When I first went through treatment for an alcohol problem back in the 1990s, I was shocked to find out that 12-step programs were a form of faith healing that depended on belief in a “Higher Power.” I remember asking my counselor if there was any evidence that these programs work and being told, “There must be evidence since all the hospitals use them.”
Since I have a scientific mind, this was not a very satisfactory explanation. In fact, the first thing I did after leaving treatment was go to a library and look for evidence. There were a ton of books which claimed that 12-step was the most effective approach without showing a single effectiveness study. The only books which cited any actual scientific studies showed that there was no evidence that 12-step programs were effective. Today, there is still a dearth of evidence for the effectiveness of 12-step programs. A recent Cochrane review claimed to demonstrate it, but as Stanton Peele has pointed out, that study is rife with flaws and fallacies, and I am frankly surprised it made it past the peer reviewers.
This still leaves us with the question: Why did so many US hospitals choose to adopt a form of faith healing with no evidence of effectiveness? But first, let’s ask: How many US hospitals are currently using 12-step programs in treating addiction?
The National Survey of Substance Abuse Treatment Services (N-SSATS) is an annual survey of addiction treatment facilities in the US, conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA). Treatment facilities have good reason to complete the survey since it gets them a free listing on the SAMHSA website; about 90 percent of facilities do so. Anyone can analyze SAMHSA’s data online for free by going here.
Of these hospital-based programs, 72 percent utilize 12-step treatment.
The most recent N-SSATS survey is from 2020, and it gives us data on 16,066 addiction treatment facilities. Of these, 1,343 (8.4 percent) are hospital-based programs. And of these hospital-based programs, 972 (72.4 percent) utilize 12-step treatment.
As an interesting aside, out of all 16,066 facilities, 10,517 (65.5 percent) reported using 12-step treatment. And of the 3,825 residential (non-hospital) facilities, 3,289 (86 percent) reported using 12-step treatment. The percentage of US addiction treatment facilities utilizing 12-step treatment seems to have dropped in recent years, however. In 2007, N-SSATS reported that an overwhelming 87.5 percent of all such facilities utilized 12-step treatment either often (66 percent) or sometimes (21.5 percent).
Now that we know how many hospitals use 12-step programs, let’s look at how these programs got into hospitals in the first place. As we shall see, science and evidence had nothing to do with it.
Although a number of hospitals—such as Lutheran General in Park Ridge, Illinois—got their 12-step programs directly from Hazelden and Willmar, the prime mover in placing the programs in US hospitals was a now-forgotten company known as CompCare (Comprehensive Care Corporation).
Originally named Neuro-Psychiatric & Health Services, Inc., CompCare was incorporated in Newport Beach, California in January 1969 for the purpose of creating and operating a chain of for-profit psychiatric and convalescent hospitals. By August 1969, the chain owned and operated six facilities: Brea Hospital, Alta Mesa Hospital, Terracina Hospital, Gilmar Manor, Bayview Hospital and Raleigh Hills. Raleigh Hills treated alcoholism using aversion therapy; the other five did not offer alcoholism treatment at all. (I use the stigmatizing term “alcoholism” throughout this article because it was used historically, and is not an exact synonym for “alcohol use disorder.”) However, by 1972, the hospital chain was deep in debt due to poor management and the fact that Alta Mesa Hospital had been closed down after being damaged in a February 9, 1971 earthquake.
B. Lee Karns and His Ingenious Plan
In May 1972, the hospital chain hired Byford Lee Karns (1930-2002), better known as B. Lee Karns, as CEO to get it out of debt. Karns held a degree in finance and accounting from the University of Illinois. He’d previously worked as an accountant and supervisor for the Peoria-based Caterpillar Tractor Company, and for the consultants Alexander Proudfoot Company. In 1967, Karns formed his own company, Systems Development Services, which specialized in health care service issues, particularly the challenges faced by hospitals dealing with the then-newly implemented Medicare and Medicaid reimbursement systems. Karns sold Systems Development Services at a great profit in 1971, and was looking for a new challenge when he was offered the position of CEO for what later became CompCare.
CEO Karns began by selling off the Raleigh Hills aversion therapy operation in order to raise some much-needed working capital and because aversion therapy was expensive, since physicians were required to administer it. He then looked around for ways to make big money with little outlay, and came up with an ingenious plan.
They would supply the empty beds, he would supply the personnel and expertise, and they would split the profits.
By 1972, hospital overbuilding had left a lot of empty beds in hospitals, which were desperate to fill them or lose money and go out of business. Meanwhile, insurance companies had begun offering coverage of alcoholism treatment as early as 1962, but they only offered full coverage of treatment given in a hospital, not a residential center like Hazelden. Very few US hospitals offered treatment programs in 1972, and very few doctors were willing to treat alcoholism. This is where Karns’s plan came in.
Karns decided that he would make a deal with hospitals wherein they would supply the empty beds, and he would supply the treatment personnel and expertise, and they would split the profits between them. Karns opted for 12-step-based treatment programs because they were very cheap to deliver; he could hire paraprofessional alcoholism counselors with no degrees, whom he could pay next to nothing.
It was around this time that Karns renamed the company CompCare. He called the treatment delivery units in the hospitals CareUnits (Comprehensive Alcoholic Rehabilitation Environment Units). The contracts with the hospitals ran for two years. The CareUnit teams consisted of five people: a doctor, a psychologist, a program coordinator, a social worker and an alcoholism counselor (whose poorly paid hours would dominate delivery). The program was 21 days with 10 weeks of aftercare.
The CareUnits spread like wildfire, and by 1982, CompCare was the largest provider of hospital-based alcoholism treatment in the United States.
The first CareUnit was established at South Coast Hospital in Laguna Beach in May 1973. It was a huge financial success. The CareUnit program itself was created by Muriel Zink (1917-2006). Zink was a self-identified recovering alcoholic, an AA member, and had received a certificate in alcoholism counseling from UCLA in 1969, after which she had worked in an alcoholism treatment program at the West Los Angeles Veterans Administration Hospital.
The CareUnits spread like wildfire, and by 1982, CompCare was the largest provider of hospital-based alcoholism treatment in the United States. CompCare’s profits peaked in 1985 at $17,226,000. CompCare’s provision of “chemical dependency treatment” peaked in 1986, when it operated 123 CareUnits in 33 states as well as 16 freestanding chemical dependency facilities in 10 states.
However, a lot of hospitals which had been utilizing CompCare’s services began to realize that operating a 12-step treatment program was a financial no-brainer, and that they didn’t need CompCare to do it for them. So they began canceling their contracts with CompCare when the term was up, and running 12-step treatment programs on their own. The increasing dominance of managed care and increasing limitations on insurance coverage also cut into CompCare’s business. In 1990, instead of making a profit, CompCare lost a whopping $59,308,000.
Wall Street shark Chriss W. Street was made CEO of CompCare in 1994. Street focused on transforming CompCare from an organization which provided services directly into a middleman which matched HMOs with service providers. CompCare’s last CareUnit closed in 1997 and its last freestanding chemical dependency facility was sold in 1999. In 2014, CompCare changed its name to Advanzeon Solutions, Inc., which is still in operation today.
So that’s how the 12 Steps became the standard addiction treatment in US hospitals. It wasn’t because of evidence published in peer-reviewed journals. Nor was it because doctors made a pilgrimage to Hazelden to learn the mysteries of addiction treatment. It was because a former accountant for Caterpillar Tractors saw a way to make a quick buck.
Photograph by B. Jamie via Pxhere/Public Domain