Confrontational counseling, sometimes known as attack therapy, is most commonly associated with so-called “therapeutic communities” for people with addictions.
It is worth noting that the term “therapeutic community” was originally coined by South African psychiatrist Maxwell Jones, who created a gentle and caring environment for people with mental health conditions to support each other.
Yet a number of programs described by this term, operating in the United States from the mid-20th century, were characterized by inflicting humiliating punishments on people with addictions, in a direct reflection of the contempt society has held for them.
The central activity of these therapeutic communities consisted of marathon sessions of what was known as “the game.”
In such programs, minor infractions of the rules might bring penalties such as having one’s head shaved, or being forced to dress in a diaper and wear a sign proclaiming, “I am a big baby.” If a man in the community said hello to a woman, he might be made to wear women’s clothing. Failure to empty an ashtray with even a single cigarette butt in it might result in wearing said ashtray around one’s neck for a week.
However, the central activity of these therapeutic communities consisted of marathon sessions of what was known as “the game.”
The game generally lasted 40 hours, with a four-hour break for sleep. It consisted of members of the group, one by one, being verbally humiliated and insulted by all the other members, in an attempt to destroy the ego. In the course of the game, you’d be targeted by any number of belittling, sexist or stigmatizing slurs—“junkie” was the least of them. Once the victim of these verbal attacks was considered sufficiently cowed, the group moved on to the next person.
The first therapeutic community of this kind for drug users was Synanon. It is unclear how it was first labeled a “therapeutic community,” despite the fact that it was quite the opposite of the community created by Maxwell Jones.
Synanon was founded in 1958 by Chuck Dederich (1913-1997), a member of Alcoholics Anonymous in Santa Monica, California, who had no training in psychology, or anything else.
The media fell in love with Dederich and Synanon, painting him as having a magic cure for addiction.
When Dederich had joined AA a few years previously, he was homeless and isolated, as well as addicted to alcohol. He flourished in the program, however, where he soon achieved the status of a guru. After meetings, Dederich would hold hours-long bull sessions in his home, and from these the game was born.
At a time when very little treatment was available, Dederich claimed success in addressing addictions to alcohol and other drugs via the game. He then rented a storefront and dubbed it Synanon. Tradition has it that the name was the result of one of Dederich’s followers attempting to say “seminar” and “symposium” and slurring the two together.
The media fell in love with Dederich and Synanon, painting him as having a magic cure for addiction. Synanon boasted a good success rate, attributable to the fact that only the most motivated individuals were allowed to join.
Soon, a number of other therapeutic communities for drug users sprang up, such as Daytop Village, Phoenix House, Odyssey House and others, which originally resembled Synanon to greater or lesser degrees, though they later changed.
Synanon’s attack therapy spread into alcoholism treatment through two principal sources.
Moreover, Synanon and the game began to attract “squares”—people who had never used drugs—who sought a personality transformation. In the early 1960s, comparable encounter groups such as those at the Esalen Institute sprang up, where well-to-do Americans paid good money to be sworn at and humiliated.
Synanon’s attack therapy spread into alcoholism treatment through two principal sources. (I will use the stigmatizing term “alcoholism” in this article both to reflect historical usage and because it is not an exact synonym for alcohol use disorder.)
The first of these sources was the Johnson Institute in Minneapolis, Minnesota. It was the brainchild of Episcopal priest Vernon Edwin Johnson (1920-1999). According to Forrest Richeson, Rev. Johnson underwent treatment for alcoholism at the Hazelden rehab in 1962 and decided to dedicate his own life to such work.
From 1962 to 1966, Johnson was assigned to the Action Program at St. Martin’s by-the-Lake Episcopal Church in Minnetonka Beach, Minnesota. Johnson also served as a consultant to Hazelden during this period. It was during this time that Johnson developed what would become known as the Johnson Institute Intervention—essentially the same practice that can be seen on the television show Intervention today. Although Johnson claimed an 85 percent success rate for his family interventions, independent researchers put the rate at 30 percent, far below CRAFT, at 64 percent.
It was Johnson’s contention that an “alcoholic” had developed a complex psychic defense system, and that only by breaking this down could the person be changed, else they were doomed to death.
Johnson also established an AA “slipper’s group” at St. Martin’s, for members who were constantly “relapsing.” This group added hard confrontation methods, borrowed from the encounter groups of the era, to the 12 Steps.
It was Johnson’s contention that an “alcoholic” had developed a complex psychic defense system consisting of denial, rationalization and delusions, and that only by breaking this down could the person be changed, else they were doomed to death.
In 1964, Johnson staged an intervention for Irene Copeland Whitney. Her husband, wealthy businessman Wheelock Whitney Jr., was so grateful that he decided to fund Johnson to create an institute to conduct interventions.
The Johnson Institute was incorporated in 1966. Its mission was threefold: to help families stage interventions; to establish confrontational treatment programs in hospitals and other facilities; and to train alcoholism counselors in confrontational counseling.
The institute established its first confrontational treatment program in St. Mary’s Hospital, in Minneapolis. It was the first time St. Mary’s had offered alcoholism treatment. The pilot program had 16 beds, expanded to 44 beds in 1970 and later to over 100 beds. Under Medical Director George Adam Mann, MD, the program became notorious for verbal abuse of patients, à la Synanon.
In 1973, Johnson published I’ll Quit Tomorrow. This book detailed his theories on alcoholism and alcoholic defense mechanisms, and gave a detailed blueprint for setting up a treatment program based on confrontational counseling. Johnson reported that he had set up programs at Miller Dwan Hospital in Duluth, Minnesota, and Lincoln General Hospital in Lincoln, Nebraska, as well as St. Mary’s.
In the 1980 edition, he reported having established confrontational treatment programs at over three dozen facilities, including Scripps Hospital in La Jolla, California; Baton Rouge General Hospital in Louisiana; Bethesda Hospital in Cincinnati, Ohio; and Flower Hospital in Toledo, Ohio.
This, of course, does not include programs which may have adopted confrontational counseling as a result of Johnson’s book.
The second main source of confrontational alcoholism counseling was Eagleville Hospital and Rehabilitation Center in Eagleville, Pennsylvania. The facility had been converted from a tuberculosis sanatorium to an alcoholism treatment hospital in 1966. Donald Jay Ottenberg, MD (1919-2004), was the medical director. According to Ottenberg, Eagleville initially tried treating alcoholics using conventional group therapy and broad-band behavior therapy; however, this was not successful.
As a result, Hazelden instituted the “hot seat” as a part of its treatment regimen.
In 1967, some of the Eagleville staff visited Daytop Village in New York City and took part in a marathon. Thereafter, confrontational “marathon therapy” was adopted as the standard treatment for alcoholism at Eagleville. In 1968, it admitted its first patients with addictions to drugs other than alcohol, making it the first facility to offer combined treatment since pre-Prohibition days.
By 1970, the demographics of patients admitted to Hazelden had changed, and many were addicted to both alcohol and other drugs. Since Hazelden staff were unfamiliar with the non-alcohol addictions, they made a visit to Eagleville that year to see how its system worked.
As a result, Hazelden instituted the “hot seat” as a part of its treatment regimen. Patients would undergo one hot seat session during their 28-day stay (originally between the 10th and 14th days but later moved up to the fifth).
The chair of the subject would be placed in the center of a circle; all other participating patients were given a list of 23 items to use in evaluating the person in the hot seat. Twenty-two of the 23 items were “character defects.”
In the early 1980s, the hot seat was replaced by peer evaluation, aka the “love seat.” The only change was that now the people in the circle listed both the subject’s assets and their character defects.
In 1985, Hazelden made a statement denouncing confrontational counseling. Peer evaluation appears to have been discontinued at Hazelden in 1987.
Hazelden and the Johnson Institute, together with Willmar State Hospital in Minnesota, dominated alcoholism counselor training in the 1960 and ‘70s. Willmar’s training program was established in 1962, Hazelden’s in 1966, and the Johnson Institute’s in 1967. Their preeminence ensured that what became known as the Minnesota Model would dominate treatment nationwide.
Alternatives to the Minnesota Model did exist, however, such as the Baltimore City Health Department counselor training program, established in 1967. The VA had also begun large-scale alcoholism counselor training by 1969.
Whenever a new treatment program opened, the director was frequently a counselor trained at Hazelden or the Johnson Institute, which spread use of the hot seat and hard confrontation.
The 1970s were a period of huge growth in the number of alcoholism treatment facilities in operation in general hospitals, residential facilities, and VA hospitals (together with a major decline in the number of state mental health hospitals). A handful of programs operating in 1970 had increased to several hundred by 1980.
And whenever a new treatment program opened, the director was frequently a counselor trained at Hazelden or the Johnson Institute, which spread the use of the hot seat and hard confrontation far and wide.
The biggest competitors to the Minnesota Model promoted by Hazelden and the Johnson Institute were CompCare Corporation, which offered hospital inpatient 12-step programs without confrontation, and Raleigh Hills, which offered aversion therapy. By 1980, CompCare operated CareUnits in 53 hospitals, operated three psychiatric hospitals specializing in treatment of addictions to alcohol and other drugs, and one alcoholism hospital. Raleigh Hills was meanwhile operating 17 aversion therapy hospitals.
The number of Minnesota Model programs in 1980 likely numbered over 100, and all of them offered some form of confrontational counseling.
Confrontational counseling began to fall into disrepute in the late 1970s, however. On December 2, 1978, Synanon founder Chuck Dederich was arrested for attempted murder.
Dederich was accused of ordering two Synanon members to place a rattlesnake with its rattles cut off in the mailbox of lawyer Paul Morantz, in an act of revenge after Morantz had won a $300,000 lawsuit against Synanon. Morantz was bitten when he opened his mailbox.
The story was juicy enough to make the national news and was broadcast by all the television networks. When Dederich was arrested, he had to be carried out of Synanon on a stretcher because he was dead drunk. He was ultimately sentenced to five years’ probation after pleading no contest to a conspiracy charge.
As researchers William White and William Miller described, confrontation has no therapeutic value.
The May 25, 1979 issue of the Minneapolis Tribune ran an article exposing confrontational treatments at St. Mary’s, Chanhassen Center and other Minnesota Model alcohol programs. The article stated:
At Chanhassen Center, Robert Turpin took over as program director three years ago and promptly fired 45 counselors and therapists trained in the confrontive style. “When I came in here the patients were kicking walls and pounding pillows,” Turpin said contemptuously. “They reinforced that here. The staff wasn’t happy until people came out crying. They called it anger therapy.
“I call it destructive behavior. Alcoholics punish themselves. Why should they pay to go to a treatment center and be punished some more?” In place of the stereotype of alcoholics that was the focus of treatment by his predecessor, Turpin installed a working policy that each patient “is not only fallible but unique, deserves respect and is responsible for his or her own feelings and behavior.”
Confrontation gradually fell out of favor in alcohol treatment programs. The 1988 book Rehab: A Comprehensive Guide to Recommended Drug-Alcohol Treatment Centers in the United States lists 146 alcohol treatment programs; only 19 reported still using the hot seat or other forms of confrontation.
Therapeutic communities for adult drug users also toned down some of their abusive approaches in the 1980s, although, as Maia Szalavitz pointed out in Help at Any Cost (2006), many of the worst abuses continued to be practiced in adolescent treatment programs.
Confrontational counseling was an abhorrent practice to use against vulnerable people. And as researchers William White and William Miller described in their 2007 article “The Use of Confrontation in Addiction Treatment,” it has no therapeutic value. They found that “the more the counselor confronted, the more the client drank.”
Photograph by Andrew Kimmel via Flickr/Creative Commons 2.0