Coerced Treatment: Too Many Steps in the Right Direction

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.