The idea that treatment in place of prison is inevitably beneficial is so naïve and wrong-headed that it must be challenged each time it is introduced even when done so by drug policy reformers who are right that imprisoning both casual users and addicts is a horrible mistake. This article describes in both theoretical and practical terms (with numerous examples from Stanton's vast correspondence) just how ineffective therapy may be, as well as some truly horrible outcomes from coercive therapy.
Reconsider Quarterly, Winter 2000-1001, pp. 20-23
Court-Ordered Treatment for Drug Offenders is Much Better than Prison: Or Is It?
Stanton Peele, Ph.D., Esq.
This past June, New York became the first state in the union to require all nonviolent criminals found guilty of drug charges to be offered treatment for drug addiction instead of serving jail time. The benefits are obvious: this policy will sharply reduce the number of repeat offenders clogging the courts, relieve crowding in state prisons and jails, and help addicts conquer their disease. Surely, this is an enlightened policy that can only help drug users. Well, not quite.
Labeling Drug Users as Disease Causes Further Problems
In the first place, receiving treatment in this context requires one to be labeled a drug addict. Thus, everyone who enters such a program is saddled with a dependence diagnosis, and counseled for addiction, even if they are merely recreational users. Furthermore, virtually all substance-abuse treatment in the United States is rooted in the assumption that drug addiction and alcoholism are diseases, the so-called medical model. Yet, virtually all adopt a decidedly non-medical, spiritual model of treatment the 12-step Alcoholics Anonymous (AA) program. The primary technique of 12-step programs is the group-confrontation session in which addicts are prodded to acknowledge the error of their ways, that they are powerless over their drug use, and that they must turn themselves over to a higher power. This mea culpa/self-abnegation treatment is supervised by former addicts or alcoholics. In this context, all "addicts" are counseled more like commanded to adopt total abstinence. According to the federally sponsored National Treatment Center Study, 93 percent of private substance abuse treatment programs are based on the 12 steps, and public programs are, if anything, even more dominated by this philosophy. Almost 100 percent of programs, according to this survey, endorse only abstinence.
But to tell everyone who uses a drug or has had a drinking problem he is diseased, and must abstain forever, leads to worse problems for many than those with which they originally reported to treatment. As a psychologist with more than 30 years' of experience working with drug users, both addicted and non-addicted, I have seen again and again that 12-step programs not only fail drug users, they can have negative impacts. When 12-steppers "fall of the wagon," they tend to fall hard and fast into binge use, rather as a dieter will gorge after starving himself for days or months. This is not only due to a reaction against "starvation," it is due to the core philosophy 12-step programs teach that people are "powerless" over their drug use. For these and other reasons, I co-wrote, with Charles Bufe and Archie Brodsky, Resisting 12-Step Coercion.
Forced Abstinence Can Lead to Powerlessness and Depression
What does it mean to feel powerless? Depression is marked by such feelings. Indeed, for many, it is such feelings which cause them to reach for a drink or a drug to make themselves feel better. Through my Web site, www.peele.net, I frequently answer questions about drug use, abuse, and treatment. The stories I receive are grim testimony to how compulsory treatment policies regularly fail. Recently, I heard from Marie, who wrote me about her son, Johnny a 19-year-old college freshman:
My son was charged with DWI in October...[As a result,] he enrolled in alcohol classes through the college, which he says were a joke (they showed them a movie once a week for five weeks). In January, he moved off campus into a house with four other students. Well, in April, police raided their house and they were all charged with possession. The police found a small amount of marijuana and cocaine in the house.
The court offered Johnny a diversionary program, involving "group counseling four times a week and attending two AA meetings a week for 20 weeks." Under our current policy choices, Johnny can either "fess up" to alcoholism/addiction and abstain for as long as he is supervised by the court, or else face prison time as a 19-year-old college freshman! According to his mom, "He has been very good about attending meetings including roller blading over two miles to the classes because his license was suspended." But, she indicates, it's not really working.
The problem is my son says that he does not feel that he is an alcoholic. Does he drink and sometimes abuse yes, but does this mean he is an alcoholic or a typical college student? He is really trying hard to get his life together and is trying to cooperate, but he is finding this process isn't working for him; what should we do?
Of course, facing negative consequences for antisocial behavior like drunk driving is to be expected and may even be beneficial. Unlike the idea that we should replace ordinary judicial processes with therapy, outcomes in a massive government experiment in which several Southern California counties presented treatment options for drunk drivers while other counties simply suspended licenses and jailed repeat offenders found that the counties which did not offer treatment recorded fewer re-arrests and lower recidivism rates.
The treatment in these cases would have been as it is around the U.S. 12-step based. However, behavioral programs for drunk drivers a majority of whom have been found not to be alcoholics have shown good success. But these programs are regularly dismantled, even after they have been found to work, since they conflict with the basic assumptions of the 12-step ideology. Instead of telling people they are born with a disease, such programs counsel personal responsibility, offer exercises where drivers practice confronting choice situations like those which led them to drive drunk, and explore feelings and social pressures that have led them to make bad choices in the past.
Johnny has already had his driver's license suspended. And he had better stop getting arrested or he is going to lose any choices that remain to him these are life lessons people need to learn. But to decide because he and his roommates possessed drugs that Johnny requires counseling as an alcoholic/addict is irrational, demeaning, and counterproductive. Perhaps if the authorities wear Johnny down enough, they WILL convince him he is a lifelong drug addict. Aside from the ethical and legal propriety of the government working to force this self-image on a person, it is also counterpoductive therapeutically. It will not make Johnny a happier, more controlled, or better citizen.
Forced Treatment vs. Prison Threat Can Extend Indefinitely
Reformers often argue forcefully for introducing treatment in prisons or as alternatives to prison sentences, since they feel such an approach will be far more humane than incarceration. But they ignore the fact that people like Johnny will never be able to escape their diagnosis, treatment, labeling, and record of court supervision. Rather than sparing more people prison terms, this approach instead will expand government intrusion into the lives of Americans. And this religion cum therapy which toys with people's self-concepts has the potential to wreak far more fundamental and pervasive havoc on a person's life than a prison sentence. Among other things, requirements to attend 12-step meetings and to abstain can be extended virtually indefinitely, with the threat of prison to keep the person in line.
Research from the Rand Corporation indicated that funds are better spent on drug treatment than for drug interdiction and criminal pursuit of drug users. This is true up to a point, since our current drug policies are completely wrongheaded and highly expensive failures. But to compare what happens to an individual in prison or faced with a sentence who actually enters treatment with one who does not often produces a much different picture. In 1999, an independent research group, the Criminal Justice Policy Council, evaluated three-year drug-use recidivism rates for offenders participating in substance abuse treatment programs in Texas. They found that those who participated in an in-prison program had the same recidivism rates as those who did not take part in the programs.
Offenders who actually completed the In-Prison Therapeutic Community (IPTC) programs had lower recidivism rates than comparison offenders who did not participate in the program. (Although, technically, therapeutic communities adopt a different approach from AA and specifically do not accept that addiction is a disease at this point it is usually the case that IPTCs have been significantly influenced by disease- and 12-step concepts. The same is true with most methadone programs, which, while regarding addiction as a disease, supposedly do not accept AA's abstinence fixation, but in fact now often do.) However, the higher recidivism rate of offenders who participated in but did not complete the program made the overall recidivism rate of participants equivalent to that of nonparticipants. Of the offenders who completed the IPTC program in the first group, 34% were reincarcerated after three years compared to 42% for all program participants and 42% for the comparison group. For the second group the equivalent rates were 33% for completers, 37% for all program participants, and 37% for the comparison group.
Forced Treatment Results in Higher Recidivism than NO Treatment and Adolescent Use INCREASES Following Treatment
Researchers found that the two groups in a diversionary (probation) Substance Abuse Felony Punishment (SAFP) treatment program had HIGHER recidivism rates than for those who did not participate in the program. Of the offenders who completed the SAFP program, in the first SAFP group, 32% were reincarcerated after three years compared to a 38% rate for all program participants and 35% for those not participating in the program. For the second SAFP group it was not possible to collect program completion information due to prior administrative problems with the program. However the recidivism rate for all program participants was 44% compared to 35% for those not participating in the program. For both prison and probation, the state lost $1 for each $1 of program costs since the programs did not work. These researchers pointed out that, if authorities had only considered those who entered but did not drop out of such programs (which is frequently done), they might actually have been misled into thinking that treatment offered slight benefits.
But the treatment results look even worse when borderline or less severe cases are those involved. In one notable case, the federal Substance Abuse and Mental Health Service Administration's Services Research Outcomes Study (SROS), the group that did worst in treatment was adolescents, who INCREASED their cocaine and alcohol use FOLLOWING treatment. The likely explanation is that, in these settings, younger and less severe users learn more serious habits from experienced druggies.
Federal AA Study Finds That Treated Drinkers Were More Likely to Continue to Abuse Alcohol
We have very strong evidence that treating substance abusers in current programs is not particularly fruitful. The federal government, through the National Institute on Alcohol Abuse and Alcoholism, conducted the National Longitudinal Alcohol Epidemiologic Survey (NLAES) in 1992 based on face-to-face interviews with 45,000 Americans about past and current drug and alcohol use, treatment, and concurrent emotional problems.
The NIAAA's Deborah Dawson analyzed over 4,500 NLAES subjects whose drinking at some point in their lives qualified for a diagnosis for alcohol dependence. Only about a quarter of those who had ever been alcohol dependent were ever actually treated (or entered AA). Remarkably, NLAES found that more of these treated alcoholics (33%) than untreated (26%) subjects were abusing or dependent on alcohol in the past year. Of those whose alcohol dependence appeared within the last five years, 70 percent who received treatment were drinking alcoholically in the previous year. The main reason for the difference was that most of the untreated alcoholics continue to drink without being diagnosable as alcohol abusers. Although treated alcoholics were somewhat more heavily alcohol dependent on average than untreated alcoholics, the results nonetheless show that alcoholics undergoing treatment in the United States do not experience reliable improvement, while people on their own often do succeed.
Drug and Alcohol Abuse Is a Way of Coping with Stress, But Is Not a Medical Condition
People who repeatedly abuse drugs or drink as a way of escaping or dealing with life's pressures, do so because they can't cope. But why do we, in the land of the free, make the inability to productively cope with life a crime? Addiction is a way of coping with life, albeit a largely destructive way of artificially attaining feelings and rewards people feel they cannot achieve in any other way. As such, addiction, while not a crime, it is no more a treatable medical problem than are unemployment, lack of coping skills, or degraded communities and despairing lives. The only remedy for addiction is for more people to have the resources, values, and environments necessary for living productive lives. More treatment will not win our badly misguided War on Drugs. Nor will imprisonment. These approaches only distract our attention from the real issues of addiction.
That otherwise critical and skeptical drug reformers are accepting compulsory treatment plans, despite treatment's dismal success record, shows how much the therapeutic society has been oversold, and how much its assumptions remain unexamined. We will NOT benefit from increased substance abuse treatment (over already record levels) in the American justice system. Unfortunately, we may need to experience even more negative consequences of our treatment fixation before we become convinced of this. Alternately, we may simply have lost the ability to discern that something called "therapy" can be so harmful. We might need to run seminars with Americans whose lives have been ruined by coerced 12-step treatment just as we need to present to Americans people whose lives have been ruined by drug laws to make clear the dangers of the therapeutic state.
Forced Treatment Can Ruin Lives, Not Save Them
Take, for instance, Paul, one of my recent correspondents, a man who took marijuana to control his migraines. Although his story involves coercion at the hands of an employer, court-ordered treatment and/or AA or NA attendance is often administered under similar circumstances. It shows how coercive treatment sweeps up many people who by no standard could be considered addicts, and the ill-effects of forcing people into treatment for any and all drug use.
About 3 months ago I took a hair drug test at work. The test showed positive for marijuana. I had been using marijuana for a few years and only used a small amount each night before bedtime. After having severe migraines for years, I turned to it as a last resort (I had used Imitrex, Vicodin, among other painkillers almost daily and Covera HS) and it helped considerably, almost completely eliminating the migraines.
Upon failing the drug test I was subject to being terminated by my employer if I didn't enter an Employee Assistance Program. I had to go through a four-hours-a-day/four-days-a-week program for 3 weeks at a rehab facility, even though I still believe I was using the marijuana for relief of my migraines and sleeping disorders. I did not abuse the drug or use it recreationally.
After the hospital rehab program I've been forced to go to at least 4 AA meetings a week in order to be in compliance with my employer's EAP. People laughed at my marijuana habit at the first AA group I went to one guy told me, "In LA we used to smoke marijuana after our AA meetings." I went to another AA group and admitted I was a marijuana addict. Afterwards, a lady came up to me and said, "You should say you are an alcoholic, you will be accepted better." I told her I don't drink alcohol and never developed a taste for it because of my migraines. So now I'm going to my third group, where I just say I'm an addict so I will be accepted by the group.
After about ten meetings I became so depressed I lost all my energy and I just lay around and have gained 20 lbs. I'm single, and recently have found myself thinking that life is no longer worth living. I feel that I'm not an addict and somehow I must take a stand with this issue.
But to do so will endanger his livelihood. Of course, if he were in treatment due to the legal system, his alternative would be to lose his freedom.
If we don't coerce people into treatment, how do we help them? Whether people succeed through treatment or on their own, they generally do so for similar reasons. Research has shown that certain characteristics of the patient, not the treatment, are crucial to the outcome of alcoholism and addiction treatment. Patients with stable family and work lives succeed far more often (this is why private treatment centers can claim better remission rates than public hospitals). "The best predictor of success is whether the addict has a job," says Dr. Charles Schuster, former director of the National Institute on Drug Abuse. And Dr. Herbert Kleber, the official in charge of demand reduction in the Bush Administration's War on Drugs, indicated that successful treatment for minority crack addicts, who are also saddled with poverty and lack social and economic resources, entails "habilitation more than rehabilitation."
Habilitation Can Save Lives
By habilitation, Kleber means developing life skills, life structures, and constructive communities to support people in life. But if the ability to function free of drugs depends on job training, social skills, and pro-social attitudes, why do so many Americans fail to acquire these in the first place? For every person who can possibly be cured in therapy, many more young addicts will appear. What successful therapy actually demonstrates is the need, not for more or better therapy, but programs to strengthen families, communities, education, housing, and job training. Indeed, assisting people to acquire these things could itself be termed therapy a kind of reality therapy as opposed to therapy that involves people sitting around in groups talking about their powerlessness and making amends for their lives. Such therapy directed at redressing real-world deficiencies is productive and sane. Incarceration and forced spiritual treatment are not.
Unfortunately, the trend towards forced treatment as an adjunct to the criminal justice system will most affect lower level, recreational, and casual users, such as Johnny and Paul, because there are simply more people who fit this profile than there are addicts. Also, since their lives are more manageable they are more easily recruited into treatment. The end result? Millions of otherwise productive citizens will be saddled with inappropriately broad clinical diagnoses. In this way, so-called addiction treatment will simply be another coercive technique to enforce unrealistic zero-tolerance goals. In the meantime, by sinking our resources into these ineffective programs, we'll have no resources for building the programs and approaches that can cure hard-core addicts or prevent addiction in the first place.