In 2006, Bill Miller and I shared a book signing at a state addictions conference in Arizona. I had long considered Bill one of the true scholars and gentlemen of the addictions field—a man whose insight and productivity was matched only by his personal integrity. As we chatted about our current projects, he asked me about the historical roots of the use of confrontation as a therapeutic orientation in addiction counseling. I knew parts of that history—particularly the confrontation techniques of America’s early therapeutic communities, but I acknowledged that I suspected there was much more to this story.
After the conference, I began piecing together disparate pieces of this history and contacted Bill to see if he would collaborate on an article on the history and scientific status of so-called therapeutic confrontation. He agreed and we prepared an article that we published in Counselor Magazine—a choice that reflected our desire to reach the largest possible number of addiction counselors. The article, published in the fall of 2007, traced the history of confrontation from the theories of Kolb and Tiebout through the therapeutic communities and fringe psychotherapies of the 1960s to the evolution of its use in Minnesota Model alcoholism programs. It then summarized the best studies on confrontation, noting the lack of evidence for its effectiveness and evidence for its potential harm. The article ended as follows:
It is time to declare a final moratorium on the use of harsh, humiliating confrontational techniques in addiction treatment. It is time to lay to rest once and for all the arrogant notion that we should or even can dismantle other human beings and then put them back together in better and wiser form. With impressive consistency, research tells us that authoritarian confrontation is highly unlikely to heal and may well do harm, particularly to the more vulnerable among those we serve. Within this context, such confrontational treatment is professionally unethical, and is doubly problematic when used with coerced populations such as court-ordered or employer-mandated populations….It is time to conduct a historical self-inventory of such practices, admit that these practices were ill-chosen, end their use, make amends where we can to those injured by such practices, and embrace different practices that are more effective and more respectful. There is now a strong science base for addiction treatment, and a related menu of evidence-based treatment methods that provide ample alternatives.…As is true for our clients, it is painful sometimes to face reality and change our ways. But it is time, long since time, to wash our hands of authoritarian confrontation, and to listen instead to the co-therapist we have within every client.
This article triggered many communications of appreciation in the weeks following its publication. Some were from other researchers (e.g., Tom McLellan), but most were from clinical directors and front line counselors who simply wanted to say thank you and that an article declaring a moratorium on such techniques was long overdue. Most important among these were emails from counselors who reported that the article was forcing them to rethink their use of such methods in their counseling. I suspect there were many readers who did not like the article, but who found it harder to go back to their usual confrontational style of counseling. We’ve all had learning experiences so penetrating that it was impossible to go back to our routine patterns of thinking and behaving—at least without a new level of consciousness and discomfort. Can you recall such an awakening that you experienced or provoked in others?