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VOLUME 1, ISSUE 6 PSYCHNEWS INTERNATIONAL October 1996
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SECTION B: THE FIFTH COLUMN 1/2
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Note: The Fifth Column is a regular, independent column
written by Jeffrey A. Schaler, Ph.D.
For this issue, Dr. Schaler has invited his colleague
Stanton Peele, PhD, to contribute to the PsychNews as
guest columnist.
Opinions and comments are invited. Please send them to
the PsychNews Int'l mailbox: pni@badlands.nodak.edu
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THE RESULTS FOR DRUG REFORM GOALS OF
SHIFTING FROM INTERDICTION/PUNISHMENT TO TREATMENT (1)
Stanton Peele, Ph.D. (2)
ABSTRACT
The most popular idea in drug reform is that money now
spent on interdicting drugs and arresting and
imprisoning drug abusers should instead be spent on
treating drug users. However, the likely results of
such an expansion of treatment -- based on the current
example of massive treatment of alcohol problems in the
U.S. -- would seem to be counter to critical drug
policy reform goals. These goals include provision of
care and enhanced treatment for the severely addicted,
acceptance of nonharmful illicit substance use,
diminution of moralism in public health and policy
towards substance use, and elimination of guilt and
self-doubt among controlled drug users. Expansion of
alcohol treatment in the U.S. has not led to adoption
of treatments demonstrated to be effective but rather
supports moralistic approaches that capitalize on deep-
seated American ambivalence towards alcohol. Finally,
there is no evidence that substance abuse treatment
reduces overall substance abuse rates. In the case of
alcohol, expanded treatment has coincided with greater
numbers of Americans reporting they are alcohol
dependent, while studies of community populations
find that untreated alcohol and drug dependent subjects
fare better than those who are treated.
TREATING DRUG USE
The most popular version of drug reform is that we should
shift funds from our massive drug interdiction and law
enforcement efforts to the treatment of people with drug
problems. The failures of current punitive approaches are so
obvious, and the value of treatment is so unquestionable, that a
wide range of those involved in substance abuse policy and
treatment endorse this shift.
There is also a large industry engaged in propagandizing on
behalf of this position. On the Internet (www.health.org/csat/)
and through other media, "Treatment Works! Month" is celebrated
annually. "Designed by SAMHSA (Substance Abuse and Mental Health
Services Administration)/CSAT (Center for Substance Abuse
Treatment) with the cooperation of the National Association of
Alcoholism and Drug Abuse Counselors (NAADAC), these promotional
materials will help educate people throughout your state, county,
city or community about the true value of treatment and the fact
that it really works."
September 1996 is the 7th annual celebration of
Treatment Works! Month. It's time to celebrate and
promote the fact that treatment is an effective way of
tackling American's substance abuse problems.
Treatment not only saves the taxpayer a tremendous
amount of money in the long run, it also saves lives;
reduces crime and health care costs; and reunites
families. In short, treatment helps everyone, not only
the individual battling addiction.
AN OPPOSING POSITION
This presentation looks to the massive alcohol treatment
that already exists in the United States for likely clues about
where a grossly expanded drug treatment system would take us.
Alcohol is, after all, legal, and presumably the only problem
with alcohol use is when it becomes abusive, at which point
treatment is the indicated response. This seems like the ideal
towards which many in the drug policy field aspire. But we shall
see that some key goals of drug reform are not in fact the likely
results of making the shift to a policy like that followed in the
United States towards alcohol.
Some of the goals from shifting from a punitive towards a
treatment-oriented drug policy reform are pictured in Table 1:
Table 1
GOALS OF A LESS PUNITIVE DRUG POLICY
INTENDED GOAL LIKELY RESULT
harm reduction warehousing, homelessness
more treatment of addicts reject addicts as clients
less moralism zero-tolerance/moralism
accept controlled use treatment of casual users
greater personal freedom more coercive treatment
acceptance of drugs ambivalence around drug use,
more self-labeling by users
THE EXPLOSION IN ALCOHOLISM TREATMENT
The fate of alcoholism treatment illustrates how these
likely results will come about. Table 2 depicts changes in
alcohol treatment beds in the United States between 1978 and 1984.
Table 2
CHANGES IN ALCOHOLISM BEDS 1978-1984
1978 1984
Government 10,240 10,458
Not for profit 4,952 11,520
For profit 813 4,003
Total 16,005 25,981
Source: USDHHS (1987), p. 121
The total number of beds increased dramatically in this six-
year period (62 percent), but only among non-governmental non-
profit (133 percent) and for-profit (390 percent) institutions
(USDHHS, 1987). State, municipal, and federal hospital beds for
alcoholics remained constant. This shift occurred in a burst,
but is part of a long-term increase in treatment of alcoholics,
much of which comprised AA group attendance (AA claimed 6,000
members in the United States in 1941 and 1,127,471 members in
1995; A.A., 1995).
The 1978-1984 period represented a sharp upturn in an
overall upward trend in hospital treatment of alcoholism. This
shift occurred because federal funding for alcohol treatment in
the mid-1970s took the form of block grants which permitted
states to support private institutions, as well as due to an
expansion in coverage for alcohol abuse by private insurers
(Peele, 1991). Soon after this period, insurers withdrew support
for large-scale inpatient treatment because of data indicating
the hospital treatment for alcohol problems was not cost-
effective (Miller and Hester, 1986). However, total alcohol
treatment in the United States remains high to the present, both
historically and in comparison with other countries (Room and
Greenfield, 1993).
WHO IS BEING TREATED? -- NOT STREET ALCOHOLICS
That the number of beds dedicated to alcoholics in public
institutions remained constant indicates that no greater number
of low-income and underclass or homeless alcoholics were being
handled during a period of massively expanded alcoholism
treatment. Among the reasons for this: (1) the financial rewards
for treating such uninsured and impoverished populations are
limited, (2) these populations are often less personable, more
intransigent, and less popular among treatment providers than are
middle class drinkers. For these alcoholics in municipal, state
and federal institutions, evidence is of very low remission rates
(one study found that 7 percent of alcoholics treated in an
inner-city hospital alcoholism unit survived and were in
remission 5-8 years later; Helzer et al., 1985), leading to either
a revolving-door or warehousing approach to inner-city or other
poor treatment clients.
Certainly, middle-class alcoholics became much more visible
and common alcoholism patients, particularly in private
hospitals. The most visible example of this client was Betty
Ford. But the typical new alcohol treatment enrollee was more
likely an adolescent. In any case, the new client was better-off
economically, likely to be insured, better-behaved, and didn't
drink as much as earlier clinical alcoholics. Although no
comparative data are available, by the end of 1980s a substantial
number of Americans over the age of 18 had been in treatment. A
1990 general population survey found that 4 percent of U.S. men
(1 percent of women) had sought formal help (including A.A.) for
a drinking problem in the past year, and 8 percent (2 percent of
women) had done so at some point in their lives (Room and
Greenfield, 1993). Unfortunately, Room and Greenfield gave no
breakdowns by any social, educational, or economic indicators.
If the greatest growth in treatment was among employed and
middle-class drinkers, then we would not expect the plight of
street inebriates to improve. Indeed, during a period of rapidly
expanding provision of alcohol treatment, probably the number of
homeless alcoholics -- which had already begun to climb --
continued to grow rapidly. A survey of Baltimore homeless in the
1980s (Breakey et al., 1989) found that, while major mental
illnesses were very prevalent (42% of men; 49% of women), alcohol
disorders were more so (among men 68%; 38% of women). In the
1950s through the 1960s, in many urban centers, such alcoholics
were privately handled through a series of SRO (single-room-
occupancy) hotels and through "flop houses."
Income from federal assistance programs and even panhandling
were sufficient to gain a berth in these establishments, which
were highly tolerant of their clientele's drinking habits (think
of Charles Bukowski's novel -- and the film -- "Barfly"). But the
1960s and 1970s saw urban renewal and "yuppification" eradicate
such housing in many urban centers. There is no longer, for
example, a Bowery in lower Manhattan. The idea that those on the
public dole or panhandlers could afford to live in this district
today is impossible to imagine. At the same time, charity
institutions in the United States charged with housing the poor
and/or homeless, including both private groups such as the
Salvation Army and homeless shelters, typically exclude drinkers
or intoxicated residents.
In other words, there is no existing basic subsistence "harm
reduction" structure in place in the United States. This is not
because there are not abundant AA chapters or Salvation Army
units and other religiously-oriented missions willing to assist
the street alcoholic, or because there aren't many homeless
shelters (although perhaps not enough to handle all potential
clients). But continued drinking by many street alcoholics runs
afoul of the ground rules of such institutions, which are steeped
in a no-use moralism which dictates that help can only be offered
to those willing and able to stop drinking.
THE GROWTH IN ALCOHOL DEPENDENCE PROBLEMS
Meanwhile, Table 3 reveals that growing numbers of Americans
were reporting serious alcohol problems in the 1980s. The number
of American men reporting alcohol dependence symptoms in 1984
more than doubled, while it grew one-and-a-half times for
women, compared with the 1967 survey (Blake and Clark, 1991).
This was at the tail end of a period of rapidly expanding
treatment, and at a time when alcohol consumption had begun to
drop steadily. Blake and Clark found consumption did not
increase between 1967 and 1984, nor did actual patterns of
drinking change (except for an increase in abstainers!). Thus,
without drinking more, and while undergoing much more treatment,
Americans reported far more alcohol dependence symptoms (the most
severe symptoms of alcohol abuse) in the 1980s.
Table 3
CHANGES IN DRINKING PROBLEMS 1967-1984
Men Women
1967 1984 1967 1984
Dependence 8.2 18.8* 5.2 8.2*
Symptoms+
Age
23-29 13.5 31.0* 9.5 18.1
30-39 7.5 18.0* 6.0 9.3
40-49 7.6 21.9* 5.2 8.4
50-59 9.1 8.8 1.2 0.5
60+ 3.1 9.2 3.3 0.6
Education
< high school 8.4 21.0* 6.6 12.1
H.S. graduate 7.8 22.2* 2.2 5.7
some college 9.9 16.3 7.2 8.3
college grad 6.9 14.4 5.5 9.0
Income
above median 8.6 20.4* 5.9 9.0
below median 8.1 17.7* 4.8 7.6
+within last year, skipped meals, loss of memory,
couldn't stop, binges
* significance level < .05
Source: Hilton and Clark (1991)
These figures are especially interesting because earlier
surveys had revealed very few people (fewer than one percent) who
had consumption and problem levels typical for those who at the
time entered treatment clinics (Room, 1980). One argument had
been that genuine alcoholics were hard to reach by such surveys.
Thus, the growth in reported dependence-type symptoms occurred
among the non-skid-row-type of alcoholic who used to typify
alcoholism. Nonetheless -- despite reporting skipping meals,
blackout drinking, an inability to stop, and binge drinking --
these drinkers still drank less than the median 17 drinks daily
in a treated population in the mid-1970s (Polich et al., 1981).
What characterizes the new "alcoholic," other than that many
are functioning as ordinary members of society? Although
dependence symptoms increased among all groups of men and women,
Table 3 shows the highest incidence of such symptoms occured among
lower education respondents -- for example, a 184 percent jump
among men with only a high school degree. But, although more
lower education respondents reported alcohol dependence symptoms,
higher income respondents were somewhat more likely to experience
these. In addition, alcohol dependent respondents were younger:
almost a third of men 23-29 reported dependence symptoms, a 130
percent increase in this age group between 1967 and 1984.
Dependence symptoms did not increase significantly for those over
50, but among middle-aged men (40-49), the increase in those
reporting dependence symptoms was 188 percent.
In summary, alcoholism treatment expanded dramatically among
the middle class beginning in the 1970s and continuing to the
1990s. Those diagnosed as alcoholic (self-diagnosed or
otherwise) included middle class Americans, but more often
Americans with less education (but more income) than average.
These groups, however, are distinct from the contemporary
homeless alcoholic or the severely clinical alcoholic that
typified hospital treatment in prior years. One popular argument
has been that a large group of invisible but substantial
alcoholics was being discovered in this period. Considering a
definition of alcoholism as out-of-control drinking, many of
these "functioning" alcoholics may have drunk too much for their
own good, but they seem far from being unable to manage their
existences.
THE NATURE OF TREATMENT
When hospital inpatient treatment was growing, it was nearly
entirely 12-step based. While alcoholism shifted from inpatient
to outpatient in the late 1980s, the nature of the treatment
remained the same. This is despite the fact that treatment
efficacy studies had consistently shown the typical treatment
provided in these programs to be ineffective. Miller and his
colleagues (1995) ranked 43 treatments in terms of 217 published
clinical research trials, although 13 therapies (including AA)
had too few studies to be definitively rated. (Table 4)
Of the treatments reliably rated, brief interventions had
the highest score, followed by social skills training. These
social skills include those required to avoid drinking
situations, to cope with stressful settings, and to deal with
bosses, spouses, children, and other relationships. At the
bottom of the list of effectiveness were general alcoholism
counseling and educational lectures and films about alcoholism.
AA had the lowest score among treatments that had been
inadequately tested.
Table 4
MOST AND LEAST EFFECTIVE ALCOHOLISM TREATMENTS
Highest Rated
Brief interventions +239
Social skills training +128
Motivational enhancement +87
Community reinforcement +80
Behavioral contracting +73
Lowest Rated
Metronidazole -102
Relaxation training -109
Confrontational counseling -125
Psychotherapy -127
General alcoholism counseling -214
Educational programs about alcoholism -239
Methods with Too Few Tests to be Reliably Rated
Sensory deprivation +40
Developmental counseling +28
Acupuncture +20
......
Calcium carbimide -32
Antipsychotic medication -36
AA -52
Source: Miller et al. (1995)
As Miller et al. noted, it is the treatments with the worst
clinical records that are almost universally employed by American
alcoholism programs. Educational lectures and general alcoholism
counseling in the United States are almost entirely 12-step and
disease oriented, while the successful treatments are
specifically non-disease oriented. Table 5 lists the differences
between the disease school of thinking and what I call the life
process approach (Peele et al., 1991). American treatment
programs reject these innovations in treatment that have been
shown to be considerably more effective than current practices.
For example, brief interventions -- by utilizing reduced drinking
goals for patients and not labeling them as "alcoholics" -- run
afoul of the basic tenets of AA.
Table 5
DIFFERENCES BETWEEN THE DISEASE AND
LIFE PROCESS APPROACHES TO ADDICTION
Disease Model Life Process Program
Addiction is inbred Addiction is a way of
(genetic, biological) coping with life experience
Everyone gets Design a treatment that
same therapy fits individual
Must accept addict/ Focus on problems,
alcoholic identity not labels
Therapy and cure are Person arrives at own goals
dictated to person and therapy plan
Person either addicted Addiction will vary
or not depending on situation
Addictive symptoms are Person must identify
drummed into person negative consequences for self
Claims of being okay Positive aspects of self-image
are attacked as denial are accepted and amplified
Person taught he has no The need for control and
control/cannot choose making choices is fostered
Focus on addiction Focus on dealing with
environment
Total abstinence is the Improved control and relapse
only treatment goal reduction are sought
Primary social supports Primary social supports
are fellow addicts are work, family, friends
Require same treatment/ Treatment or group
group support forever support evolves over life
Person must always think Can outgrow addiction
of self as addict and no longer need to think
of self as an addict
Source: Peele et al. (1991), p. 174
Thus, the standard for treatment remained the 12-step
approach which is heavily didactic, built on the concept that
alcoholics are out of control and need to be compelled to enter
treatment, and that all drinking problems require abstinence.
Meanwhile, drug treatment has already shifted in the 12-step
direction. That is, drug treatment in the U.S. has historically
offered a wider set of treatment modalities than alcohol
treatment. For example, therapeutic communities, methadone
maintenance, skills-oriented training, and so on -- which reflect
some of the modalities found most effective in alcoholism
treatment -- were already part and parcel of the array of
available drug abuse treatments. As drug treatment has
expanded, the influence of the 12-step approach has grown, and it
has become part of practically every treatment program in
America.
The lack of demonstrated efficacy of AA and its continued
dominance in American treatment is a social phenomenon well worth
analyzing on its own. AA appeals to American religious
fundamentalism, as expressed in its nineteenth century
revivalist style involving public confession, contrition, and
restitution. The success of AA is a tribute both to its appeal
to fundamental tenets of American culture and to the skills of
Marty Mann and subsequent gifted AA marketers. The morality tale
of the repentant sinner who used to enjoy drinking and
intoxication but who now recognizes the folly of his ways and the
need for abstinence will always be a sure seller in the United
States.
Likewise, this tale will market well as drug treatment
expands. The marijuana smoker or cocaine user who used to enjoy
the high life but who now sees the error of his ways, affirming
the correctness of his sober and abstemious brethren, will soon
dominate drug treatment the way it does alcohol treatment (as it
already shows signs of doing). William Bennett and succeeding
drug tsars, drug education specialists, and U.S. presidents are
always on the look out for such spokespeople for the cause of
treatment.
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