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VOLUME 1, ISSUE 6 PSYCHNEWS INTERNATIONAL October 1996
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SECTION B: THE FIFTH COLUMN 2/2
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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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