In December, Gov. Kathy Hochul of New York unexpectedly vetoed a bipartisan bill that would have required judges to inform drug court participants of their right to choose nonreligious rehabilitation.
The governor didn’t dispute that New Yorkers are entitled to secular care when ordered to treatment. Rather, she said she nixed the bill because disclosure requirements could become a burden for judges. But the omnipresence of religious addiction programs — and the rarity of therapies that don’t preach reliance on God — is a burden for people with addiction.
Today, around two-thirds of American addiction treatment programs for alcohol and other drug disorders, including over 90 percent of residential treatment centers surveyed, use the 12 steps originated by Alcoholics Anonymous, often telling patients that this is the only way to recover. These 12 steps — common to other “anonymous” groups, like Narcotics Anonymous — are based on Christian principles. A.A.’s founders were members of an early-20th-century revival movement known as the Oxford Group, and they adopted the steps from its doctrine.
As part of voluntary self-help, the 12 steps can be powerful and life-changing. But they can also do harm when treatment centers or judges impose them without providing other options.
Delving into the content of the steps is required to understand how religious they are. The first three include admitting “powerlessness” over substance use and turning “our will and our lives” over to the care of a higher power to “restore us to sanity.” While some members argue that this power can be anything other than oneself — even a doorknob — it’s hard to see this as anything other than a stand-in for a loving God.
The rest of the steps include taking “moral inventory,” uncovering “defects of character” that are thought to underlie addiction and praying for God to “remove” them. Many meetings close with the Lord’s Prayer. Such clearly religious practices would not be accepted as medical or psychological treatment for any other condition.
Treatment programs that center their approach on the steps argue that they are spiritual, not religious. They point out that because some atheists and non-Christians credit A.A. for their recovery, its Christian ideology is irrelevant.
However, dozens of courts have ruled on this issue, and determined that 12-step programs are indeed religious, making it unconstitutional to require participation. For example, a Buddhist pilot recently won a $305,000 judgment against United Airlines; he had been unable to obtain the medical certificate permitting him to fly again after demanding an alternative addiction treatment.
To make real progress in fighting overdose and addiction, we need to separate medical care and religion in treatment, as we do for every other health disorder. Voluntary 12-step groups can be beneficial, but they are not and never should have been seen as therapy for addiction. Advances in treatment — like the use of medication for addiction — should not be delayed because religious ideas from self-help groups rarely change in response to medical progress.
Alison Gill, vice president for legal and policy issues at American Atheists, which helped draft the legislation Governor Hochul vetoed, said her organization regularly hears from people who have been forced into religious treatment by judges or employers. “The courts have been very clear that that’s unconstitutional,” she said.
There is good historical reason for the strange marriage of faith and medicine in addiction care. By the 1930s, the health system had backed away from treating alcohol and drug problems, leaving few options for those who needed help.
However, after a stockbroker, Bill Wilson, and a proctologist, Bob Smith, known as Dr. Bob, started A.A. in 1935, stories of its success restored hope for recovery. Physicians began to develop formal treatment programs centered on it. This became known as the Minnesota Model because it was developed in that state at programs like Hazelden, which is still a leader in the field.
Many people with addiction — including me when I was given no other option in treatment — do find aspects of 12-step programs helpful. But research suggests that the active ingredient in their success is peer support, not the steps themselves, because secular groups seem to be similarly useful.
Many people find success with A.A. However, fewer than half of 12-step participants are abstinent for a year after starting, and it is clear that additional options are needed. Since the 1990s, researchers have known that different approaches for alcohol use disorders — such as cognitive behavioral therapy and motivational enhancement therapy — are just as effective at reducing heavy drinking and its consequences.
Given all of this, since 12-step groups are free and easily available outside of professional treatment, it makes little sense for government or insurers to pay rehabilitation centers that use the 12 steps in therapy groups and daily programming for these services, as they do currently. Instead, government payers and insurers should spend their limited funds on approaches that aren’t free elsewhere and that don’t have constitutional issues.
When it comes to opioid use disorder, religious elements of 12-step programs can be especially harmful. Narcotics Anonymous, the group focused on opioid addiction, is philosophically opposed to the most effective medications — methadone and buprenorphine. The group says in its literature that N.A. is a program of total abstinence — so people using these medications are not considered “clean.” This is an article of faith, not a principle based on data.
In practice, it means that in many groups, N.A. members who take medication are not permitted to speak at meetings and are not allowed to count their days of recovery (since they are “still using,” even by taking only prescribed medication). Some N.A. members shame and disparage medication, pushing cessation. A study of 368 rehabs across the United States found that 21 percent actively advised researchers posing as patients to avoid medication, in line with N.A.’s position.
This stance ignores decades of data: Buprenorphine and methadone are the only treatments that reduce the death rate from opioid use disorder by 50 percent or more — no abstinence treatment has been shown to have this lifesaving effect. Since these medications work only as long as people stay on them, encouraging quitting can put lives at risk, especially with a street market so flooded with fentanyl that a single return to use can be deadly.
So how can addiction medicine be brought into the 21st century? First, as we do with other disorders, we need to separate the medical and psychological guidance given in treatment from the ideology of religious support groups. In cancer care, the doctrine of support groups doesn’t dominate treatment. Oncologists, for example, don’t argue that only people who receive chemotherapy count as being in remission, not those who use radiation. The specialty as a whole recognizes that different people need different regimens.
Religious and spiritual support groups can still be critical to cancer care: Some patients couldn’t persist through harrowing treatments without them. But this doesn’t mean that the advice of fellow sufferers supersedes that of physicians — and the same must become true for addiction treatment.
Of course, a divorce between support and treatment needn’t mean that rehabilitation programs be banned from recommending or discussing 12-step principles or making meetings available. Instead, programs need to replace daily counseling sessions, therapy groups and lectures that teach them as gospel with unqualified support for multiple recovery paths and evidence-based therapies.
Separating 12-step and treatment also doesn’t mean rejecting the critical role that people in recovery play in helping each other. However, when hired as professionals, they need to be trained in multiple approaches.
As the death toll from overdose has risen, Dr. Chinazo Cunningham, commissioner of New York State’s Office of Addiction Services and Supports, has seen more willingness to change among providers. “I think that people really understand the need for providing medication treatment and evidence-based treatment,” she said.
An irony here is that A.A.’s co-founder Bill Wilson once told Vincent Dole, a co-developer of methadone treatment, that he hoped a similar medication could be found for alcoholism. He didn’t see A.A. as the only way to sobriety. In fact, he personally found LSD therapy useful — an idea supported by more recent studies suggesting that psychedelic drugs may aid recovery.
No single approach is ever likely to work for everyone who struggles with this complex condition. But we owe it to those who have substance use disorders to ensure that secular, science-based treatment is the mainstay of their medical care, especially when rehabilitation is court mandated.
Maia Szalavitz is a contributing Opinion writer and the author, most recently, of “Undoing Drugs: How Harm Reduction Is Changing the Future of Drugs and Addiction.”
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