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.
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.
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.