The man Donald Trump is reportedly set to tap as America's next "drug czar"—officially, the director of the Office of National Drug Control Policy—shares Attorney General Jeff Session's passion for renewing the War on Drugs. At a hearing on the heroin problem last year, Congressman Tom Marino said he supports mandatory inpatient treatment for "nondealer, nonviolent drug abusers", and that he likes the idea of placing them in a "hospital-slash-prison" setting.
Let's set aside for a second that a plurality of drug arrests in America involve non-addicted pot smokers who do not need any treatment. What the public and the press typically fail to question in covering this issue is whether coerced treatment works at all—and if it does, if it is the best use of limited resources.
To the National Institute on Drug Abuse, this is a settled question: in its Principles of Drug Addiction Treatment, one of the key planks is that "treatment doesn't need to be voluntary to be effective." But some researchers who have recently reviewed the data came to the opposite conclusion, and in my own experience and reporting, I've found demonstrable negative effects when people are coerced into getting help.
A frightening report released last year by Massachusetts, for instance, found that, at least in their state, people who had been treated for addiction without their consent were more than twice as likely to die from an opioid overdose compared to those who had attended voluntarily. Meanwhile, according to the most recent data, around one third of patients in the addiction treatment system nationally are there under some sort of legal pressure—and in some programs, criminal justice referrals make up the overwhelming majority of patients. Drug courts, which are designed expressly to use coercion to get people into treatment, now include some 120,000 defendants annually.
Dan Werb, assistant professor of public health at the University of California—San Diego, recently reviewed the data on the "hospitals-slash-prisons" Marino is so high on. In these centers, participants don't have a choice: they are forced into treatment and not even given the option of a cell.
"The main finding is that there is so little evidence," he tells me. "There's much more robust evidence on the value of voluntary treatment." Of the studies that exist on compulsory treatment, the majority (77 percent) found either no clearly proven effect on drug use or crime—or that forced treatment actually made people worse by increasing their likelihood of arrest or relapse(22 percent).
Some of the included studies were conducted in countries where compulsory treatment is little more than forced labour (and some of it is torture). But even in the United States, there is plenty of forced rehab that doesn't actually do much good. One study of 506 defendants mandated to a Texas rehab for six months found no significant difference in recidivism between graduates, dropouts and people who weren't mandated to the program. Another study of over 2,000 American military veterans found that although those who were mandated into treatment initially seemed more likely to succeed, five years later they were no more likely to be in recovery than those who chose to be in treatment.
David Farabee, professor of psychiatry at the University of California—Los Angeles, who has studied the effects of coercion on treatment for decades, notes that much of the data here is confounded by what scientists call a "selection effect." What this means, essentially, is that pre-existing differences between the groups being compared actually account for what look like treatment effects. In the case of addiction treatment, research has long shown that—up to a point—spending more time in treatment is associated with better outcomes.
That has led to the conclusion that a "higher dose" of treatment is more effective. But there's a massive problem with drawing that lesson from these data. That is: many treatment centers expel people for relapsing—and those who drop out are often doing so because rehab has not made them better at sustaining abstinence. In other words, those who stay longer are more motivated to recover, regardless of any effect of treatment. According to Farabee, research on legal sanctions to motivate people to stay in treatment shows that they do stay longer—but that doesn't mean that they actually have better outcomes.
Adds Farabee, "The more you dig, the more you see that the notion that coercion is a panacea is unfounded. The best thing you can say is that people are more likely to show up if made to do so."
Alex Stevens, professor of criminal justice at the University of Kent in the United Kingdom, is the author of a review of the data on people who are given a choice between treatment and prison. He found that in this case, legally-coerced patients do no better or worse than those who come voluntarily. But it's hard to tell what that really means. For one, people who were considered as being there "voluntarily" actually had other pressures on them. "His wife said he had to come, otherwise she'd leave, his boss said he'd lose his job—or someone is just bored of being arrested all the time," he explains.
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A bigger problem is the effects that coercion has on treatment quality and the programs themselves. Consider, for example, the fact that trauma and PTSD are highly linked to addiction, particularly childhood sexual abuse. Imagine trying to sincerely open up about these painful and highly personal experiences in a room full of people who are rolling their eyes and crossing their arms and are unlikely to maintain any type of confidentiality since they haven't really consented to the conditions of treatment.
Farabee has conducted focus groups with prisoners about addiction treatment during incarceration. "Every single time, generally older guys would say, 'I actually am sick and tired, I want to quit. Can you get rid of the guys who don't want to be here?' That was repeated in multiple focus groups over the years."
Another negative effect that coercion can have on treatment quality is less obvious, but perhaps more important. Research shows clearly that having a strong therapeutic connection between practitioners and patients is one of the best predictors of good outcomes. But this is difficult to do when patients see their therapist as just another agent of the government who will report them to the court when they fail.
Moreover, there's lots of evidence that a more respectful treatment environment—not a punitive or confrontational one—is way more effective. If programs have to work to attract people into attending—rather than having customers forced to accept their services—they are far more likely to create such spaces. This problem is further reinforced by the ideology of legal coercion: treatment failure results in incarceration or other punishment for the patient—not negative consequences or fewer referrals from the justice system for the program. When you don't hold programs accountable for how they treat patients and when treatment quality actually requires kindness and empathy, criminal justice coercion can be a seriously negative force.
There's also a basic fairness question here: Why should people who've been arrested have priority in getting healthcare over those who voluntarily seek help?
"It's generally widely accepted that addiction is a mental illness that should be treated through the public health system and through clinical protocols," says Werb. "That begs the question: what is the best deliverer of healthcare in addiction treatment? I think it would be very difficult to make the case that somehow the justice system is a better deliverer than the health care system."
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