Viewpoint: Why Tough-Love Rehab Won’t Die

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Despite decades of research showing the harmfulness of coercive rehab for addiction, these abusive, tough-love programs refuse to go away.

On Wednesday, reported on the phenomenon of “blood cashews,” nuts produced for export in Vietnamese drug-rehabilitation programs where addicts are forced to perform “labor therapy,” such as sewing clothes, making bricks or, most commonly, shelling cashews.

Last Sunday, the New York Times described Russia’s harsh new treatment camps, where addicts are locked up for as long as a month in “quarantine rooms” to endure withdrawal.

And last week a lawsuit was refiled against a Utah-based school for teens with drug or behavioral problems, with 350 former students alleging that the school engaged in abusive disciplinary tactics like locking students in outdoor dog cages overnight.

Yet, to date, there has been no evidence that the use of forced labor, public humiliation or generally brutal confrontation has ever been effective in rehabilitating people with drug problems — or any other kind of problem, for that matter. What’s more, when tough-love approaches are compared directly with kinder treatment alternatives for addiction, the studies find that compassionate strategies win by a large margin.

So why does the whip-’em-into-shape approach continue to get re-invented around the world? Three main factors typically foster support for harsh rehab, and each is important to understand if societies ever hope to rehabilitate addiction treatment and turn it into something that works.

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The first is economic: genuine medical treatment, which requires the participation of qualified professionals and, often, the use of medications, is costly and is therefore a money-losing proposition.

Tough, boot-camp-style addiction treatment programs, on the other hand, are profitable. Staff members are primarily low-educated former addicts, who are usually paid little or nothing, since “giving back” can be framed as essential to their own recovery. Their training consists of being treated — no expense there. The inmates in such rehab programs must work too, of course, and that labor is not only free, but, again, can also be justified as service or training necessary to help addicts get back into the workforce. Even better, the fruits of the addicts’ labor can be sold for profit.

Some coercive programs forgo the cost of maintaining a facility altogether simply by selling harsh “wilderness therapy,” which involves sending clients into the woods to essentially fend for themselves — or starve, so no need to pay for food — in order to teach responsibility.

What should be considered red flags are often cast as selling points. For example, here’s how the Times described one Russian program known as City Without Drugs:

A thick silence fills the little room crammed with tall metal beds, obscuring the fact that there are 37 men lying shoulder to shoulder, each lost in a personal world of misery.

Outside the chamber, known as the quarantine room, 60 men who have emerged — after as long as a month with only bread and water or gruel — work at menial jobs, lift weights or cook in a regimen of continued isolation from the world that staff members said usually takes a year.

“To put someone in handcuffs, it calms them psychologically,” Mr. Shipachev said as he paged through photographs of men shackled to their beds or to each other.

Obviously, in most cases, handcuffing one’s clients wouldn’t be something to boast about.

A second and often crucial part of the appeal of tough-love programs is that they often claim a high “success” rate. City Without Drugs, for example, claims 70% success. The Times notes that the Russian organization has no studies to back this contention. But, in America, tough rehabs have found a way around the lack of evidence: a clever statistical trick that creates the illusion of effective care.

Consider that the harsher the rehab program, the more likely people are to drop out. So those who stick with it are typically those who are most motivated to stop taking drugs in the first place — and would have likely succeeded with any program. If you include only the people who “graduate” in your success rate, it’s easy to make even the most abusive program appear effective.

Do the math: about 80% of people who start a harsh, punishing rehab regimen will drop out within days or weeks. That leaves 20% eligible for graduation: the 15% of the original group who were highly motivated to get clean and another 5% who will eventually relapse. If you count only this smaller group, however, your success rate will be an impressive 75%. (This is the kind of math that allowed early research on the granddaddy of tough love rehabs, Synanon, to “show” that it worked.)

Of course, if you don’t actually allow people to drop out, such data manipulation is impossible. That’s why the Vietnamese forced-labor rehab programs’ official success rate is just 20% to 30%, according to the World Health Organization (WHO), and possibly as low as 5%, according to a 2009 WHO report.

In a new Human Rights Watch report that reveals that some 40,000 people are being subjected to this form of rehab in Vietnam, the organization described one addict’s treatment this way:

Que Phong … was in his late 20s when his family encouraged him to go to one of the Binh Phuoc centers for drug dependency treatment. He agreed to get help for his heroin addiction and signed up for what he thought would be 12 months of treatment. Instead, he endured five years of forced labor, torture and abuse.

During his time at the center, Que Phong was given a daily quota of cashews to husk and peel. Although the caustic resin from the cashews burnt his hands, he was forced to work for six or seven hours a day. Asked why he performed such hazardous work, he said:

If you refused to work they slapped you. If you still refused to work then they sent you to the punishment room. Everyone worked. …

Although he had entered voluntarily, Que Phong was not free to leave: the center management told him that his time in “drug treatment” was extended, first by an extra year, then by an extra three. Throughout, he continued to work and receive beatings. On one occasion, when caught playing cards with other detainees, center staff tied his hands behind his back and beat him with a truncheon for an hour.

Under reasonable standards, such conduct would never be proposed as medical care. But the third factor that continually keeps reviving tough-love programs is the stigma associated with addiction. Even among those who have learned to call addiction a disease, that contention is rarely carried to its logical conclusions.

MORE: Why the New Definition of Addiction, as ‘Brain Disease,’ Falls Short

Instead, addicts are seen as people who take unearned pleasure, as enemies of the war on drugs, as unproductive parasites against whom all discrimination is justified. The popularly drawn caricature of the addict is strikingly similar to the most offensive racist stereotypes.

When people with addiction are sufficiently dehumanized in the public’s perception, it becomes easy to believe that punishment is the only type of treatment able to “get through” to the brutes. And once abuse is recast as care, therapy easily slips into torture.

No one would propose such treatment regimes for multiple sclerosis, Alzheimer’s disease or Parkinson’s. Therapy for these conditions is left to trained doctors, not to fellow patients, for-profit programs or the police. Addiction treatment should similarly be based on evidence, not prejudice.

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

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