In the Belly of the American Society of Addiction Medicine Beast

G. Douglas Talbott is the founder of America's premier medical organization for the treatment of addiction — the American Society of Addiction Medicine, "The nation's medical specialty society dedicated to educating physicians and improving the treatment of individuals suffering from alcoholism or other addictions." He has been president of the organization — most recently from 1997 to April 1999 — after which he has continued to serve as a member of ASAM's Board.

Talbott has owned and directed a number of Atlanta-based facilities, most recently the Talbott Recovery Program. Talbott's programs are the preferred referrals for physicians and other health care workers ordered into treatment by their licensing boards. Throughout his tenure, Talbott's programs have been troubled with high failure rates — most notably a high prevalence of suicides. In one four-year period, according to the Atlanta Journal and Constitution, five health care professionals committed suicide at Ridgeview, one of Talbott's programs. But this was only the tip of the iceberg; according to the paper: "At least 20 doctors, nurses and other health professionals who have gone through the Ridgeview Institute's nationally acclaimed treatment program over the past 12 years have killed themselves since leaving the hospital."

Many observers have noted the take-no-prisoners approach of Talbott and his staff (including his daughter-in-law, Dr. Martha Morrison, who attempted suicide when she entered Talbott's program but who survived after the belt she used broke!). Among these critics have been Assistant Surgeon General John C. Duffy, who was a pioneer in addressing impaired physicians, Dr. LeClair Bissell, a psychiatrist and another pioneer in physician care programs, and Dr. Paul G. Cohen. Cohen, a local physician who regularly found fault with Talbott's program, was repeatedly accused by Talbott of having a drug and alcohol problem, as a result of which he underwent at least five psychiatric evaluations and more than 30 drug tests, none of which revealed substance abuse.

In May, 1999, just after Talbott stepped down as president of ASAM, a jury awarded Dr. Leonard Masters, of Jacksonville Florida, a judgment of $1.3 million against Talbott, his daughter-in-law Morrison, and other Talbott associates for malpractice, fraud, and false imprisonment, based on Masters' stay with Talbott in 1994. Testifying at Masters' trial that he was not in fact alcohol dependent, as he had been diagnosed by Talbott et al., was Anne Geller, the president of ASAM prior to Talbott. Talbott's attorneys quickly settled with the plaintiff before the jury decided on punitive damages against Talbott and his colleagues (an amount which is usually a multiple of the compensatory damages that had already been awarded).

Despite this legal setback, Talbott has faced no professional repercussions. Indeed, the ASAM has neglected to discuss the case at all in the year since the Masters' decision in its newsletter or at its Web site. And ASAM and Talbott continue to bask in their roles as the premier medical advocates for and caretakers of addicted individuals. The ASAM publishes a volume, Principles of Addiction Medicine, complete with introductions and laudatory comments from Drs. Enoch Gordis and Alan Leshner, Directors, respectively, of the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse. Nowhere does the volume address ethical issues — such as violations of confidentiality and informed consent, and coercion and abuse of patients — that have been publicly revealed to be standard features of Talbott's programs.

In Talbott's boot-camp type programs, uncooperative patients (and this covers a range of sins of commission or omission, including that of offering one's opinion about one's treatment) are threatened with expulsion and with not being certified — or advocated for — with their boards after leaving Talbott's, often the equivalent of professional death. One such professional has offered his first person experiences for SPAWS readers, out of his desire to blow the whistle on this monstrous, ongoing assault on patient rights, often involving highly vulnerable individuals.

Jack Wright entered Talbott's program (then called the Talbott-Marsh Recovery Campus, which Mr. Wright refers to as TMRC) in 1997, after he had relapsed to drug and alcohol addiction. But Wright was also receiving medication for manic-depression — a condition which worsened after he entered Talbott's program. Moreover, Wright was an attorney, and had a sizable conception of what an individual patient's rights are. Immediately after he left the program (for reasons that will become clear), he wrote a letter to Talbott on November 25, 1997. In it, he complained about his and other patient's treatment, which he found trivial, demeaning, coercive, and often unethical. Wright wrote to Talbott:

During my stay at Talbott-Marsh, I observed rule violations being used as examples of "diseased" behavior (a majority of our "therapy" time was devoted to addressing the pathological implications of trivial rule violations). Clients who offered any resistance to the methods employed by more aggressive staff members were told that their "best thinking" got them there and that they had to be willing to go to "any lengths" to achieve recovery, even if those lengths were personally distasteful. In short, anything short of substantial compliance with staff directives was tagged as diseased behavior or denial (a notion that, by the way, is not discussed in any of the literature that you have put together regarding the disease concept of addiction). Moral platitudes were routinely used to encourage change, as was the need for a spiritual conversion.

Do you see the irony here? More importantly, do you see how this approach reinforces the myth that alcoholics and drug addicts are morally defective and incapable of adjusting to life — the very notion that your research (and numerous studies) directly contradict? Considering the high level of intelligence of most of your clients, this heavy handed double talk not only reinforces the moral approach to this disease (a notion that you ostensibly reject), it sets up a coercive dynamic whereby any non-compliant resident is labeled and pathologized as he naturally tries to sift through the moral imperatives and considerable demonstrations of authority that he is confronted with. As one of my peers aptly exclaimed: "This is a holy war!"

There is an added dynamic, unique to your facility, that only makes this situation worse. During my time at TMRC, I observed numerous professionals who were literally required to obtain treatment at your facility or face severe consequences with respect to their licenses. Those individuals, in turn, were promised "advocacy" upon successful consummation of treatment. On the surface, the provision of these services was both beneficial and empowering to those who successfully completed their treatment at TMRC. On a deeper level, this dynamic brought coercive pressure to bear on many extremely frightened clients and, in turn, promoted false compliance, dishonesty and, ultimately, undermined the patient's absolute right to refuse treatment without fear of reprisal (this, by the way, is a right of constitutional dimension, particularly when State Licensing Agencies are involved). More importantly (and this is the issue), the dynamic outlined above presupposes that TMRC is the only viable treatment option (as you know, many Licensing Agencies mandate treatment at your facility). In short, the power differential, and resulting potential for coercion, is extremely high, all to the detriment of your clients.

In this respect, please consider the following (true) example: One of my peers at TMRC was mandated to complete treatment at your facility or have his license revoked (he was a doctor). . . . when his wife arrived for family week, she was asked to take a urine test (she was never informed that this was a possibility before she made expensive arrangements to participate in this program). She refused to do so (which is her right). My peer was then told that she was no longer welcome on the premises and denied visitation with someone he loved dearly. Then, the ax fell: He was told that she must obtain an addiction assessment at your facility. In addition, he was told that he would not obtain advocacy if he returned to his wife after completing treatment (unless, of course, she got involved in an acceptable recovery program). For weeks, I witnessed this young man experience anguish and stress that I could not have imagined, as their relationship was pushed to the brink of divorce.

Serious ethical questions are raised here: What right does your staff have to use or withhold advocacy in an attempt to coerce significant life changes that affect an innocent third person who is not even one of your clients? What right does anybody have to tell somebody that they are in their "disease" because they question or reject such inappropriate demonstrations of authority? In light of the right to autonomy (a critical right for mental health patients), what right does your facility have to force anybody to make life changes that are unacceptable to him?

Apparently worried that Wright might take his complaints farther, Talbott responded graciously: "The purpose of this letter was to simply thank you and tell you of my appreciation of you [sic] sending the letter to me. I did not find it caustic or hostile, but found it very helpful. . . . I will continue to review your letter to see if we can put into place and expedite some of the suggestions you have made. Thank you for caring enough to write me this letter."

Of course, Mr. Wright never heard again from Talbott about which of Wright's helpful suggestions Talbott would be adopting at his program. After additional letters from Wright and exchanges between Wright's and Talbott's attorneys (and a concerned letter about a Talbott counselor's comments about Wright from Wright's psychiatrist, under whose care Wright had regulated his manic-depression and abstained from drugs and alcohol for several years), Wright wrote to Talbott — this time through Talbott's attorney — on October 21, 1999.

Wright's letter, which is reprinted below, alleges critical ethical and professional violations that Wright either witnessed or experienced personally or gathered from his medical records at the facility. When Wright requested care for a pre-existing psychiatric condition, Talbott's staff simply labeled his complaints symptoms of his addiction. At the same time, Wright objected to staff behavior that, as an attorney, he reckoned was unethical, with highly negative consequences for himself. This punitive approach was carried out at Talbott's center in the name of medical diagnosis and care — as though maintaining personal dignity is the symptom of a disease. Wright then describes how federal confidentiality laws were routinely broken by TMRC staff, and, as a final indignity, how inaccurate and highly pejorative information was entered in his record after he left Talbott's facility against medical advice (AMA).

Mr. Wright has given SPAWS permission to include his October 21, 1999 letter to Talbott's attorney on this web site with the proviso that his letter reflects his own personal observations and opinions only, and that no findings of unethical behavior or malpractice have been entered against Talbott as a result of his accusations. However, Mr. Wright adds that he is gravely concerned about the negative consequences (including suicide) among Talbott's patients both that he observed, and that have been documented by the Atlanta Journal and Constitution and the civil courts. Indeed, he reports that he left Talbott's facility in deep despair and suicidal as a result of the treatment that he received there. It should be noted that Dr. Talbott and his attorney have never provided a substantive response to the incidents and concerns identified by Mr. Wright.

Dear Dr. Talbott:

As you know, I have been in contact with you many times in an effort to gain a deeper understanding of the difficulties I experienced while I was a resident at TMRC during the Spring of 1997. The purpose of this letter is to explain these difficulties in some detail, for the last time, in hopes that you will understand why I have been so concerned. Maybe this letter will be helpful to you and your staff.

Last week, I had an opportunity to review my entire TMRC records for the very first time. After discussing these documents with a number of psychiatrists and my own attorney, I have identified a number of problems that you may want to consider. This letter should be read along with my November, 1997 letter and the more recent correspondence that you have received from my psychiatrist. It is my sincere hope that you consider this letter in the spirit that it has been offered. As you know, I am a student of your work and I respect you a great deal.

The Treatment (Counselor 1)

In February of 1997, I entered your facility after a brief relapse into drug and alcohol addiction. I was informally referred to your facility by Mr. ________, the director of the assistance program for the ______ State Bar Association. When I arrived at TMRC, I was in bad shape. I was very depressed and in need of medical care. I experienced drastic mood swings, ranging from irritability and anger to depression. While these symptoms may have been initially attributed to my alcohol use prior to admission, they persisted, and even worsened, as I continued my treatment.

During my initial detoxification period, I met briefly with an intake psychiatrist, who expressly stated that a "more comprehensive evaluation" of my mood disorder would be needed to insure appropriate treatment. Even though I told the doctor that my current medication was not helping, and that I responded better to Lithium, he did not change my prescription. More importantly, I never received the psychiatric evaluation that was charted as a necessity for my ongoing treatment. In fact, if you review my "Master Treatment Plan," my pressing psychiatric issues are not even referenced at all ("Addictive Disease" is the principal, if not exclusive, focus of this document). From this standpoint, it is not surprising that common symptoms of my bi-polar illness (irritability, resistance, noncompliance and intense mood swings) were assessed and treated, by your staff, as manifestations of "grandiosity," "dishonesty" and "self-centeredness" that were targeted in my Master Treatment Plan. This dynamic, which manifests itself in virtually all of my TMRC records, forced my difficult departure from your facility.

After leaving Anchor Hospital, I was integrated into a small community [still part of the Talbott campus] and placed in a group with Counselor 1, a campus therapist. For the first month, I was required to attend numerous group sessions that focused on the twelve-step philosophy that serves as the backbone of your facility's treatment program. Most of the focus in these group sessions was to correct trivial rule violations by clients, which were viewed as symptoms of addictive illness and "diseased thinking." This process was tedious, patronizing and, in my estimate, unrelated to the pressing needs of most of your clients. While I made it clear to Counselor 1 that this type of "therapy" had failed me on many previous occasions, my concerns were written off as "diseased behavior," "self-will" and "manipulation." In short, I was expected to comply, stop "analyzing," and do what I was told. As the promise of "advocacy" loomed over my head (as both a threat and an incentive), I felt compelled to comply with these directives.

Obviously, Counselor 1 is not a doctor. By principally diagnosing my troubles under the umbrella of "addictive disease" (which is what he was trained to do), Counselor 1 treated my symptoms as evidence of a biological process that is somehow defined by behavioral and cognitive attributes that are easily ascribed to other equally plausible diagnoses. Every move I made was scrutinized as a "twelve-step" recovery issue when, in fact, there were deeper psychiatric issues that were causing me severe emotional pain and not getting the attention that was necessary. The more this happened, the more my condition worsened and the more I withdrew from the efforts of your staff. My immediate perceptions of this are fully outlined in my November, 1997 letter, which I invite you to review again.

As the weeks passed, I repeatedly expressed my concerns over my emotional well-being to your staff members. These complaints were ignored (and charted in the most derogatory terms imaginable) until a community group meeting in which my own roommates confronted your staff for their failure to address and treat my pressing psychiatric issues. After this happened, my medications were changed and I was giving extremely limited access to a psychiatrist (your records suggest three sessions with your psychiatrist, for less than 90 minutes, in a five week period — this is an extremely liberal estimate). While I did notice improvement from the adjustment in medication, these advances were quickly reversed by the endless "confrontations" and judgments by your staff members, who demonstrated no understanding of my condition. When I asked for more time with the doctor, I was informed that all of my therapy work was to be done in the group setting. As a result, my condition continued to worsen.

During my short stay at your facility, I observed a number of problems that flowed directly from the fact that most of your clients were being treated under direct or indirect pressure from state licensing agencies. Many of your clients were very concerned about their professional status, and I think it is fair to say that your staff was not shy about using these concerns to promote compliance and continued treatment at your facility. Many clients reported that they were told that medical records "cleared up" and "looked better" after treatment at TMRC was completed successfully. Others sought desired advocacy services, often at the cost of expressing themselves about the direction of their own treatment. These concerns are outlined in my November 1997 letter....

The "First Step" Episode (Counselor 2)

One episode stands out which is not covered in my November, 1997 letter. As you know, TMRC clients are required to give "first steps" in front of the entire TMRC client population. These exercises involve very detailed and intimate accounts of the client's drug addiction, which are not easy to share with a room full of people (and, indeed, complete strangers). One afternoon, a client was giving a first step when the group was interrupted by a staff member who escorted a number of "visiting fellows" from a local university into the room, where they were seated and invited to listen to the remainder of this individual's drug history. No one, especially the client, was asked whether this was acceptable, releases were not obtained and, in a few short moments, a number of serious ethical breaches and legal violations were committed as this client's "process" was interrupted and turned into a sideshow for your guests. A number of residents, including myself, complained vigorously, noting the serious ethical issues raised by this irresponsible display of authority. We were invited to leave, which many of us did.

What happened next was amazing. A staff member at your facility named Counselor 2 saw me walking out of the group room and immediately "confronted" me for leaving, accusing me of being "in my disease" for my unwillingness to acquiesce to this rather obvious ethical lapse. When I challenged her on this point, she yelled at me in front of a group of clients (in your lobby area) and insisted that I follow her into her office (which I refused to do). Moments later, I was summoned into my office by my primary therapist, where I was encouraged to "make amends" to Counselor 2 for being angry and disrespectful. Reluctantly, I followed this directive. Of course, Counselor 2 took no responsibility whatsoever for her inappropriate outburst, and I was left accepting blame for a series of unprofessional and unethical decisions by your staff — lapses which should have been accounted for and corrected on the spot. It was at that moment that I saw how the TMRC treatment philosophy, when placed in the wrong hands, completely insulated your staff from accountability for their actions. I became even more depressed and, as my condition worsened, I made the decision to leave. This episode was one of the major contributing factors for this decision.

The Breach of Confidentiality

When I left your facility on April 23, 1997, I placed a signed letter in Counselor 1's mailbox which stated, in no uncertain terms, that every single release, signed by me, was expressly revoked as of that moment. I circulated this letter to other staff members in your facility on that same day. Obviously, I was concerned that your staff would take it upon themselves to report my departure to the _________ State Bar Association without giving a full or meaningful account of what happened while I was there. This is exactly what happened as, the very next day, one of your staff members contacted the _______ State Bar Association, to inform them that I had left the facility "AMA." As you should know, such breaches of confidentiality are criminal in nature, punishable by substantial fines and even jail time. See, 42 U.S.C.A. § 290dd-2. This concern, which is proven by the records I have in my possession, is one example of the serious ethical lapses that dogged my treatment process.

The Impact

When I left your facility, I was extremely distraught. I was suicidal for a short period of time. I felt terribly betrayed, and ignored, by a facility that I had paid good money to help me find my own recovery. I felt humiliated and berated by your staff members, who clearly had no understanding of the dynamics of depression and bi-polar illness. I could not sleep, my appetite was gone and, as time rolled on, I was forced to repeatedly deal with this deep sense of betrayal in counseling sessions and additional psychiatric care. This is all carefully documented, and I think it is fair to say that, while sober, my emotional condition was exacerbated and aggravated by the events outlined in this letter.

My Medical Records

In recent months, I have developed serious concerns about the accuracy of the medical records assembled by your staff. Months ago, I was preparing information for my transfer to active status with the _________ Bar Association, when I read Counselor 3's "psychological evaluation" for the first time. I was appalled. The information contained in this report was so inaccurate and offensive that I immediately contacted my psychiatrist, who suggested that I recall of my records for a thorough evaluation (which I did). My psychiatrist determined that my records were woefully inaccurate and, due to my pending request for transfer to active status with the __________ Bar Association, my fears became quite pronounced. As you know, these concerns are shared by my psychiatrist, who has since sent you a letter explaining the deficiencies in my treatment and the records that followed. This letter speaks for itself.

Counselor 1's records — which reflect the most negative possible interpretation of my behavior and attitude during treatment — are also cause for concern. In my view, these records demonstrate how the TMRC treatment philosophy encourages staff members to attach pejorative, moral judgments on the "disease" process that you have so carefully articulated in your work.

If reviewed carefully, you will see that any decision that I made that was inconsistent with Counselor 1's wishes was labeled and categorized as an attitude problem when, in fact, each area of difficulty was directly traceable to the bi-polar illness that your staff did not and would not address in a thorough, professional manner. The result is an amazing dichotomy: Any actions that I took that were consistent with Counselor 1's views were viewed as "healthy," while any symptom of resistance was immediately tagged as "self-will" and "diseased behavior." While this is one way of insuring compliance with treatment goals, it creates a terrible problem for clients who make an informed decision to leave your facility and seek help elsewhere, as this choice is ultimately cast in the most negative terms in medical records that are likely to be reviewed by licensing agencies. . . .

Seeing Things Differently

If you examine my history, you will see that I have a long history of unsuccessful, failed treatment efforts in twelve-step treatment facilities such as yours. While I have certainly benefited from my AA involvement, something has always been missing from my life, even though I have approached my recovery obligations with tenacity and determination. I went to meetings every day, worked the steps with a vengeance, sponsored people, spoke at meetings, and lived the AA way of life. I did everything that I was told to do and I could not stay away from alcohol for over [more than] two years.

I explained this to your staff members and they did not listen. I told them that I had been sober for two years while I was managed with Lithium and they refused to pay attention and place me back on this medication until it became absolutely necessary. I told the doctors that I needed psychiatric care and they told me to go to AA meetings for support. When I resisted, I was told that I was sick when, in fact, I was simply trying to preserve some modicum of personal autonomy and be involved in the direction of my treatment. I was threatened with extensions, told I would not receive advocacy unless I complied and, as my condition worsened, I felt trapped. On top of that, I had just lost my career, embarrassed myself professionally and I was so depressed I could not sleep or get out of bed. Under these circumstances, it should come as no surprise at all that I was resistant to treatment and noncompliant with your staff's wishes. In retrospect, that was a healthy and natural response to the inappropriate treatment that I ultimately received.

In reading over my charts, and writing this letter, I could see how your staff members would easily interpret this correspondence as further evidence of "diseased behavior" on my part. After all, I am asking for accountability, and I am doing many of the things that Counselor 1 charted as direct evidence of this ongoing pathology. The facts are these: After leaving TMRC, I found an excellent psychiatrist who knew that I was not the type of person who would respond to the intrusive, confrontational tenor of twelve-step therapy. I was placed on medication that worked, and given an opportunity to stabilize medically. When I was ready, I was invited to examine many of the issues that underscored my addictive process, and I began to heal at my own pace. I have not had any drugs or alcohol since then, and I enjoy comfortable sobriety on levels I never imagined. I do not attend AA, I continue to confront irresponsible behavior and I have accepted (not pathologized) my natural tendency to be outspoken and energetic about what I believe in. I have never been happier in my life.

This will be the last time I contact you unless you wish further dialogue on the issues raised in this letter. I offer my story in hopes that you will share this letter with Counselor 1 and Counselor 2 so that my experience can be used as an opportunity for growth and development in your facility. I thank you for listening and I wish you all the best.

Very truly yours,
Jack Wright

G. Douglas Talbott and ASAM (through their attorneys) were sent copies of this letter and introductory material and were invited to respond.

The Stanton Peele Addiction Website