Moralism and Coercion in Treatment

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). Among the host of mechanisms for compelling drinkers to seek treatment, the primary 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: (1) a social value on treating the alcoholic, (2) a lower threshold for labeling alcohol problems, (3) powerful residual attitude of disapproval of alcohol intoxication and, really, of all drinking, (d) the idea that alcohol problems, understood in terms of loss of control, lead alcoholics to "deny" their drinking problems and to require outside interventions to get them to seek necessary treatment (although Hilton and Clark, 1991, showed that Americans in large numbers readily acknowledge alcohol dependence symptoms).

Drug treatment is also highly coercive, since drug use is ipso facto illegal and treatment is now frequently 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 12­step 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."

The idea many have of drug reform is that, by making drug use legal or allowing people who feel they have a drug problem to seek treatment as they feel they need it, the element of coercion will be minimized in drug treatment. The experience with American alcoholism treatment would lead us to expect otherwise.

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. The burden of this coalition is to present "Myths and Facts About Addiction and Treatment." Among the "FACTS" described at the "Treatment Works" web site are the following:

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, while 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 10­25 percent of regular users, or about 1-2 percent of all current users, resemble clinical addicts (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, Reinarman, and Waldorf, 1989; Siegel, 1984). Moreover, most users who do encounter problems—problems that usually fall far short of "loss of control" (Cohen & Sas, 1994; Siegel, 1984)—do not seek treatment. Rather, they overcome their problems by quitting or cutting back without treatment (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 are, in addition to cocaine, "highly addictive"—alcohol and heroin.