"Coercive treatment" -- the term conjures up images from "One Flew Over the Cuckoo's Nest" of forced shock treatments and surgical lobotomy. The notion seems to offend the bedrock ideals of privacy and free choice, specifically the right of people to decide whether to undergo treatment.
What then justifies forcing thousands of drug addicts into treatment programs, as is customary throughout the country? Even if forced treatment can be justified, is it effective when the addict is otherwise unmotivated to stop using drugs?
Coercive treatment occurs within both the public medical and prison systems. Pending legal action accounts for an estimated 40 to 70 percent of referrals to public alcohol and drug programs; as drug-related arrests and convictions continue to rise, it is expected that a larger proportion will be ordered into treatment as a condition of probation or parole.
Drug treatment programs also have become a necessary and prominent part of the prison system, since about 70 percent of inmates abuse substances.
Since continued alcohol or drug use is associated with criminal activity, the hope is that substance abuse treatment, offered either as a part of, or as an alternative to, incarceration will lead to decreased drug-related criminal activity.
Ethically, coercive treatment can be justified as a less restrictive alternative to jail. Ideally, such external coercion is replaced by internal motivation, as the benefits of sobriety become more evident to the recovering addict.
Sanctions following drug use, such as imprisonment or increased probation supervision, are an effective means of confronting an addict's denial and may contribute to successful drug treatment. Support for this approach comes from studies showing that prolonged periods of supervised parole following prison increase the likelihood of abstinence.
Despite the potential for success of coercive treatment, problems may still arise if treatment is confused with punishment. At their worst, coercive treatment programs can give rise to abuse -- humiliating comments, performance of degrading activities and even physical abuse, all of which have been justified in the name of "confronting denial."
To prevent abuse, I believe it is useful to differentiate between the goals of the criminal justice system -- to punish and deter criminal activity, to protect society and to rehabilitate offenders -- and the goals of substance abuse treatment -- to decrease problems resulting from substance abuse and to improve the functioning of the patient.
To avoid problems, the criminal justice system should focus on identifying drug and alcohol patients and providing incentives to enter treatment. The roles of probation and corrections officers and of therapists must also be clearly defined.
Incentives would include the increased likelihood of remaining abstinent (and thus staying out of prison) and the opportunity to get enhanced vocational skills training, an essential component of treatment. Inmates who successfully complete treatment might be offered the possibility of earlier discharge from prison, followed by a closely supervised release program. The first two incentives would also apply to those on probation or parole.
Although ethical and non-coercive treatment programs can be developed, the likelihood is slim. Currently, public resources are inadequate to meet the needs of addicts who voluntarily seek help. Long waiting lists to enter programs are common, and few programs provide sufficient counseling, vocational training, medical services, job opportunities or community support.
Ethically, it is hard to justify coercive treatment when addicts and alcoholics do not have the opportunity to enter treatment voluntarily before they get into trouble with the law.
Tougher drug laws and vast increases in the number of drug-related arrests have resulted in severe overcrowding of prisons, which are primarily filled with poor, often illiterate, people who have limited resources and skills. Funds to house prisoners humanely are already stretched thin. Money for treatment is likely to become even scarcer, and there are too few skilled treatment providers to run good programs. These limitations mean that the ideals of coercive treatment will not be accomplished and that abuse, rather than rehabilitation, may result.
Some may believe that substance-abusing criminals deserve punishment, not treatment; that society's resources should not be wasted on criminals and that abusive treatment is an acceptable form of punishment. These views, however, are both short-sighted and morally unjustifiable. Ineffective treatment will result in perpetuation of substance abuse and crime, making all of us less secure. Society's interest in punishing criminal activity does not justify abuse in coercive treatment programs.
Richard S. Schottenfeld, an associate professor of psychiatry at Yale University School of Medicine, is acting co-director of the Substance Abuse Treatment Unit at the Connecticut Mental Health Center.