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.

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."