_________________________________________________________________ VOLUME 1, ISSUE 6 PSYCHNEWS INTERNATIONAL October 1996 _________________________________________________________________ SECTION B: THE FIFTH COLUMN 2/2 -------------------------------------------------------- MORALISM AND COERCION IN TREATMENT When Mary Tyler Moore went to the Betty Ford Center, she said it was not because she was an alcoholic but because her diabetes meant she shouldn't drink at all. (In fact, moderate drinking is an anti-diabetes measure.) She was one version of the idea that alcoholism treatment was not for the severely- impaired alcoholic, but a method to eliminate all drinking for those for whom alcohol might in any way be a problem. The proscription against drinking and all other 12-step tenets are enforced equally with such problem drinkers. Thus, alcoholism treatment is another expression of an abstinence fixation and anti-alcohol sentiment which has always been strong in the United States, and which expressed itself in the nineteenth century Temperance movement and national prohibition in 1920. Despite the fact that many Americans claim to be alcohol dependent and that alcohol treatment has become relatively commonplace in many middle-class communities, most Americans who enter alcohol treatment are not volunteers (Weisner, 1990; Weisner and Room, 1984). There are a host of mechanisms for compelling drinkers to seek treatment. Perhaps the primary mechanisms are DUI regulations and, in the private sector, EAPs. However, a number of federal agencies (such as those requiring treatment among public assistance recipients) and criminal proceedings aside from drunk-driving contribute to these trends. Moreover, the largest single age category in expanded treatment rolls has been teenagers, who are not usually voluntary treatment clients. It is ironic in the extreme that the majority of people entering treatment for alcohol are coerced (or strongly encouraged with unpleasant alternatives) to seek such treatment, given that alcohol is legal. This situation is due to a series of distinctive strands in American culture, to wit: (a) a social value on treating the alcoholic, (b) a lower threshold for labeling alcohol problems, (c) powerful residual strands in America that disapprove of alcohol intoxication and, really, of all drinking, (d) the idea that alcohol problems, typified by the concept of loss of control, lead alcoholics to "deny" their drinking problems and to require outside interventions to get them to seek necessary treatment. Drug treatment is already highly coercive, offered as an alternative to sentencing for drug possession and other drug- related crimes. This trend is accelerating with the so-called drug courts. As described in the Los Angeles Times, "Court's War on Drugs" (August 13, 1996): "Defendants are sent to a 12-step style rehabilitation program instead of jail under the program. It is held as a model across the nation and is scheduled for expansion.... Drug courts, which sentence addicts to treatment programs instead of time behind bars, are multiplying across the country, fueled by enthusiasm from the Clinton administration.... 'Drug courts provide the incentive, and the "stick" without which many young people would never seek drug treatment and alternatives to drug use,' U.S. Atty. Gen. Janet Reno has said." TREAT PEOPLE AND SOON WE'LL HAVE NO MORE SUBSTANCE PROBLEMS -- NOT The "Treatment Works" program is sponsored by an alliance among government and private treatment organizations. (All of the linked sites to "Treatment Works" are treatment or government sites; there is not a single link to a drug reform group.) The burden of this coalition is to present "Myths and Facts About Addiction and Treatment." Among the "FACTS" it describes are: Fact: Addiction is a chronic, life-threatening condition, like hypertension and adult diabetes. Fact: Certain drugs are highly addictive, rapidly causing biochemical and structural changes in the brain. Fact: Few people addicted to alcohol and other drugs can simply stop using them, no matter how strong their inner resolve. Most need one or more courses of structured substance abuse treatment to reduce or end their dependence on alcohol or other drugs. The first of these "facts" is certainly a matter of interpretation. And no study has found the last to be true. Studies of general populations (called community studies) typically find that the overwhelming majority of substance users, even those who encounter substantial problems, never enter treatment. This has been the case, for example, with every community study of cocaine users (which would seem to be one of the highly addictive drugs "Treatment Works" has in mind). In the first place, most cocaine users do not use regularly; most regular users do not become compulsive users. A World Health Organization multinational survey, the largest ever of cocaine users, found "an enormous variety in the types of people who use cocaine, the amount of drug used, the frequency of use, the duration and intensity of use, the reasons for using cocaine and any associated problems that users experience" (WHO, 1995). For example, a Canadian survey found 5 percent of current users used monthly or more often (Adlaf et al., 1991). But monthly and weekly use are far from addiction, and only 10-25 percent of regular users resemble clinical addicts, or about 1-2 percent of all current users (Erickson and Alexander, 1989). Studies of ongoing cocaine users in Canada, Scotland, Australia, and Holland identify controlled use as the most common usage pattern (Cohen, 1989; Ditton et al., 1991; Fagan and Chin, 1989; Harrison, 1994; Mugford and Cohen, 1989; Murphy et al. 1989; Siegel, 1984). Moreover, most users who do encounter problems -- problems that usually fall far short of "loss of control" (Cohen and Sas, 1994; Siegel, 1984;) -- do not seek treatment and overcome their problems by quitting or cutting back without treatment (Cohen and Sas, 1994; Erickson, 1993; Erickson et al., 1987; Waldorf et al., 1991). In Holland, of 64 users of cocaine for five or more years, only one actually underwent treatment for cocaine use (Cohen and Sas, 1994). When "Treatment Works" identifies treatment as a necessity for those who have substance problems, without which it claims that people rarely recover, it is expounding a philosophical and an economic position, one that both the government and private treatment providers welcome. However, let us turn to two U.S. government studies, more than a decade apart, to test this claim. The studies concern the two other drugs "Treatment Works" probably means to indicate, in addition to cocaine, as being "highly addictive" -- alcohol and heroin. In the more recent study, Dawson (1996) utilized 1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES) data, designed and sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and conducted (face-to-face) by the U.S. Census Bureau. The key results were that: (1) Of 4,585 adults who had ever met DSM-IV criteria for alcohol dependence, 28% were currently diagnosable as alcohol dependent/abusers, 22% were abstinent, 50% were drinking but did not meet DSM-IV abuse/dependence criteria. (2) Those who had been in treatment were more than twice as likely to be abstainers (39% v. 16%), and half as likely to be non-abusive/dependent drinkers (28% v. 58%), although nonetheless a quarter of treated alcohol dependent subjects were drinking but not abusive/dependent drinkers. (3) More treated alcohol dependent subjects (a third) than untreated subjects (a quarter) were alcohol abusers/dependent in the current year. Although dependence/abuse decreased for both groups substantially over time, the ratio of continued alcohol abusers/dependent subjects grew more favorable for the untreated subjects the longer since they had been alcohol dependent. Table 6 NLAES SURVEY DATA ON ALCOHOL DEPENDENT SUBJECTS Outcome categories <5 years since 20+ years since onset dependence onset dependence Treated (n=1,233) abuse/dependence 70% 20% abstinent 11% 55% drinking w/o dependence 19% 24% Untreated (n=3,309) abuse/dependence 53% 10% abstinent 5% 30% drinking w/o dependence 41% 60% Source: Dawson (1996) These data seriously question most assumptions made in alcoholism treatment today: (1) Only those whose alcohol abuse does not meet dependence criteria may continue/resume drinking without clinical problems. In fact, non-abusive/dependent drinking was by far the largest outcome category in this group of formerly dependent drinkers. (2) Treatment is necessary for recovery. Treated alcohol- dependent subjects in fact had lower remission rates than untreated dependent subjects, and this ratio of remission advantage grew with the passage of years. Treatment mainly served to turn people towards abstinence versus drinking without clinical problems as an escape from dependence. Those who only know alcoholics in clinical settings (and then only during treatment or briefly afterwards) seem to be missing the larger picture of alcoholism, including the large majority who remain untreated. These data strongly affirm similar in-person data from the Vietnam study as reported by Lee Robins, John Helzer, and their colleagues (1980) over 15 years earlier. These researchers reported the following challenges to conventional wisdom based on their research: (3) "Is addiction to heroin more or less permanent without prolonged treatment? Of all the men addicted in Vietnam [defined as prolonged heavy use and severe withdrawal symptoms lasting more than two days], only 12% have relapsed to addiction at any time since their return. . . . Of those men who were addicted in the first year back, half were treated and half were not. . . . Of those treated, 47 percent were addicted in the second period; of those not treated, 17 percent were addicted... (4) Does recovery from addiction require abstinence? Perhaps an even more surprising finding than the high proportion of men who recovered from addiction after Vietnam was the number who went back to heroin without becoming readdicted . . . . Half of the men who had been addicted in Vietnam used heroin on their return home, but only one-eighth became readdicted to heroin. Even when heroin was used frequently..., only one-half became readdicted." These government-funded studies (the Vietnam research was funded by the Defense Department) seem to contradict the impetus of a massive government propaganda effort. Shouldn't the U.S. government get its story straight? LATE-BREAKING NEWS Many of you have heard of the results recently announced from Project MATCH, a clinical trial comparing coping skills, motivational enhancement, and 12-step approaches to alcohol treatment (Schaler, 1996). The overriding goal of the project was to uncover the traits that predicted which type of alcoholic responded best to each type of treatment (and hence, should be matched with it). The broad results of this study were that no treatment proved superior to any other, while no identifiable patterns differentiated those who responded to each treatment. Faced with a $25 million boondoggle that did little more than disconfirm a decade's worth of theorizing about optimizing patient-therapy matching, the NIAAA put the best face forward on this study. They did this by pointing to the high remission rates reported for all treatments. The man charged with this task was Enoch Gordis, an MD and career hospital/treatment/government bureaucrat. Gordis had not started out as a treatment booster. A decade ago, shortly after Gordis became the NIAAA's director (in October, 1986), he issued (in February, 1987) the following rather pessimistic pronouncement about the state of American alcoholism treatment, which at the time (as it is today) was basically completely 12-step oriented. After all [many of us assert], we have provided many of our treatments for years. We really are confident that the treatment approaches are sound. We can point to thousands of caring....treatment staff, many of whom are recovering alcoholics themselves. It seems impossible to imagine that what these splendid people are doing may be, at least in part, useless, wasteful or occasionally harmful. Yet the history of medicine demonstrates repeatedly that unevaluated treatment...is frequently useless and wasteful and sometimes dangerous and harmful. (Gordis, 1987, p. 582) Gordis's apparent skepticism here reflects his own research showing that public hospital alcoholism patients didn't fare very well (Gordis et al., 1981). But, a decade later, Gordis has become the main flack for the success of treatment. His impetus is the need to spin the results of Project MATCH, which -- despite not supporting the hypothesis it was intended to prove -- can at least be spun to show treatment is a great boon. But why do the MATCH results differ so dramatically from the decades of research summarized by Miller et al. (1995)? Could it be that, in this heavily subsidized project, where leading therapists trained and supervised the ongoing administration of therapy, where funding was abundant to provide the most supportive context for therapy, and where both those being treated and those providing treatment realized they were under the spotlight, that the results are hardly generalizable? But this treatment was not designed to show that treatment works in general. After all, the study had no non-treatment group experiencing comparable attention and support (without therapy) to the treatment groups. This study's all-encompassing positive outcomes resemble those in the famed Hawthorne studies at the Western Electric plant, where hourly employees were separated and subjected to a study of the effects of different lighting, rest intervals, and other trivial environmental factors. What in fact caused productivity to rise dramatically in all the conditions was the intensive, personalized attention all received no matter what the experimental variation being studied. CONCLUSIONS -- THE LIKELY RESULTS OF MORE TREATMENT If the expansion of drug treatment follows the already dominant model of substance abuse treatment created in the case of alcoholism, then the results of liberalizing laws concerning drugs so that they are less punitive but instead focus on treating the substance abuser will be at odds with many of the goals of the drug reformers favoring more treatment. The actuality would seem to differ from the intended in the following ways: 1. While the goal of reformers is harm reduction, which focuses on the extremely addicted individual with few social and economic resources, the greater availability of alcohol treatment in the U.S. has not increased either treatment of, or care for, such addicted drinkers. Rather, the street alcoholic and other hard-to-reach populations remains the odd person out in the treatment system, and homelessness among such drinkers has increased. 2. The growth in treatment has been almost entirely in the direction of the more prosperous -- and less severely impaired -- drinker with greater economic and social resources in the first place. This expanded marketplace was essentially a commercial one, which sought out the least costly drinker to treat who had the most money to pay. 3. The fact that alcohol is a legal drug has in no way lessened the influence of strongly moralistic strands of American thought which disapprove of intoxication and any use, emphasizing abstinence and the need to avoid intoxicating substances in even moderate doses. Thus, the drug reform goal of greater recognition and acceptance of controlled drug use will not be served by expanded drug treatment. Rather, to judge from the alcohol treatment experience, expanded treatment inevitably lowers the threshold for the level of drug use and problems thought to require treatment. 4. Even with a legal substance, treatment will be more often coercive when treatment rolls expand, because this is the major way in which new slots must be filled. People simply don't recommend themselves for treatment in sufficient numbers to fill expanded drug slots. Indeed, today in the U.S. drug treatment is already largely coercive, indicating that more treatment slots can only be filled by forcing people into them. 5. The idea that shifting from a law enforcement to a treatment model will not actually increase the freedom of ordinary Americans who use drugs or the choices available to drug addicts seems a paradoxical and alarming consequence of drug policies meant to be more liberal and less punitive. Yet, the path in this direction is inexorable. 6. Despite the coerciveness and intolerance of American drug and alcohol treatment policy, the most alarming consequence of the expansion of treatment rolls is not the external imposition of views of alcoholism, but the willingness of so many people to accept and internalize these definitions of themselves as drug abusers and addicts. The expansion of treatment enlarges the number of people who feel they need treatment. These shifts in reported dependence symptoms are not because people drink or use drugs more or in a worse way, but because they believe they have less control over their drinking and drug use and over themselves. At the same time, they come to define more and more of their life problems in terms of their substance use. In the U.S. today, addiction is already the dominant paradigm for people to understand and deal with their problems. And when you are addicted, what you need is treatment. Finally, despite all this greater treatment, we have no indication that addiction, alcoholism, etc. are declining. We have no indication when we examine community populations who experience treatment as it is actually administered en masse in the U.S. that treatment reduces substance abuse. Remarkably, we have substantial evidence, from the most authoritative and mainstream government organizations, that the reverse is true, and that getting treatment is a risk factor for substance abuse. NOTES 1. Presentation to 10th International Conference on Drug Policy Reform, Washington, DC, Nov. 6-9, 1996. 2. Stanton Peele, Ph.D., is a social psychologist and renowned expert on addiction and social policy. He is affiliated with The Lindesmith Center in New York city. Address correspondence to Dr. Stanton Peele, 27 West Lake Blvd., Morristown, N.J. 07960, USA. See the Stanton Peele Addiction Web Site at http://www.frw.uva.nl/cedro/peele/.
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