"Gruff Love" in AA vs. "Tough Love" in Rehab

By Maia Szalavitz 05/14/13

Some things done in 12-step meetings may be humiliating or hurtful—but when done in treatment programs, they're toxic to mental and physical health. The difference is about power.

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Power turns tough love toxic.

AA meetings have long been filled with gruff sayings like “Take the cotton out of your ears and put it in your mouth” and “Keep it simple, Stupid.” And both the “gruff love” practiced by 12-step members and the “tough love” touted in treatment can make the person targeted experience stress, often intensely. But there’s a big difference between AA’s “gruff love” and treatment “tough love”—and this distinction is essential in understanding the best ways to help addicted people. For healing, power relationships matter.

Being called out by a fellow AA member generally has fewer negative psychological and physiological effects than being subject to confrontational therapy in a treatment program. The difference comes down to power—having it or not having it (and I’m not talking about over alcohol).

In power terms, AA is one of the world’s most egalitarian organizations. It has no leaders. Bill W. and Dr. Bob set the program up deliberately in this way, recognizing well the dangers of creating a cult of personality. No individual speaks for 12-step programs, and people elected to chair meetings do not have any significant authority aside from picking speakers. While there are certainly informal hierarchies as in any social group, they do not have the sanction of official force intrinsic to workplaces.

Of course, each meeting has its own unique character. Some are more rigid than others, emphasizing a strict “right” way to work the program. The extent to which members respect the rule against crosstalking (commenting directly and often disparagingly on what others share) tends to be a sign of the extent to which members respect one another. For example, after a speaker tells his or her story, another member might curtly respond, “Call your sponsor.” Or during a share that is unfocused, someone may even shout down the speaker, rudely demanding, “Did you drink?”

Empathy and support are clearly promoted in the Big Book: “If your talk has been sane, quiet and full of human understanding, you have perhaps made a friend. Maybe you have disturbed him about the question of alcoholism. This is all to the good. The more hopeless he feels, the better. He will be more likely to follow your suggestions.”

In practice, however, some “gruff love” adherents in AA focus only on the last two sentences: “The more hopeless he feels, the better. He will be more likely to follow your suggestions.” By taking it out of context, the entire message is twisted.

Still, these exceptions prove the rule, and a group in which power is equally shared among peers can, by consensus, enforce rules intended to prevent abuses of power. Small cults of personality can and have grown up in certain AA groups—but the fellowship itself is largely protected.

By contrast, treatment programs have bosses and steep hierarchies. People are paid—sometimes very large salaries, even in supposedly nonprofit organizations—and the buck typically stops with the CEO or director.

While many program staff are themselves in recovery, most are required to have some training or professional credentials, even if that “expertise” amounts merely to on-the-job training from someone whose only training was the same. When “peer counselors” are used, they act as lower level members of this hierarchy.

In the past, many treatment programs openly practiced attack therapy: putting one patient in the “hot seat” for hours without breaks as everyone else yelled, screamed, berated, harangued and ridiculed the victim. This “spit therapy” (so-called because the participants often literally spit in the victims’ face) was often accompanied by “contracts,” like wearing signs saying “I am an asshole” or dressing in drag or “bum clothes” to reinforce the humiliation.

Nowadays, most, but unfortunately not all, mainstream programs have eliminated these extremes of tough love. However, the idea that humiliation, degradation and an induced feeling of powerlessness are positive remains in many, as do numerous petty rules and practices intended to elicit these feelings more subtly. All of these exacerbate the severe stress that can result from being on the bottom of a hierarchy. Indeed, the bullying inherent in tough love treatment is essentially the root of bullying itself: a practice aimed at reinforcing a dominance hierarchy.

Being called a junkie, bum or idiot is quite a different experience when it's done in a meeting of peers that you can leave at any time and when it’s done in a group session that you can only leave at risk of being disciplined.

The power imbalance in treatment programs for illegal drugs is magnified by criminalization: As many as half of all patients in most programs are there by order of a judge, giving staff a great deal of authority to determine their ultimate freedom and criminal records. Breaking a rule—even by a transgression that has nothing to do with substance use, like having consensual sex with another adult—can sometimes mean the difference between liberty and decades in prison.

Even for those who are not court-ordered, family or employer pressures to stay in treatment and institutional policies work together to send a message of low status to patients, even more extreme than the ordinary dehumanization patients feel in a hospital.

All of this means that being called a junkie, bum or idiot is quite a different experience when it's done in a meeting of peers that you can leave at any time and when it’s done in a group session that you can only leave at risk of being disciplined or, at the extreme, sent to prison. While humiliating and shaming can be harmful in any setting, they are many times worse in a program where the whole idea is to keep you aware of your essential lack of power and control over your life.

“Powerlessness” is, of course, a common theme in 12-step programs, where the goal is to help someone recognize that the only way for them to control their drinking or using is not to do so at all. Unfortunately, this sensible notion that abstinence is key to some types of recovery has been extrapolated by many AAs into an ideology that suggests that people with addictions are powerless over everything. 

And it has further been taken to mean that it is acceptable to become a “higher power” and impose a sense of powerlessness on patients in treatment in order to spur recovery. Whatever the stated goal, imposing powerlessness in treatment is counterproductive: It activates the deeply engrained stresses of hierarchy and prompts inner rebellion as a way of attempting to fight it.

There are clear physiological reasons why such power differences matter.

We are wired to be extremely sensitive to status and power—and to have an entirely different stress response when we face challenges voluntarily in collaboration with our equals and when we are forced into stressful experiences by our superiors. 

The latter situation creates stress that is much more destructive to our mental and physical health. Indeed, research shows repeatedly that being ranked low on a steep hierarchy can be as bad for health as smoking—and that greater inequality leads to lower life expectancy. The effect on stress of feeling in control can be seen even in rats: Yoke them together and give one but not the other control over whether it will be shocked, and the out-of-control rat will be more susceptible to cancer and infectious disease.

These data suggest that “tough love” can be a recipe for traumatic stress, with its characteristic feelings of helplessness and lack of control experienced by the victim. The potential for emotional assaults to cause such feelings is greatly magnified the larger the power difference between those involved. And people who have been abused, women, minorities and others who have spent much of their lives dealing with others’ power over them, are especially susceptible to these effects.

The take-home? In 12-step programs, gruff love and even harsh confrontation are mainly an annoyance, while in treatment programs, they are frequently toxic. When your friend humiliates you, it’s awful; when your boss does it, it’s far worse. Failing to understand the critical issue of power causes a world of harm to people with addictions, reinforcing previous abuse and trauma that many of us have suffered—when what we need is to be recognized as fellow human beings with dignity.

Maia Szalavitz is a columnist at The Fix. She is also a health reporter at Time magazine online, and co-author, with Bruce Perry, of Born for Love: Why Empathy Is Essential—and Endangered (Morrow, 2010), and author of Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead, 2006).

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Maia Szalavitz is an author and journalist working at the intersection of brain, culture and behavior.  She has reported for Time magazine online, and is the co-author, with Bruce Perry, of Born for Love: Why Empathy Is Essential—and Endangered, and author of Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids. You can find her on Linkedin and  Twitter.