Opinion

Why Forced Addiction Treatment Fails

Jason Norelli, a San Francisco native, spent several years homeless in and around the city’s Tenderloin district, addicted to methamphetamine. In 2001, he was legally mandated to attend rehab and has been in recovery ever since. Today he helps others like him get care.

Mr. Norelli’s experience makes him seem like a poster child for legally mandated addiction treatment. At least 37 states now have laws on the books that allow parents, police or concerned others to petition courts to compel rehab through civil commitment if a judge deems someone a threat to themselves or others.

Twenty-five such laws were passed or expanded between 2015 and 2018 alone, according to a recent investigation by The Intercept, and this growth continues. This month, Massachusetts proposed an increase in funding to its civil commitment program for addiction, bringing it to about $23 million. In March, Gov. Gavin Newsom of California proposed a new system of “CARE Courts,” to expand civil commitment for homeless people with schizophrenia and often addiction.

But voluntary rehab has a better track record and is less likely to harm the people it is intended to help. Criminalization and coercion have helped create a patchwork of addiction programs that is harsh, low quality, underfunded, understaffed and too often fraudulent. Since legally mandated care is often the only way to get immediate and free treatment, a damaging cycle continues.

To do better, the United States needs more evidence-based treatment. And since the data shows that the best treatment is compassionate and inviting, coercion should be the last resort, not the first.

Mr. Norelli opposes compulsory drug treatment. He feels that being forced into treatment can push people in the other direction if they are not ready to quit. “Of the hundred people that came in at the same time I did, only a few completed it,” he said, adding that he is still disturbed by the “humiliating” way they were treated.

Despite having some inspiring counselors, the rehab he was required to attend used, among other methods, so-called attack therapy, an unscientific approach in which the therapist and other group members try to break individuals by shouting hurtful things at them to destroy a person’s “addictive” personality.

Instead, Mr. Norelli believes it was positive forces in his life, like his family and the desire to spend time with his son, that kept him motivated, despite the dehumanizing tactics.

Supporters of compulsory drug treatment — which often include family members of people with addiction — frequently argue that it is the only way to get their loved ones to stop doing drugs, and so remain alive. And for decades, addiction experts argued that research supports legally mandated treatment. In 2018, the National Institute on Drug Abuse said that “treatment doesn’t need to be voluntary to be effective,” in its document on principles of quality care.

Now, however, the consensus has shifted. “The data does not show that it’s beneficial to put someone in jail or prison or force them against their will to go to treatment,” said Dr. Nora Volkow, the director of the N.I.D.A. She notes that people frequently use anecdotes (like Mr. Norelli’s) to favor mandatory treatment. “There are absolutely instances where people may have had a positive outcome,” she said. “But it’s the minority.”

A 2016 research review shows why. Of the nine studies included, five found no significant reductions in drug use or crime among people who underwent required treatment, and two studies found that mandated therapy made those measures worse. Only two studies found a small benefit in short-term recovery. This is in contrast with the strong literature on voluntary medication use for opioid addiction, which shows that it can reduce mortality by 50 percent or more.

Massachusetts has one of the most frequently used civil commitment systems for addiction, and the results are grim. Much of the treatment takes place in prisons, and lawsuits and reporting has described filthy conditions and lack of access to addiction medications proven to save lives. The state’s statistics show that people who have been committed are twice as likely to die of opioid-related overdose as those who seek help voluntarily. A meta-analysis looking at studies in the United States and around the world of involuntary treatment and H.I.V. and overdose-related risk found similar results.

So why is forced rehab so politically popular? One answer is that it comes across as centrist, mixing law and order with therapy. Another is that families often aren’t aware that there are more effective ways to motivate recovery.

Legal coercion undermines many aspects of effective addiction therapy. It can be difficult to trust providers whose job involves reporting on you to a court. Since relapse is common and often leads to legal consequences, this can discourage disclosure. Coercion can also smother the internal desire to change, which is known to be critical for long-term success.

Fortunately, the same people who balk at commands will often voluntarily take action if persuaded that it will help them get what they want. One of the most successful addiction treatments, motivational enhancement therapy, focuses on helping people build relationship and career goals. Proponents of this approach say it allows people to see for themselves that their drug use is an obstacle, creating desire to change.

Another therapy, called Community Reinforcement and Family Therapy (CRAFT), teaches families to lovingly motivate people with addiction and is more effective than other treatments. A third highly effective approach, known as contingency management, uses rewards like free movie tickets instead of punishment. But these therapies are, unsurprisingly, rarely available in mandated treatment.

It’s often argued that people with the most severe addictions won’t accept help because they deny that they need it. The California CARE Court system, for example, will treat people with schizophrenia, including those who have addiction as well, who are seen as more likely to be resistant to receiving treatment.

But even here, coercion is rarely needed. Research finds that 86 percent of people with long histories of frequent emergency room visits and arrests who have diagnoses of substance use and severe mental illness will accept and persist in housing with supportive care. This includes being guided by advocates through the bureaucracy and welcomed without the rigid rules requiring perfect abstinence that are typical in rehabs and housing programs.

In other words, spending more on reducing barriers to care and housing, and improving the quality of treatment so that people with addiction actually want to participate will be far more effective than adding yet more money for courts and cops.

Moreover, reducing compulsory treatment will improve the quality. Currently, more than a quarter of people in rehab are legally mandated. Many more have little choice about the help they receive because of insurance rules, or lack of insurance.

But if fewer people were forced to simply accept what’s offered, programs would have to become friendlier. It’s basic capitalism: Customer service is better when businesses compete than when consumers have no choice.

Today Mr. Norelli is a manager at Glide Harm Reduction, part of a church in the heart of the Tenderloin, which, since the crack era, has explicitly tried to attract people into recovery with love, not shame. This includes offering meals, referrals to treatment and housing and clean needles — as well as joyous musical worship.

“Any chance I get to bring some love and compassion into that formula, I do it,” he said. “And I see the results of that. People have better outcomes.”

Maia Szalavitz is a contributing Opinion writer and the author, most recently, of “Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction.”

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