As a prosecutor in the mid-90s, I thought that coerced substance abuse treatment was a central strategy for reducing addiction and crime.
When technology improvements made drug testing cheap in the 80s, the federal government launched mass drug testing studies of arrestees. These studies revealed that the majority of people arrested for felonies in most major cities were abusing cocaine.
From these results, it became clear that (a) the drug using population was much greater than previously indicated by household survey data and (b) the vast majority of hard core drug users were involved in the criminal justice system — not necessarily for drug crimes, but for other income-producing crimes, like robbery, larceny and prostitution.
This insight led to a renewed focus on how we treat drug users in the criminal justice system. Interest in “drug courts” surged. Research suggested that (a) people who remain in treatment longer do tend to recover; (b) the threat of incarceration keeps people in treatment longer and does not diminish the effectiveness of treatment.
Locked treatment or treatment under threat of incarceration seemed like a very promising strategy if only it could be fully implemented. A related coercive idea was that frequent drug testing could be used to detect drug use of people on probation and that swift moderate sanctions could punish them into changing their behavior.
For several years, I embraced this line of thought, but I was always a little afraid that my perspective might be academic, that I might not have my mind around the real heart of the issue. So, I began representing defendants in drug courts. This gave me the chance to really listen to defendants and they taught me a lot.
I began to feel that a lot of what was happening in the treatment system wasn’t helpful to people with addictions. I do believe that, not very often, but all too often, residential treatment providers bully and mistreat their clients and really do not help them get better.
Conversations with national treatment experts convinced me that I was not just adopting the resentful perspective of the addict — the quality of treatment across the country is very uneven and much of it is poor.
The fundamental problem is funding. The Reagan budget cuts hollowed out the sytem and it has never recovered.
But another part of the problem is political. There is a very close relationship between treatment providers and local legislators. Treatment providers always have a bed when a legislator calls on behalf of the family of a troubled young person. And reciprocally, the legislators earmark and defend funding for the providers.
These close relationships make it much harder to hold providers accountable for results. Treatment system managers have to defer to the legislators that provide their funding and noone really believes the kids when they complain about what is happening to them.
So, while I still believe that you can lead a horse to water and make him drink — that coerced treatment works — I don’t believe that we have a system that reliably provides sympathetic effective treatment.
I also believe that the high prevalence of coerced treatment is doing a lot of damage to the treatment system. If everyone in a facility is there against there wishes, it turns the facility into a jail with another name and makes treatment success even less likely no matter how well the facility is run.