By William R. Miller, PhD and William White, MA   

The use of confrontational strategies in individual, group and family substance abuse counseling emerged through a confluence of cultural factors in U.S. history, pre-dating the development of methods for reliably evaluating the effects of such treatment.

Originally practiced within voluntary peer-based communities, confrontational approaches soon extended to authority-based professional relationships where the potential for abuse and harm greatly increased.

Four decades of research have failed to yield a single clinical trial showing efficacy of confrontational counseling, whereas a number have documented harmful effects, particularly for more vulnerable populations.

There are now numerous evidence-based alternatives to confrontational counseling, and clinical studies show that more effective substance abuse counselors are those who practice with an empathic, supportive style.

It is time to accept that the harsh confrontational practices of the past are generally ineffective, potentially harmful, and professionally inappropriate.

Treatment for substance use disorders in the United States took a peculiar turn in the mid-20th century. There arose a widespread belief that addiction treatment required the use of fairly aggressive confrontational strategies to break down pernicious defense mechanisms that were presumed to accompany substance use disorders.

Although this approach was emulated to some extent in certain treatment centers outside the United States, such reliance on confrontation was predominantly an American phenomenon. As discussed below, there was some broader exploration of confrontational therapies, but nowhere did they take such deep root as in U.S. addiction treatment. Indeed, few would now regard such harsh methods as therapeutic for any other Axis I disorder in The Diagnostic and Statistical Manual of Mental Disorders.

What accounts for this odd detour in American addiction treatment? In this article we trace the historical roots of belief in and practice of confrontational treatment, and explore relevant scientific evidence on the effects of such methods. We then offer summary conclusions and recommendations for treatment of substance use disorders in the 21st century.

A history of confrontational therapies - What is confrontation?

Therapeutic confrontation has been defined as the process by which a therapist provides direct, reality-oriented feedback to a client regarding the client's own thoughts, feelings or behavior.

Such communications may spring from compassion and concern, or from exasperation and contempt.

They also vary in their intent, timing, intensity, emotional content, accompanying interventions, and the relationships and organizational contexts within which they occur .

In the mid-20th century, addiction counselors developed and advocated a particular style of direct verbal confrontation of those with alcohol and other drug problems.

These communications varied from frank feedback to profanity-laden indictments, screamed denunciations of character, challenges and ultimatums, intense argumentation, ridicule, and purposeful humiliation. Confrontation marked a dramatic break from earlier therapeutic traditions premised on the importance of neutral exploration, empathy, compassionate support, and positive regard for clients.   

Many examples of allegedly therapeutic confrontation can be found in the addiction literature of the 1960s and 1970s. Two brief examples serve here as illustrations. The first is from the front page of the January 13, 1983, Wall Street Journal, describing a physician-led intervention with a corporate executive:

They called a surprise meeting, surrounded him with colleagues critical of his work and threatened to fire him if he didn't seek help quickly. When the executive tried to deny that he had a drinking problem, the medical director . . . came down hard. "Shut up and listen," he said. "Alcoholics are liars, so we don't want to hear what you have to say" .

The second comes from Chuck Dederich, the founder of Synanon, counseling a Mexican-American addict in a therapeutic community, who balked at being ordered what to do:

Now, Buster, I'm going to tell you what to do. And I'll show you. You either do it or you'll get the hell off Synanon property. You shave off the mustache, you attend groups, and you behave like a gentleman as long as you live here. You don't like it here? God bless you, I'll give you the same good wishes that I gave other people like you when they left and went off to jail. That's the way we operate in Synanon; you see, you're getting a little emotional surgery. If you don't like the surgery, fine, go and do what you have to. Maybe we'll get you again after you get out of the penitentiary or after you get a drug overdose. "Nobody tells me what to do!" Nobody in the world says that except dingbats like dope fiends, alcoholics, and brush-faced-covered El Gatos.

Theoretical foundation

Although treatment systems for alcoholism and for narcotic addiction constituted two separate professional domains during much of the 20th century, both fields developed parallel theories that fostered confrontational approaches to therapy.

Between the 1920s and 1950s, U.S. theories of narcotic addiction shifted from biological models of causation to models that posited the source of addiction as lying within the flawed character of the addict. Dr. Lawrence Kolb, a prominent psychiatrist and the first medical director of the Federal Narcotic Hospital in Lexington, Ky., was an early figure in this shift of perspective.

Kolb observed that the dominant profile of addiction had shifted from the "innocent" addict who had accidentally become drug dependent as a side-effect of medical treatment, to the "vicious" addict who sought narcotics as a source of excitement and pleasure.

In Kolb's view, the latter type of addict had a defective, psychopathic personality with a prolonged history of social maladjustment and enmeshment in deviant criminal subcultures . This led initially to a view of treatment as requiring a period of quarantine with a structured program of institutional care that could enhance personal maturation and pro-social values.

It was assumed that a drug-free social adjustment in the institution would then transfer to a similar style of adjustment in the community.

The failure of this assumption, confirmed by  reports of very high post-discharge relapse rates, created a climate of frustration that fostered a search for alternative treatments - alternatives that included confrontational therapies.

       Continued in Counselor Magazine