This article offers a way to honor generations of men and women who spent their lives laying the foundation for what would become the profession of addiction counseling. We can still draw upon these individuals' lives and their stories for wisdom and inspiration.

Before there were counselors

No formal role of addiction counselor existed in the 18^th and 19^th centuries, but there were those who reached out to people with alcohol and other drug problems through activities that later would be integrated into this role. Those activities could be found in two settings: the earliest addiction recovery mutual aid societies, and within America's first inebriate homes, inebriate asylums, private addiction cure institutes, and faith-based recovery ministries.

Early addiction recovery support groups included Native American recovery circles, the Washingtonians, recovery-based fraternal temperance societies, the Ribbon Reform Clubs, the Drunkard's Club, and the United Order of Ex-Boozers.1,2,3 The reformed drunkard turned temperance missionary became a prominent figure in the American temperance movement. Individuals such as John Gough and John Hawkins used charismatic speeches detailing their fall and redemption to call others into recovery.4,5 They also provided personal consultations with alcoholics and their families, helped organize local recovery support groups, and maintained a prolific correspondence with individuals and families in recovery.

The therapeutic branch of the American temperance movement became involved in “rescue work” with confirmed drunkards, and these efforts spawned calls for specialized treatment institutions. What followed in the mid-19^th century was an ever-expanding network of inebriate homes, medically directed inebriate asylums, private for-profit addiction cure institutes, and urban rescue missions catering to late-stage alcoholics. As “reformed men” sought service roles in these institutions, controversies raged about who was best equipped to do this work. The relapse of some prominent recovering temperance lecturers added to this debate.6,7

T.D. Crothers, MD, a prominent leader in the American Association for the Study and Cure of Inebriety—the first professional association of addiction treatment providers—adamantly opposed the hiring of persons in recovery. He wrote, “Physicians and others who, after being cured, enter upon the work of curing others in asylums and homes, are found to be incompetent by reason of organic deficits of the higher mentality. … The strain of treating persons who are afflicted with the same malady from which they formerly suffered is invariably followed by relapse, if they continue in the work any length of time.”8

This debate died in the larger collapse of addiction treatment in the opening decades of the 20^th century—a collapse resulting from a perfect storm of intrafield factors (e.g., ideological schisms within the field, ethical abuses, aging leadership) and contextual factors (economic depressions, lost cultural faith in the prospects of long-term addiction recovery, and the advent of national alcohol and drug prohibition laws). In spite of the collapse of addiction treatment as a field, key functions performed by those in recovery carried into the 20^th century: self-disclosing, educating (including providing lectures during residential treatment), advising, encouraging, modeling, and linking individuals to sources of long-term sober fellowship. These functions mark a thread of historical continuity that influenced the later rise of addiction counseling.

The lay therapy movement

Between 1900 and 1920, local efforts to treat alcoholism continued in spite of the larger national collapse of addiction treatment as a field. In 1906, the Emmanuel Church of Boston established a clinic that integrated religion, psychology, and medicine in the treatment of alcoholism. The clinic provided medical evaluation, educational classes, individual and group counseling, mutual support (the Jacoby Club), and personal support of “friendly visitors” (recovered alcoholics). Within a few years, the latter evolved into a formal system of lay therapy. Selected patients who had been successfully treated at the Emmanuel Clinic were trained to provide the same type of counseling they had received.9

Courtenay Baylor was hired as a lay therapist at the Emmanuel Clinic in 1913 following his own treatment there by Dr. Elwood Worcester. Baylor was the first person without traditional medical or psychological training to be employed full-time as a therapist specializing in the treatment of addiction. He was followed by other noted lay therapists, including Richard Peabody, Francis Chambers, William Wister, Samuel Crocker, Wilson McKay, and James Bellamy. Chambers worked with noted psychiatrist Edward Strecker, MD, and was the first lay alcoholism therapist to work as a fully accepted member of the multidisciplinary team within a major psychiatric hospital.10

The essential approach of the lay therapists included negotiating a treatment goal of lifelong abstinence, eliciting a commitment for 60 to 100 hours of outpatient therapy, negotiating a contract for mutual confidentiality, sharing the therapist's personal addiction/recovery story, eliciting the client's story, analyzing the inciting causes of the client's alcoholism, educating the client about alcoholism, giving the client reading assignments, creating a daily schedule for each client, training the client in relaxation techniques, utilizing hypnotic suggestion, and teaching each client positive self-talk.11 Baylor's Remaking a Man12 and Peabody's The Common Sense of Drinking13 stand as the first texts devoted to the structure and techniques of alcoholism counseling.

The lay therapy movement exerted great influence on the re-emergence of alcoholism treatment, but these therapists worked in isolation, maintained only informal contact with one another, and did not constitute an organized field of addiction counseling. The isolation within which they worked may have contributed to the relapse of some prominent lay therapists. If there is a single person who forms a human bridge between the early lay therapy movement and the rise of new outpatient alcoholism counseling clinics in the 1940s, it would be Ray McCarthy, who pioneered many alcoholism counseling techniques at clinics established by the Yale Center of Alcohol Studies in the 1940s.

AA and the counselor

Alcoholics Anonymous experienced explosive growth in the early 1940s, and this growth and the efforts of the newly created National Committee for Education on Alcoholism (the precursor to today's National Council on Alcoholism and Drug Dependence) spawned a parallel growth in alcoholism treatment facilities.

AA members, continuing a long “wounded healer” tradition, began working in various service roles within new alcoholism units in community hospitals (e.g., St. Thomas Hospital in Akron, Ohio and Knickerbocker Hospital in New York City), alcoholism units in psychiatric hospitals (e.g., Rockland State Hospital in New York and Manteno State Hospital in Illinois), alcoholic “retreats” and “farms” (e.g., High Watch in Connecticut and Alina Lodge in New Jersey), and new facilities operated by members of AA clubhouses (e.g., Twelfth Step House in New York and Friendly House in Los Angeles). What emerged were guidelines that helped AA members clearly distinguish their AA activities from their paid activities as nurses, social workers, psychologists, and lay therapists.

The road from lay therapy to modern addiction counseling wound through the state of Minnesota in the late 1940s and 1950s. It was there that three abstinence-based, AA-oriented alcoholism programs—Pioneer House, Hazelden, and Willmar State Hospital—birthed what came to be called the Minnesota Model of chemical dependency treatment. For purposes of this discussion, this model had two very important influences. First, it gave rise to the role of the alcoholism counselor at the center of a multidisciplinary alcoholism treatment team—even getting the State of Minnesota Civil Service Commission to establish the civil service position of “counselor on alcoholism” in 1954. (The position required two years of sobriety and a high school education.) Second, the model was widely replicated across the United States. That replication sparked the rise of the new specialty role of alcoholism counselor in communities across the country.3


Mel Schulstad, one of NAADAC's founders, speaking at the 2006 NAADAC Annual Conference in Burbank, Calif. Photo by Ghia Larkins

That therapy for the alcoholic would be relegated to the lay alcoholism psychotherapist was not without its challenges. Alcoholics regularly found themselves in service settings with physicians, nurses, psychologists, social workers, and pastoral counselors, and many of these traditional service professions were employed to work in specialized alcoholism treatment settings. A central debate of the 1960s was, “Who is qualified to treat the alcoholic?”14

The ex-addict counselor

In 1958, Charles Dederich founded Synanon—the first ex-addict directed therapeutic community for the treatment of drug addiction. Six years later, Marie Nyswander, MD, and Vincent Dole, MD, introduced methadone maintenance treatment in the United States. As TCs and methadone maintenance spread in communities across the country, the “drug abuse counselor” role emerged as a central service role within each modality.

The polydrug epidemic of the 1960s generated new mainstream and countercultural service institutions (e.g., free clinics, crisis lines, drop-in centers, “acid rescue”). Many of these institutions morphed into “outpatient drug-free” counseling clinics in the 1960s and early 1970s. The primary service role within these clinics was also that of the drug abuse counselor. Added across these settings was a mix of traditionally trained nurses, psychologists, social workers, and clergy drawn to service with this particular client population and the frontier nature of the field, or drawn to the field to work out their own troublesome relationships with alcohol and other drugs.

The first national meetings that brought together what were then christened “para-professional counselors” from these diverse service settings were something to behold. Meetings were loud and boisterous as treatment philosophies (more like religions then) and personal values and lifestyles collided. Such differences were further amplified in the first meetings that brought the alcoholism treatment workforce together with the drug abuse treatment workforce. That a professional field emerged from these building blocks is something of a miracle—a miracle of leadership in which NAADAC played a significant role.

Closing reflection

As we celebrate this historical milestone for NAADAC, we should pause to consider the state of the field when NAADAC was founded. In 1972, the federal, state, and local partnership that has been the hallmark of modern addiction treatment was just being formed—with no promise that it could sustain itself. The field at all levels was really two fields—an alcoholism field and a drug abuse field—that viewed each other with mutual hostility and distrust. It took more than a decade and much heated debate to forge an integrated field of addiction treatment that could distinguish itself from the broader arenas of health and human services.

In 1972, few treatment programs rested on a solid financial infrastructure. Programs lived from single grant to single grant, staff were paid a pittance, and at the end of each funding year, counselors often left work on a Friday not knowing if their organization or their jobs would exist on the following Monday.

In 1972, there was no defined core of knowledge and skills for addiction counseling, no formal addiction counselor training programs, and no advanced degrees in addiction studies. There were no nationally established standards of practice for programs or individual practitioners. There was no universally accepted code of ethical conduct in the practice of addiction counseling, and not a single book available on that subject.

Happy birthday, NAADAC. You nurtured the field of addiction counseling through a turbulent birth and adolescence. You lit our pathway from para-professional to professional status. You have been there to guide us into maturity.

Some would say we are now facing a mid-life crisis in which we need to redefine the very essence of who and what we are as a profession. The threats to, and opportunities for, the profession of addiction counseling have never been greater. Today, we need NAADAC's leadership more than ever.