Autonomy and 12-Step Therapy: Can They Co-Exist?

Autonomy is a fundamental ethical right that allows mental health and substance abuse clients to make informed decisions about the course of their treatment. Legally speaking, autonomy is a liberty interest that is protected by the Fourteenth Amendment. 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 client's right to informed self-determination.

At each level, autonomy is an indispensable ingredient in the appropriate treatment of addicted persons, but realistically, it is a qualified right. For instance, institutional and therapeutic goals may limit the client's right to self-determination. Clients obviously lack the freedom to engage in behaviour that disrupts the orderly administration of treatment, for example. For similar reasons, facilities may impose reasonable consequences in an attempt to correct self-destructive behaviour. In these cases, where the claim to autonomy is outweighed by legitimate institutional goals, the resulting tension is resolved in favour of the facility.

Autonomy is influenced by other factors. Many clients enter residential treatment centres as the result of outside coercion, such as court action or employment demands. Bufe (1995) reports that coerced individuals constitute a majority of those undergoing treatment. 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 himself or herself. These measures are legally and ethically proper.

A Unique Profession
Setting these cases aside, autonomy interests are often overlooked in the addictions treatment field, 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 that has historically given autonomy a low, and unenforced, ethical priority. The relationship between the addictions counsellor and the client is also unique. Unlike most professional relationships, addictions counsellors often assume that clients are incapable of making important decisions in the most intimate areas of their lives. These counsellors 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 counsellors, namely, that addiction overrides the client's ability to make decisions in his/her own best interest. According to Bissell & Royce (1994, p.24):
"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 ... The 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 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 12 steps and the disease concept of addiction as principle therapeutic tools.

AA in the Institution: Collision of Values
The traditions of Alcoholics Anonymous contain a strong commitment to non-professionalism and individual autonomy. Tradition 6 states that AA groups "ought never endorse, finance or lend the AA name to any related facility or outside enterprise." Tradition 8 states this principle a bit differently: "Alcoholics Anonymous should remain forever non-professional..." In support of AA'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 "counselling of alcoholics for fee or hire," AA's traditions incorporate autonomy and equality as guiding principles.
Over the years, most residential treatment facilities have incorporated AA teachings into their daily treatment plan (Roman & Bloom 1997). Most facilities host AA meetings, provide 12-step lectures and workshops and, most importantly, require their clients to complete a number of AA's 12 steps as a prerequisite to graduation. AA "language" is common parlance in these facilities, among both staff and clientele. It is fair to say that AA's commitment to non-professionalism has been set aside in these facilities, where addicted clients are strongly encouraged to incorporate highly charged spiritual-indeed, moral-principles into their daily lives. This forced marriage of AA's guiding principles and professional authority is a combustible mix, one that AA's founders were careful to avoid. At the institutional level, mandatory AA participation raises serious questions. By definition, AA presents a recovery program that carries significant moral overtones. When AA participation is encouraged in the residential facility, these principles are fused with institutional and therapeutic authority that converts AA into a mandatory, rather than an elective, rite 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
Many inpatient facilities rely heavily on the disease concept, which defines addiction as a medical illness characterized by mental obsession and a corresponding desire to use drugs despite adverse consequences (NIAAA, 1993). The disease model conceptualizes addiction in a simple manner that most addicted persons can identify with and understand. The disease concept also serves as a useful therapeutic tool by placing an intervening agent, the disease, between the addict and his/her behaviour. This reduces shame and guilt, facilitating 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 behaviour 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-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.

Many Faces of Coercion
With the backing of institutional sanction, AA therapy and the disease concept provide fertile ground for systematic overreaching into important autonomy interests. Technically, all autonomy violations occur through fraud, coercion, or undue influence. In each violation, a person with special knowledge and control dominates 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 residential treatment centres based on the 12 steps. Consider the following example, which is a composite drawn from addicted persons I have worked with as an attorney.
William, 19, has a history of drinking problems. After a recent DUI, his probation officer told him he would go to jail if he did not successfully complete an inpatient alcoholism program. He admitted himself to a facility that boasted a "75% success rate" for graduating clients, but his attitude was poor, and when he failed to complete and present his "First Step," his counsellor 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 he said he would not participate, his counsellor 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 counsellors and two members of his group. The director, who had no clinical training, reminded him that his probation officer would be contacted if he did not start "working on his recovery." The other group members and his counsellor told him he was "in denial" and had to "surrender" by "turning his will over to the group" (again, all common AA sayings). He refused.
Two hours later, William was told to pack his bags and leave. The next day, the director of the facility called his probation officer, and a warrant was issued for his arrest. After learning that William had 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.

Abuse of Trust and Power
William's story demonstrates how AA teachings and the disease concept are routinely misapplied in the residential treatment setting. It also illustrates how these principles create an atmosphere in which the client is given no choice but to conform to the expectations of a unified group process. William's counsellor 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").
The pressure was intensified when William was outnumbered in the second "intervention," as his counsellor 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 he was forced to choose between treatment and jail. 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, counsellors and group members 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 AA meeting, where it is not, creates a dangerous battleground where autonomy is reduced to a variable that the therapist can disregard when he determines that intervention is required.

Taking Inventory
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" (Boland & Lindloom, 1992). 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 behaviour of members. Behaviour that is not compliant is often viewed as resistant or a sign of character flaws. These behaviours are then targets of 'therapy,' with the goal being that the member would surrender the identified deviance and adhere to group norms."
A number of common factors present themselves in facilities that promote institutional or therapeutic goals over the client's right to autonomy. Questions should include the following:
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 may 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 12-step therapy. This dynamic is especially dangerous when the facility fails to diagnose co-occurring disorders that are beyond the reach of traditional 12-step therapy.
Does the facility impose consequences against clients who resist therapy? Rigid, 12-step facilities promote compliance over the honest expression of thoughts and feelings. Clients who resist are subject to group pressure and perhaps punishment as well. Clients who fail to respond are often blamed for their refusal to "surrender," labelled "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 about 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 ensure that personal bias does not override the client's best interests.
Are financial relationships manipulated to discourage autonomy? Many residential facilities require prepayment or otherwise bill for services that have not yet been delivered. It is not uncommon for a client to be 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? Sometimes clients who leave "against medical advice" are not permitted to contact remaining clients or even their counsellor. I know of a halfway house in Northern Arizona that "terminates" clients by giving them 30 minutes to leave or face arrest. These coercive practices put pressure on the client, forcing him/her to choose between inappropriate therapy and potential homelessness.
Are unlicensed administrative staff allowed to participate in therapy? Some facilities have no enforceable boundaries that prohibit administrators and non-clinical staff from intruding in the clinical realm. Thus, many administrators and adjunct staff provide "treatment" that is derived solely from personal experience. By blurring the line between 12-step and legitimate therapy, these individuals wield considerable influence in an area in which they are unqualified.

Conclusion
Understandably, many addictions counsellors feel a sense of urgency when dealing with a reluctant client. As with most serious disorders with mental or emotional components, addiction invites us to assume that the client is incapable of making decisions. This assumption places addicted clients on the same footing as legally incompetent persons and tempts the counsellor 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 is not therapy. It is a breakdown of the therapeutic process, one that reflects the counsellor’s inability to reach the client through conventional, ethical means.
Many counsellors feel that autonomy is always intact because the client has the absolute right to leave the facility at any time. This is a fallacy. 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 counsellor tells the client that early departure will result in inevitable relapse or even death. It is thus incumbent on the facility, and the counsellor, 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.

References
1. Bissell, L., and Royce, J. (1994). Ethics for Addictions Professionals, 24. Center City, MN: Hazelden Press.
2. Boland, K., and Lindloom, G. (1992). Psychotherapy Cults: An Ethical Analysis. 9 Cultic Studies Journal, 2, 137, 141.
3. Bufe, Charles (1995). Alcoholics Anonymous, Cult or Cure? Tucson, AZ: Sharpe Press.
4. National Institute on Alcohol Abuse and Alcoholism (1993). Alcohol and Health: Eighth Special
5. Report to the U.S. Congress on Alcohol and Health. Rockville, MD.
6. Roman, P., and Bloom, T. (1997). National Treatment Center Study Report 10, Institute for Behavioral Research, Athens, GA.