Should States Let Families Force Addicts Into Rehab?

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Addiction is a heartbreaking condition for parents and spouses: they watch, often helplessly as their loved one self-destructs, hurting those who care about them most.

In some states, family members have the option to legally force addicts into rehab, a mandate that is now being pushed in other states that currently don’t allow it. But the question is, does involuntary treatment help an addict who isn’t ready, or does it merely cause more harm?

In a New York Times column this week, a doctor introduced the problem through the case of J., a construction worker who suffered from both genuine pain and serious addiction to painkillers. J.’s wife had brought him in for a medical exam. But while J. voluntarily acknowledged his addiction — along with the lost work days, mounting debt, marital strain and declining health — he refused treatment, leaving his wife begging the physician to take further action.

Dr. Paul Christopher writes:

[W]hile I shared her concern, there was little I could do to force J. into treatment.

My hospital happens to be in Rhode Island, one of about a dozen states where compulsory treatment for someone like J. (that is, someone not under the purview of the criminal justice system) does not exist. Had J. been a resident of nearby Massachusetts — or from one of more than 20 other states that permit involuntary addiction treatment — I would have suggested his wife petition a judge to force him into care. Had we met in any of a dozen states, I could have hospitalized J. myself — against his will and for up to several days.

Setting aside concerns over civil liberties — which are acute when considering forced hospitalization for a condition as common as addiction — compulsory treatment can look like a good idea. If an addict apparently doesn’t want help, forced care will get their attention. And studies show that people who are coerced into rehab do no worse than those who attend voluntarily.

Unfortunately, neither group actually does very well: the vast majority of people who are treated for addiction will relapse after a single episode of care, and typically there are few provisions, other than referrals to self-help groups, for those with a chronic problem.

(MORE: Addiction Treatment in America: Not Based in Science, Not Truly ‘Medical’)

Worse, the vast majority of people who get addiction treatment don’t receive evidence-based care; in fact, many are treated using punitive techniques that are known to cause further harm. Many states have no education requirements at all for addiction counselors who provide most treatment, despite the fact that at least half of people with addictions have a co-existing mental health disorder that often requires more professional care. A recent study of our addiction treatment system by Columbia’s National Center on Addiction and Substance Abuse found that it is “largely disconnected from mainstream medical practice,” fostering treatment programs that are “not adequately regulated or held accountable” to any national standard.

Forcing more people into such a system makes little sense. Indeed, 50% of people treated for illegal drug problems are already sent into rehab by the criminal justice system. And that coercion, I believe, is actually a key reason for the sorry state of our treatment structure overall — as well as much of its ineffectiveness.

Here’s why: the reality of addiction is not pretty or pleasurable. While it may seem to family members and friends that addicted people are “doing what they want” and mindlessly seeking pleasure, in reality, by the time you are addicted, the fun is long gone. You are using drugs because they have become your only source of safety and comfort — not because they offer some extra joy or irresponsible bliss. You fear quitting not because you love drugs so much, but because you can’t imagine the alternative. This was certainly the state I was in when I was addicted to cocaine and heroin in my 20s.

In such a vulnerable condition, addicts need to be supported, treated warmly and given reassurance that they can find alternative methods of coping that will not only be bearable, but better than drugs. They need to be treated like a patient, not a criminal.

Sadly, however, a rehab system based on coercion isn’t conducive to the right treatment strategy: it’s designed to break resistance, to humble, to use force to make change. Its fundamental DNA is punitive — a system in which half the people attend involuntarily necessarily creates the impression that no one would be there unless they had no other options.

The underfunded, underregulated, undercredentialed world of addiction care is a product of the moral stigma that underlies this approach. While some programs valiantly resist and do provide excellent care, they are unfortunately not the majority.

(MORE: How to Find the Best Drug Treatment for Teens: A Guide for Parents)

Not surprisingly, few people turn up voluntarily in this system; even those who aren’t legally coerced often have family members or job pressures or a sheer lack of alternatives pressing their entry. Dr. Christopher’s reluctant patient J. may have feared cruel, demeaning or disrespectful care, which is particularly terrifying to someone who not only has addiction, but also suffers from chronic pain. And of course, J.’s reaction to treatment only reinforces the commonly held notion that “addicts don’t want help” and that they must be pushed in order to get better.

The only way out of this cycle is a complete rethink. While market-based solutions are seen as optimal for other types of problems, unfortunately this rationale is rare in addictions. If you are selling a product that no one is buying, generally the answer isn’t to pass laws to force people to do so — as is the case in addiction care. Instead, we need to learn how to attract customers, to treat them well, to find out what they want and need and then give it to them. Rather than using force, you need to learn to use persuasion; instead of punishment, rewards.

Happily, this approach is hugely consonant with what actually works to treat addiction. Research shows over and over that empathy, kindness, respect and support work better than force, brutality, humiliation and shame. All of the most successful evidence-based methods to treat addiction ultimately help people feel better, not worse — if they don’t, recovery won’t last.

Indeed, research finds that gentle approaches used by families to persuade their addicted loved ones to engage in treatment work better than the old “confront them and give them an ultimatum” response. If states want to improve their addiction treatment outcomes, we don’t need more ways to coerce people get help, we need better help that attracts people with care.

Maia Szalavitz is a health writer at TIME.com. Find her on Twitter at @maiasz. You can also continue the discussion on TIME Healthland’s Facebook page and on Twitter at @TIMEHealthland.

20 comments
LoraTrueblood
LoraTrueblood

Very good read!! It's not that people don't want help. Bu it's like a vacation you have to do the research. U don't wanna end up in some shotty tijuana hotel Where u might end up sick from food poisoning or worse...same goes for rehab and addiction therapy! U need to give people time to reflect. Calling the addict selfish makes u selfish! All u care about is how they are affecting you! You need to be concerned about how they feel and how did these things happen in the first place. Forcing someone into rehab Does not work. The success rate at a good facility is less than 25% that rate includes forced patients! So how bout let someone chose what will work. And also face the sad reality some cannot be helped! That does not mean give up completely. But the addict already knows they have no control so if u force less control onto someone who can't even control his body you are only hurting them more! Ibogaine has a way higher success rate and American researchers proves this at the University of Miami with Dr mash yet the DEA pushed her team off shore. I don't believe the government wants to help anyone. Keeps the addicts poor and the pharmacy and private jails rich!

tlittelton
tlittelton

There is such a thing as power-of-choice. This means allowing the individual to decide for himself. It would make sense that families would want o convince their loved one to enter rehab, but not a good idea to make them do it unless they are posing a danger to themselves or others.

lupierrou
lupierrou

It is not a good idea to force someone into rehab treatment because they already feel out of control in their lives. This just furthers that feeling. if their were more effective rehab treatments available, those addicted to drugs and alcohol would check themselves into rehab. I think only when it looks like someone will die if they are not helped, should they be forced into rehab.

jimbocohles
jimbocohles

If there were affordable, nice looking, effective drug and alcohol treatment facilities, more people would go to some type of rehab. Many times, the reason that people don't voluntarily enter rehab is because of one of the above factors not being present. The stop in them going is the thought of the time involve, the money needed and can't get and the low success rates. Who would want to be subjected to what they usually receive; ridicule, poor care factor and less than kind attitudes toward them. As a society, we need to start creating the effective, successful, affordable rehab programs and they will come.

AddictionMyth
AddictionMyth

Maybe addiction is a disease.  Or maybe it's a Big Lie.  For example, this construction worker may resist treatment not because he's addicted to pain killers and sees no other option.  Maybe he just dislikes his wife and feels trapped in the marriage and takes drugs to keep her at a distance.  This may seem far-fetched, but if you go to any AA meeting you will find exactly this type of person speaking about their 'addiction' (eventually they will get divorced, though they may reconcile years later).

No one should be forced into treatment.  Instead, we need to understand excessive drug use as a free-choice behavior.  This woman needs to get this man out of her life.  In fact, this may be the intention of his drug use, but the 'addiction' label allows him to avoid taking responsibility for that and being the bad guy.

czydiamond
czydiamond

Not to demean or dismiss anyone's recovery, most "treatment centers" are extremely expensive and run hand in hand with the justice (or injustice) sustem to make money off people who are arrested on drug offenses. Most of these centers operate on a punitive style treatment regimen. The treatment industry is a major supporter of the current "War on Drugs" for obvious reasons. When you hear politicians saying "treatment instead of incarceration", realize that many people arrested for drugs are not addicts, and those who are are seldom helped by forced treatment. As the author states above, love and kindness are the best treatments. 

Drug use needs to be legalized, including pain medication. As a person in serious chronic pain, unable to legally obtain medication because of the expense of "pain specialists", I would be a prime candidate for heroin addiction if I did not have a friend who provides me some pills for free. The current drug laws only fuel addiction and crime, not mitigate it. Any substance or behavior is much more addictive if forbidden and driven underground.

Mantha08
Mantha08

I actually went voluntarily into the "forced" treatment they have in MA. I had to stay at least 30$500 days, but found that after 20the or so days clean, and being completely removed from my life, actually gave me some clarity and I decided to go on to further treatment. I stayed there about 90 days, went to a halfway house, and now I work, and keep my recovery up front. I am coming up on 18 months sober. The MA section 35 facility SAVED MY LIFE... and alot of women I was there with are still clean. Believe what you want, that addicts are hopeless cause. But i am living proof that IT WORKS!

Jill Matheny
Jill Matheny

I am somewhat dismayed that the author thinks treatment doesn't work. It's not that simple. It's not a like broken arm where one episode of treatment works and you are healed. It sometimes takes numerous treatments to get an addicted person to find recovery. To state that treatment is not effective leaves out the science around addiction and long term recovery. I hope this article doesn't continue to perpetuate the myth that treatment is a waste of time and you are a failure if you relapse. That's part of the disease process. Diabetics are never held to this same standard when they relapse and go eat candybar and throw off their insulin levels. Why do we continue to stigmatize a disease?Addiction is like cancer. It's deadly if you don't treat it and it can come back even if you do have the best treatment out there.

NeuroscienceAddict
NeuroscienceAddict

Ms. Szalavitz writes: "Research shows over and over that empathy, kindness, respect and support work better than force, brutality, humiliation and shame. All of the most successful evidence-based methods to treat addiction ultimately help people feel better, not worse — if they don’t, recovery won’t last."

While I agree with this statement generally, it's too broad in that it makes no distinction between detox and post-detox treatment. 

I was forced into rehab very much against my will and was among the most belligerent and uncooperative of patients. Though I came within a hair of drinking myself to death, I insisted I was not an alcoholic and denied I needed treatment of any kind. However, the kindness, care and (dare I say) love that I received during an arduous detox, combined with some clarity of mind resulting from completing detox and the inspirational role models of my fellow patients and the staff, made me willing to consider, then agree, I was an alcoholic. At that point, I agreed to treatment voluntarily.

In other words, rehab-based detox caused the collapse of my denial and allowed my rational brain to see that my fear of withdrawal and of living without alcohol -- that is, the emotional imperative to continue to use alcohol as my solution -- was not based in reality.  As a volunteer at a rehab for several years, I saw this same thing happen over and over. No, not for everyone, but for many.

As a result, I support compelling detox for late-stage addicts who are flirting with death. It's not an easy line to draw, I know, but turning a blind eye on the progression of the addictive process that results ultimately in a very ugly death is less humane than forcing people into detox as a last resort.

The science of addiction demonstrates convincingly that addiction to acutely-toxic drugs is fatal if left untreated. Families should be able to intervene to try to interrupt that process to save their loved ones' lives, with proper court oversight, for a limited time, to give detoxed addicts the opportunity to agree to longer-term evidence-based treatment.

If, after detox has been successful and they are compus mentus, they still refuse further treatment, that should be their right and compulsion is counter-productive, as Ms. Szalavitz says. But at least give addicts a fightng chance by getting them straight enough to make that decision unclouded by addiction-induced insanity. 

Steve Castleman

www.AddictScience.com 

spaceout
spaceout

"we should keep trying to teach responsibility like we do with alcohol" - i disagree with this. Drugs and alcohol are different. Alcohol addiction has partly to do with your genes and not everyone who likes to drink becomes addicted. Drugs however have 100% addiction rate.

jayman419
jayman419

Yes to families and doctors being able to force someone into rehab. But only if drugs are legalized and the social stigma is removed.

Someone entering rehab for illegal drugs right now is almost sure to lose any sort of decent job. Their community will shun them. Yet that same person going for alcohol rehab gets encouragement and little coins.

I'm not saying we should promote drugs. No one thinks they're good for you, and we should keep trying to teach responsibility like we do with alcohol. But lots of people would be functional if they didn't have to associate with criminals for their doses. Just think about how many people can't make it through the day without their lexapro prescription, yet are fine with medication.

Under a doctor's care, we could try to minimize some of the risks currently associated with illegal drugs, and maximize productivity and revenue.

Even if drug-users remain at the lowest income levels, taxes collected every paycheck amount to an interest-free loan for the government. That's a much better deal than China's offering.

Elwyn Williams
Elwyn Williams

Almost nothing works for addicts.  The best thing to do if you are involved with one is give them a year or two, and if they won't get treatment for whatever reason, get out while you can.  For more than 12 years, I tried the "support, treat warmly, reassure my alcoholic boyfriend he could find alternative methods of coping."  All that got me was beaten up, broke, and my life nearly destroyed.  He is still drinking even though he has destroyed his body and career.  I finally said enough and left.  He will drink himself to death soon and for that I am truly sad.  But I am not sad that he won't take me with him.  

Talendria
Talendria

Healthcare in America is typically soulless.  The doctors are taught not to get emotionally invested in their patients, and the nurses are so overworked that they turn into robots.  Mean robots.  With needles.  

While I like your idea of allowing free market forces to improve addiction recovery centers, I'm not sure it's realistic given the fact that most people can't afford swanky facilities.  I'm drawing from my experience with old folks' homes, which is a similar model of at-will treatment.  For the amount of money that my grandma's insurance was willing to pay, she wound up in a nefarious place where the orderlies tried to steal her meds.  

I'm also not sure that at-will treatment is realistic for most individuals.  Even if they recognize they have a problem and want to fix it, they may be dissuaded by the financial penalty of taking time off work, losing custody of their kids, or having the word "addiction" on their medical records.  In the meantime, that construction worker poses a danger to himself and everyone around him.

czydiamond
czydiamond

@spaceout I think you have spaced out the truth. Your statement that 100% of drug users are addicts is absurd. The sheep will believe anything they are told by those in charge.

Commentonitall
Commentonitall

Your assertions are false, the gene you reference has to do with addiction level in general.  Certain people are more likely to be addicts to anything based on their genes.  Prescription drugs are a drug, yet you do not see 100% of people become addicted to them. 

Mantha08
Mantha08

I actually went voluntarily into the "forced" treatment they have in MA. I had to stay at least 30$500 days, but found that after 20the or so days clean, and being completely removed from my life, actually gave me some clarity and I decided to go on to further treatment. I stayed there about 90 days, went to a halfway house, and now I work, and keep my recovery up front. I am coming up on 18 months sober. The MA section 35 facility SAVED MY LIFE... and alot of women I was there with are still clean. Believe what you want, that addicts are hopeless cause. But i am living proof that IT WORKS!

JeffDOC
JeffDOC

Ms. Williams, while I sympathize with your situtation I would not paint every "addict" with the same brush. There are many different levels of addiction it manifests itself many different behaviors in different people. There are many fine people who have an addiction and it wouldn't be right to simply throw them away based on on your experience with one person.

TREVONBACH
TREVONBACH

look in to naltrexone. i was a heavy drinker for years, and after one (ONE) dose, i quit immediately. it seriously changes you, and naltrexone is an odd drug. talk to his doctor. . . as for me? been sober for 3y7m6d. no AA no rehab, just me. and after 2m i was off naltrexone. i suggest rehab (i went before i quit due to judge's orders) only because they tell you things about quitting that you don't understand otherwise... like losing your drinkin buddies and such. but you then realize who your friends are. but nothing will make him quit. he has to want it. i'd forward you my blog entry on the subject, but i think they dispose of any external links. if there's a way to email, do so, and i'll forward you my blog link. good luck!