taking on a staff and changing its name to the Subcommittee on Alcoholism and Drug Abuse, formally casting aside any perception of impermanence. Federal funds weren’t immediately available until the Subcommittee’s efforts became focused on the passing of the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970 (also known as “the Hughes Act”). Bill Wilson called the Hughes Act the “Big Twelfth Step Effort.”

Once passed by Congress, the Hughes Act sought to help those suffering from alcoholism by offering assistance for those in need of substance abuse treatment. It also established a single agency, the National Institute on Alcohol Abuse and Alcoholism (N.I.A.A.A.), which would oversee alcohol and drug abuse prevention and treatment programs, and control the dispersal of related Federal grants. (To this day the institute oversees about 90% of all such funding.) The phrasing of the legislation left plenty of room for interpretation as to what exactly funds and efforts were to be focused on though: The Hughes Act “may make grants to public and nonprofit private entities and may enter into contracts with public and private entities and with individuals,” promoting “projects of a demonstrable value in developing methods for the effective coordination of all alcoholism treatment, training, prevention, and research resources available within a health service area.” This might have lead to divisive competition between a variety of organizations promoting numerous models of treatment, but previous relationships had already established which organizations would receive the most funding.

The institute quickly looked to establish a bond with Marty Mann’s council due to its perceived expertise in the field, a connection which in part stemmed from the key role Mann played in its creation. Likewise, Mann’s council became dependent on the institute’s funding as it began to grow. By 1976 the council’s budget reached $3.4 million, the bulk of which was from federal funding. In 1971 Harold Hughes, who would later serve as an N.C.A.D.D. board member, received the organization’s Gold Key Award, “to honor individuals who have made outstanding contributions to the field of alcoholism on a national level” for his role in the mutually beneficial proceedings. That same year, as all of this was happening, the Uniform Alcoholism and Intoxication Treatment Act was adopted to nationally promote the legal statute that evolved out of the Leroy Powell case. The clinical framework needed for those suffering from alcoholism would have remained underfunded had there not been a federal organization to make such necessary financial appropriations. If the Uniform Act certified that authorities could no longer put individuals publicly suffering from the disease of alcoholism in jail, it also raised the question of what was to be done with such people. This was where the detox, inpatient, and outpatient vehicles came back into the picture. Fortunately, the funding needed to help implement such a system, offering alcoholics what they were now “entitled to,” was available through the N.I.A.A.A., which now subsequently existed in part due to legislation drafted by Peter Hutt.

Funding was now in place, and the system which was to handle those suffering from the disease of alcoholism was beginning to take shape, but the question remained: Who would treat such individuals and what system of treatment would help them? The question of what qualifies a person to treat alcoholics was fiercely stirred in 1963 when Michigan psychiatrists Henry Krystal and Robert Moore first debated the issue. The foundation for their argument revolved around whether recovered alcoholics should assume the role of “treatment specialists” due to their personal histories, and whether recovered alcoholics were equipped to deal with the wide ranging clinical complexities associated with alcoholism. Stemming from their conclusions, institutions continued to selectively recruit recovered alcoholics into their treatment programs for years to come.

One of the key aspects to remember is that Alcoholics Anonymous, organizationally speaking, defends the position that in pursuing the final of its 12-steps (which reads, “Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs”) that members are to reconcile this mission to spread “the good news” per A.A.’s Twelve Traditions. Out of this context is where the term “two-hatter” was born, representing those who continued to promote A.A. as recovered alcoholics, while simultaneously developing roles for themselves within specialized treatment centers. The Twelve Traditions continue, “Alcoholics Anonymous should remain forever non-professional. We define professionalism as the occupation of counseling alcoholics for fees or hire. But we may employ alcoholics where they are going to perform those services for which we might otherwise have to engage nonalcoholics. Such special services may be well recompensed.”

While President Johnson’s “War on Poverty” continued, by the 1970s the Nixon administration made it very clear that little consideration was to be paid to the assistance of psychiatric and other wellness programs. The Hughes Act, for instance, had been prominently opposed by the administration despite being passed, due in part to support of celebrity lobbyists who were assembled by Senator Hughes. It was right around the time Hughes faced the Senate’s Labor and Public Welfare Committee that Matt Rose, himself of the Office of Economic Opportunity, approached Hughes to discuss the O.E.O.’s forthcoming legislative renewal, where he proposed an idea for an amendment to the bill.

While the Nixon administration made it clear that no federal employees, with the exception of official lobbyists for the government, were to try to influence legislation, Rose went against these adamant orders in reaching out to Hughes. Recognizing that Hughes served on the Employment, Manpower and Poverty Subcommittee which had jurisdiction over the O.E.O. bill, and understanding the Senator’s position on alcohol treatment reform, Rose (himself a recovered alcoholic who found spiritual enlightenment through A.A.) proposed that the bill be amended to include additional funds for the treatment of alcoholism. Hughes approved of the idea and pursued the amendment with the committee’s chairperson, Senator Gaylord Nelson of Wisconsin, when it was brought to Senate as a larger legislative package later that year.

Chairing the eventual hearing was again Senator Yarborough, who previously held an influential role in approving the formation of the Senate Special Subcommittee on Alcoholism and Narcotics, and who explained that this “new national program of alcoholism counseling and recovery be undertaken in conjunction with the war on poverty,” calling for $10 million to be authorized in 1970 and $15 million in 1971 to pursue such efforts. Relying on the wave of testimony earlier in the year from Hughes’ assembly of recovered alcoholics, Yarborough continued by saying, “It is clear that a worker, a housewife, a family cannot fully benefit from services provided by O.E.O. or community agencies if each step forward is to be canceled out by debilitating effects of alcoholism or problem drinking.”

As the Nixon administration wore on, the O.E.O. was systematically disassembled, with successful divisions absorbed by other federal departments. In 1973 Nixon appointed Howard Phillips as the Director of the O.E.O., which essentially served as the agency’s deathblow. While it wasn’t abolished until 1981, the O.E.O. was but a shell by then, entirely de-funded and stripped to its core with finances reallocated to other projects and organizations. During that time Matt Rose retained responsibility for the dispersal of previously allocated funds which included nearly 200 “War on Poverty” grants that were financing low income areas as well as minority beneficiaries, redirecting these funds to the N.I.A.A.A.

It was during this time that Rose retired from his government work, leaving him to focus on the development of the National Association of Alcoholism Counselors and Trainers (N.A.A.C.T.). Founded in 1974, the objective of the association was to “develop a field of professional counselors with professional qualifications and backgrounds.” With Rose serving as the Executive Director, the organization established the first minimum national standards for certification which would be used in the treatment of alcoholism, answering the need posed by the Uniform Act by defining what alcohol treatment was, how it could be implemented, and who was qualified to implement it.

Decades later in 1992 Robert Dorris, the association’s first President, explained the initial process of facilitator development in an interview with The Counselor. “Our objective was to hire people to become counselors and trainers. Since each of us was an alcoholism trainer, we had access to students, who once trained, could be placed in community service organizations. Once our own programs were in place, we organized ourselves into a national association so that we could have credibility. We knew that once counselors received training, they had to join ‘normal’ society and be a member of a professional association, just like other professions. [The] N.A.A.C.T. was founded to make alcoholism counselor trainers look professional. Our original idea was to have counselors train people in communities to deal with the growing alcoholism problem. The training we taught was not based on clinical skills; it was based on a community development model with emphasis on A.A. We discussed the development of a disease concept, what counselors’ attitudes should be toward clients, what involvement churches and community organizations should have, and we concentrated on the political structure since City Hall had the funding and resources we needed to provide our services.” By Dorris’ own account, the majority of the counselors who worked in such programs at the time had no professional training, but were deemed as competent because of the skills they’d developed in their own recovery from alcoholism. The association served to lend wounded healers formal certification as accredited treatment specialists, also solidifying A.A.’s 12 Step model as the foundation for alcohol treatment in America. As for “such special services may be well recompensed”: in the 2011 fiscal year the N.I.A.A.A.’s budget was $458.3 million.

From here, inconsistencies continued to flourish well beyond the act of calling alcoholism a disease. By 1982 Rose’s association had joined with five other organizations, formally uniting as the National Association for Alcoholism and Drug Abuse Counselors (N.A.A.D.A.C.). However, one of the keys lost in the incorporation was that of a national standards initiative, leaving each state to act on its own in defining qualifications for counselors. Additionally, by 1985 only thirty-four states had implemented the Uniform Act, signifying deeper discrepancies that blur the lines of unified treatment theory: In a 2012 state-by-state analysis, The National Center on Addiction and Substance Abuse at Columbia University reported that fourteen states still do not require addiction counselors in all settings to be licensed or certified. These organizations not only failed to establish commonly agreed upon standards under which alcohol treatment could be administered, but also neglected to determine a model of certification that delineated between who was and who was not authorized to provide specialized treatment. What the united organization did do, however, was create a treatment industry explosion structured around a limited accountability model based on a niche-group’s ideological foundation.

In 1966 there were fewer than two-hundred alcohol treatment programs in the United States. By 1977 there were 2,400, and by 1982 the Substance Abuse and Mental Health Services Administration (S.A.M.H.S.A.) registered 4,233 programs for the treatment of alcoholism. By 1990 that number hit nearly 8,000. Citing profound religious reasons, Senator Hughes retired from politics in 1973 to dedicate himself to the treatment of those inflicted with the disease of alcoholism. “Rightly or wrongly, I believe that I can move more people through a spiritual approach more effectively than I have been able to achieve through the political approach,” he said at the time. Creating his own private alcohol treatment center in the early-1980s, the Harold Hughes Center was eventually absorbed by the Des Moines General Hospital, just one of the 13,339 substance abuse facilities that reported to S.A.M.H.S.A.’s 2010 national survey.

While the trend of modifying legislation to accommodate for the disease-concept of alcoholism started all the way back with the Powell case, and has led to various states incorporating alcohol treatment into the field of insurance regulation (though, again, the general lack of national treatment standards has led to only forty-three states requiring major insurers to cover alcohol treatment), the most disturbing result of the Uniform Act has come with the widespread trend of court-ordered substance abuse counseling. The past two decades have seen a sharp increase in cases on both federal and state levels that not only challenge the court’s role in mandating substance abuse treatment, but cases that challenge how forced participation in 12-step programs actually comes in violation of constitutional rights.

The details of Robert Warner v. Orange County Department of Probation, for example, found that the grounds of Warner’s probation, which subjected him to mandatory A.A. meetings, constituted forced participation in a religious activity. The second circuit ruling stated there was “no doubt” the A.A. meetings Warner attended were “intensely religious events,” and because he was not offered an alternative of a non-religious recovery group, his continued attendance was “decidedly influenced by the possibility that any objections or non-compliance could lead to a jail sentence or revocation of probation.” Legal precedence notwithstanding, subsequent rulings have concluded that “requiring a parolee to attend religion-based treatment programs violates the First Amendment,” and yet A.A. meetings and 12 Step groups are still being included as factors in court sentencing.

This is precisely the point where the arguments from countless A.A. apologists – who might otherwise defend the nature of Alcoholics Anonymous as a system of beliefs that should be cherry-picked from, encouraging development of select principles and ideals that work for them while shrugging off the rest – falls apart. This is where such vague concepts as a Higher Power or a God as you might understand Him within the context of substance abuse recovery goes far beyond overcoming “spiritual neglect.” This is where the essence of the A.A. fellowship is corrupted by the persistence of some to include the A.A. name where it was never intended to be. This is where the foundation of A.A. became debased by the intentions of those seeking the widespread installation of a 12 Step recovery model, much to the anger of many within the A.A. community themselves. This is where some A.A. members have seen their organization misused (representing matters that are misaligned with their organization’s fundamentals) while the legal system acts as an adjunct recruiting mechanism in their missionary machine. This is where A.A. becomes a measure of involuntary, court-mandated indoctrination. This is where outsiders become angry at the take-it-or-leave-it attitude, because in many instances “leaving it” is not an option when doing so violates legal mandates such as probation. This is where the seemingly harmless distinction that A.A. is a spiritual program and not a religious one seems only a convenient self-supporting redefinition used to justify the many decades of federal funding for 12 Step programs and the A.A. message. This is why many are mad, why many linger in suffering, and why many others do not get the help they actually need.

A 2012 report revealed that roughly half of all individuals treated for illegal drug problems are ordered to court-mandated treatment. Court-mandated treatment often directs individuals into the same recovery model that was built upon religious fundamentalism, promoting spirituality over accountability and repentance over self-respect. A recovery model that maintains widespread credibility due to more than five decades of unopposed implementation initiated by government officials who redirected federal funds in the development of a public system that reflected personal religious ideals.

Guiding vulnerable individuals who are in need of help with their addictions into a system that serves a distinct religious purpose would be shameful enough on its own if it did not also serve to confuse such people about whether or not their life was the product of a diseased body. In the face of contention over the disease concept of alcoholism, advocates lean back on their platform promoting 12 Step’s venerable success rates as championed through The Big Book. But The Program does not work for most. Instead, 12 Step recovery shows an abysmal success rate, even compared to those who recover on their own without any formal treatment whatsoever. While such misinformation leaves both A.A. members and non-members confused about how beneficial government-supported 12 Step treatment actually is, not even decades of disease arguments, questionable legislation, or manipulative truth-twisting can mask the reality of A.A.’s own self-reported 5% success rate.

Prologue: Letting Go
Chapter One: Surrender
Chapter Two: One Nation Under the Influence (current chapter)
Chapter Three: Untreatable
Chapter Four: A Crisis of Identity
Chapter Five: All or Nothing
Chapter Six: Reconsidering A.A.
Chapter Seven: Adaptation
Chapter Eight: Clarity