Novembre 2001

Coerced treatment: too many steps in the right direction

Maia Szalavitz

Both New York and California are beginning to implement drug policies which attempt to put the drug reform slogan "treatment not punishment" into practice. New York's plan is slowly being phased in by its Chief Judge while awaiting legislative action on reform of the harsh Rockefeller drug laws; California is implementing Proposition 36, which voters passed 2-1 despite opposition from almost all major politicians and even the treatment industry.

Placing addicts in treatment rather than prison sounds like the ideal "third way" drug policy. For liberals skittish of legalization, coerced treatment replaces the penalty of prison with the compassion of care; for conservatives, it gets addicts off the street more cheaply and they still face incarceration if they fail.

But while proponents can point to its success at unclogging courts and prisons, coerced treatment isn't just a legal fix; it's also a clinical enterprise. Both literature and experience show that as a solution to addiction, coerced treatment has some significant problems which both reformers and the press haven't seriously examined.

Treatment providers have long claimed that forcing people into treatment gives them a better chance of recovery -- and the press seems to have swallowed this line whole without investigating the research. Throughout the debate in California, for example, the Betty Ford Center claimed that treatment couldn't work without the "hammer" of prison, but no one asked how alcoholics (like the centers namesake) whose drug is legal ever get better if that is true.

To support their use of coercion, providers pointed to studies which show that coerced patients stay in treatment longer than voluntary patients and to other research which shows that the longer someone stays in treatment, the more likely he or she is to stay clean. Their argument, then, is that coercion improves length of stay and longer stay automatically means better outcome.

What they neglect to mention, however, is that while coerced addicts' length of stay is greater, their success rate is not. This makes coerced treatment both less effective -- and more costly -- than voluntary care (though, of course, it still remains more effective and cheaper than prison).

When the National Institute on Drug Abuse reviewed the body of "outcome studies" comparing court-mandated to voluntary patients, they found no measurable statistical difference in success rates, even though coerced patients did stay longer.

There's a reason the extra time doesn't help. Length of stay is really a measure of motivation: The most motivated patients, not surprisingly, tend to stay longest, and do best afterwards. But forced treatment is a far cry from motivation. In fact, a large body of research from general psychology suggests that coercion actually reduces peoples' desire to change because it makes them feel controlled.

Current clinical research on substance abuse treatment confirms this. In studies conducted on drug and alcohol treatment, both William Miller of the University of New Mexico and Alan Marlatt of the University of Washington-Seattle found that the more personal investment an addict has in their recovery, the greater their commitment to it, and the better their chances of success. Miller's studies also show that a coercive and confrontational attitude from providers actually increases relapse rates. In short, empathy, support and empowerment produce much better results, but these traits are hardly likely to be found among counselors dealing with a room full of people who don't want to be there.

That same room is also less likely to be therapeutic for voluntary patients. Coerced addicts can be inspired by voluntary addicts, says Howard Josepher, executive director of ARRIVE, a program that trains current and former drug users to do AIDS prevention outreach, but the reverse is less likely.

People committed to recovery are inhibited if others are just biding their time or even making fun of those who are sincere; members of 12-step programs say meetings dominated by court-mandated attendees are less helpful. If all or most of the patients are coerced, "a treatment center is unbalanced," says Josepher, who was sentenced to treatment himself 30 years ago. "It could dampen the spirit."

But both New York and California's plans threaten to make coercion the norm, diverting the flood of convictions from the overloaded court system and into treatment centers, loading them with involuntary patients. Worse yet, increasing the numbers of coerced patients in treatment could lengthen waiting lists for voluntary patients. With a limited number of treatment programs -- none come close to providing enough appropriate slots for all who want them -- court-mandates may give priority to those who don't want help, while those who seek it can't get it.

Coerced treatment assumes that everyone caught possessing drugs is addicted -- an assumption that is clearly not true for marijuana and may not even be the case for hard drugs. Making it easier to get care for addictions by committing a crime than by simply entering treatment would be yet another bitter drug war irony.

So what can policy-makers do realistically? There are some common-sense solutions out there. One of them, pioneered by UCLA professor Mark Kleiman and applied to 7,000 parolees and probationers in Maryland, is to coerce abstinence, not treatment. People busted for drug possession or for drug-related petty crime are sentenced to intensive probation, primarily frequent drug-testing. With each positive test, they face swift, sure consequences -- rapidly increasing sanctions, up to a day or two in jail. Behavioral research shows that immediate penalties are far more likely to change behavior than the far-off possibility of a long, harsh sentence.

The program, called Breaking the Cycle, is designed to test for addiction. After a few rounds of sanctions, people who thought they could quit on their own realize that they can't -- and are more likely to seek help. Treatment is made easily accessible at the first sign of interest.

Thanks to bureacratic bungling and lack of adequate funding, the program only sanctioned 20 percent of those who tested positive in the program's early phases. But even a one-in-five chance of sanctions had an effect: After taking 16 drug tests, the number of subjects testing positive was cut in half, and participants were 23 percent less likely than ordinary probationers or parolees to be re-arrested for new crimes.

Kleiman's system avoids putting people who don't need or want treatment into care, cuts treatment costs by keeping out those who can control themselves, and cuts incarceration costs by not locking up those who stop using on their own. It also increases the motivation of those seeking treatment -- and avoids filling centers with patients who don't want help. It puts rehabs in their proper role of helping patients -- not acting as agents of state coercion. Which is important because providers who argue, against the evidence, that coercion is needed obviously don't have very much confidence that their methods alone can work. And providing them with a stream of replaceable customers who will be blamed for any failures won't improve matters -- in fact, it will allow them to avoid questioning whether their treatment itself is what has been keeping people away.

One solution to both of these problems is the way Arizona has coped with its drug treatment initiative -- which was the model for California's Proposition 36 and was passed in 1996. In both Arizona and California, an addict has to fail at mandatory treatment three times before incarceration is an option.

As a result, Arizona's programs began to use positive reinforcement to get addicts to participate -- making its programs more welcoming and offering rewards like free movie tickets for those who followed the rules. This is a more natural and effective way of increasing desire to change.

One 30-year veteran Arizona parole officer told Time Magazine (7/7/01) that he used to believe that only threats would work on addicts "Boy, was I wrong," he said, "Drug users are not apathetic people with glazed eyes. They care about succeeding -- pretty much like everyone else." A 1999 report by the Arizona Supreme Court found that 77 percent of its offenders were drug-free a year following arrest under the terms of the initiative -- and that the program had already saved the state $2.5 million in prison costs. Says Josepher, "If you get the right balance, you can ignite those coerced clients, you can motivate them -- if they become part of a community that does want to change. Seeing other people's desire to get better was something that captured my imagination and made me want to be a part of it."