Alcohol and Crime: Treatment and Rehabilitation

In addition to facets of "crime" surrounding the definition of alcohol problems, there is also clear evidence of "punishment." Despite the widespread usage of medicalized language to describe the behaviors of persons with alcohol problems, they are punished in everyday life by social rejection, loss of friends, marital dissolution, job discipline, or job loss. Sometimes this occurs as part of the rehabilitation process, such as divorce following treatment or the loss of a job associated with treatment entry. Rarely do cries of social injustice arise when an alcohol-troubled person suffers these consequences. While these observations of punishment may seem pedestrian, their importance lies in the fact that alcohol problems are formally defined as medical issues. Crime and punishment are usually held to be independent of disease and medical care.

By linking admission of guilt and repentance to progress through the program, facets of punishment are embedded in the steps of Alcoholics Anonymous (AA), the most prominent mode of treatment for alcohol problems in the United States, and the modality that forms the basis for the vast majority of professionalized treatment programs for alcohol problems. It is important to keep in mind that passage through the twelve steps of AA should be sequential, and that there are no prescriptions regarding how far one must go in the sequence and still be an AA member in good standing. (A desire to stop drinking is, in fact, the sole requirement for membership.) In the eighth step AA members "made a list of all persons we had harmed and became willing to make amends to them all." Although seemingly simple, this step actually encompasses three distinct behaviors (making the list, overcoming resistances to approach others, and deciding to approach all such injured persons). These acts are concrete: writing, deciding, and encompassing a potentially vast array of others. Once this step is accomplished, the individual may move on to the ninth step, wherein he makes "direct amends to such people wherever possible, except when to do so would injure them or others." These expected reparations certainly place the AA member on a continuum with individuals with alcohol problems who have committed criminal acts.

Two further points elaborate this conception. First, there are a multitude of reasons for associating the emergence and social acceptance of the medical model of alcoholism with the invention and diffusion of AA (Beauchamp; Kurtz; Roman). The content of the eighth and ninth steps of the fellowship's program do, however, assert significant deviance with the alcoholic career. It is noteworthy that the eighth step does not suggest the optional possibility of "IF we have harmed others" wherein one might skip to subsequent steps. Herein lies substantial institutional evidence of the intertwining of the definition of alcohol problems and social deviance, well before the emergence of criteria in the American Psychiatric Association's Diagnostic and Statistical Manuals.

Second, the ninth step appears to be intertwined with the eighth step in that it seems illogical that one would become "willing" to make amends to "all" and then do nothing. This possibility must have been recognized by the founders of AA. It is evident that separate "packaging" of these potentially stress-filled and painful sets of actions very likely increases the probability that the reparative actions will be taken.

AA is the dominant modality in the treatment of alcohol problems, but the past few decades have seen the rapid emergence of professional research interest in addiction treatment, much of which has challenged the somewhat single-minded approach of AA and twelve-step programming in general. Prominent among the research-based strategies is the classification of alcohol and drug programs through the Addiction Severity Index (ASI), developed by a team of researchers at the University of Pennsylvania (McLellan et al., 1992a, 1992b). The ASI and a more recent inventory used with clients, the Treatment Services Review (TSR), are centered on the assumption that persons with addiction problems bring a multitude of problems to the treatment setting, including medical, psychological, familial, occupational, legal, and financial problems.

The authors of these inventories assert that most treatments fail because they focus only upon the addiction problems and such treatment typically ignores the accumulated consequences of deviant behavior associated with the development of alcohol problems. The ASI and TSR are focused on assessing clients across all of these problem areas and coordinating treatment services in each needed area in order that full rehabilitation may result. The more serious the alcohol problems, the higher the scores on the ASI and the greater the needs reflected in the TSR.

While the AA steps and the ASI/TSR approaches to addiction treatment have vastly different institutional origins and assumptions, they are remarkably similar in their emphasis upon the deviance that has accompanied the development of alcohol problems. Both approaches argue that successful treatment outcomes will not occur if only the problem of addiction is addressed. In very different ways, both point toward the necessity that problem persons address a range of difficulties in role performance that have been generated across most areas of their lives. In so doing, both approaches demonstrate the vast difference between the medicalized conception of alcohol problems and parallel conceptions associated with other disorders, their treatment, and expectations for recovery.