Harvard Addiction Science Professor Admits Treatment is a Form of Coercion

Julie Eldred is a heroin user who violated probation by testing positive for an opioid. She’s contesting the probation violation ruling all the way up to Massachusetts’ State Supreme Court on the grounds that relapse is a symptom of the disease of addiction, and it’s therefore a cruel and unusual punishment to put her in jail for something she cannot control. This case is rocking the world of addiction treatment, drug courts, and the very concept of addiction itself, in many ways. It’s wonderful for me, watching the fantasy of the “disease of addiction” and the facts of substance use crash together like this. After all, Julie Eldred makes a good case. The core concept of addiction is that substance use becomes literally involuntary once the disease is acquired. If this is true then she shouldn’t be violated for using. Nor should the states, which endorse the disease model of addiction, be using threats such as jail time to try to keep “addicts” from using substances, if their behavior is truly involuntary.

Deterrents and incentives do have some effect on “addicts” choices though (which is one way we know they’re really choosing btw). That’s proven, and incidentally, outlined in a great amicus brief on the case written by Sally Satel, Gene Heyman and others. Unfortunately, they’re also arguing in favor of the use of deterrents/coercion against drug users, which I disagree with. My reasons for disagreement are many (especially moral – because as the owner of yourself, you have the natural right to act on your own judgment, including taking whatever drugs you like, whenever you like since it doesn’t violate anyone else’s rights), but most importantly, I disagree because coercion can never provide a long-term solution to the individual with a substance use problem. You can induce some fear and panic in people with threats and thereby persuade them sometimes to refrain from substance use. But this is short lived, because you can never really coerce a person to change a want, preference, or love of something. If that doesn’t change, then the only way you can coercively ensure that they never act on their preference is to lock them in a cage forever. So it’s a strategy with a dead end. And the fact is that these deterrence and fear based approaches to addiction cause more harm in the long run than if you’d simply left the substance user alone – this is all discussed in my book The Freedom Model for Addictions.

Here’s the thing that took me a very long time to realize: almost every form of treatment currently available is coercive and based on deterrence. You go for treatment, and they judge your drug use as so bad that nobody could really want to do it of their own free will. And therefore, they say, you have the disease of addiction. You aren’t given the opportunity to judge it for yourself. Instead, you are badgered into “admitting” that their judgment is correct, and that you have the disease of addiction. Then you must “accept the gift of treatment”, and “comply with treatment.” Complying with treatment means, among other things, trying to carry out the goal of lifelong abstinence that they assigned to you, and which you did not choose by your own judgment. Your own judgment never entered the process.

Those who work in the field seek to improve their craft by finding ways to “reduce resistance to treatment.” I kid you not. “Compliance” and “retention” are the measures by which addiction treatment success is now measured in formal research and for most other purposes. That is to say that the treatment is considered a success if they can get you to be obedient and fall in line. It’s coercive. Does it help people to find more personally rewarding outcomes – greater happiness for the individual being treated? How can a person be happy when they’re made to work every day to resist doing what they really want to do? How can a person be happy fulfilling goals they haven’t really chosen and that they do not prefer?

Most people instinctively know this is what they’re in for when someone asks or tells them to go for addiction treatment. This is why they’re “resistant.” Granted, some people seek out treatment themselves, and those cases are a bit deeper of a discussion (hint, they’ve already been persuaded that they’re helpless addicts who can’t control themselves and need to turn their lives over to some authority or powerful other – they’re often in a worse position than the “resistant addict in denial” unfortunately). Nevertheless, most people know that treatment is going to mean being ordered to never again do the thing they like doing and most want to do right now – drink/drug. They know it means signing up for a lifetime of living in constant conflict with their own desires. You have to give up self-determination in some sense to enter into addiction treatment. You have to live the rest of your life in an open prison. It’s an odd sort of coercive arrangement to say the least (and more than can be fully sorted out in this post). It’s like a punishment you have to agree to.

Now let’s get back to considering the Julie Eldred case. I was shocked to see what a distinguished professor of addiction medicine at Harvard, John Kelly, had to say when interviewed about the case for The Atlantic:

He agrees with Newman-Polk that relapse is a symptom of disease and that punishing a person for “expressing symptoms” is “unethical.” …. A deterrent, like mandatory treatment or even brief jail time, can augment recovery if the conditions are right, he said. “I would argue that you can require someone to remain drug-free, but instead of the threat of jail you can have the threat of more treatment,” Kelly said.

There you have it. “The threat of more treatment.”

In what world is a solution to a problem seen as a threat. When is a cure for a disease a threat. When is a lessening of unwanted symptoms a threat. Why should a good thing be considered a deterrent?

The fact is that addiction treatment has no magic that reduces an unwanted desire to use substances. It is a system of deterrence and coercion. Even the tactics they teach people to use to resist the desire to use substances consist mainly of self-deterrence. They tell you to make lists of all the bad things that will happen, all that you will lose, all that you will suffer if you take even a single drink or dose of a drug. Then you are told to recite those things to yourself when you want to use, in order to deter yourself from using substances. They tell you that if you don’t keep taking your suboxone, naltrexone, or keep attending meetings and counseling sessions, then you will surely relapse and fall apart. To get you into treatment, they organize elaborate interventions where they also scare your family into threatening to take everything away from you and shun you if you don’t comply with the demands of treatment. The family is even brought in as agents of coercion! (If that’s not a recipe for dysfunction, I don’t know what is.) The whole thing is built around deterrence and coercion. It’s pure misery, and it doesn’t help.

Don’t believe treatment is equivalent to jail? Check out this article in The Boston Globe, and the picture that accompanies it:

I laugh (but then regret it because it’s so damn sad), when I hear politicians say “we’re going to stop treating addiction as a crime, and start treating it as a disease.” But then what do they do? They create the kind of drug courts we’re talking about here. What’s more, they pass involuntary commitment laws that allow the following sequence of events:

1. A family member goes in front of a judge to testify that a loved one is addicted.
2. The judge issues an order for the loved one to enter a treatment center.
3. The loved one then must attend, or else a warrant is issued to take him to the treatment center.
4. The police find the loved one, put him in handcuffs, and bring him to the treatment center.

What part of this sounds any different than “treating addiction as a crime?” All of this is coercive, which again, is why people resist it. It all creates a bunch of misery, and it doesn’t help. The success rates for people who receive addiction treatment are no better than for those who don’t receive treatment. In fact, they’re worse. And treatment results in more binge use, higher overdose rates, and longer lasting “addictions.”

But what is the possible alternative if “addicts” have a disease that makes them want to continue using drugs? Logically if this were the case, any attempt to help them would have to be coercive – it would have to go against their wants. Well, there is no such disease. The alternative is to understand that people are freely acting on their own preferences, and that they have the right to do so, and that they may also change those preferences if given the chance and offered the proper information.

The Freedom Model for Addictions, the book I co-authored with Mark Scheeren and Michelle Dunbar of Baldwin Research Institute outlines such an approach. Unfortunately, to deliver the approach, we have to contend with the boatload of addiction and recovery mythology that got our culture into this coercive game in the first place. But here’s a little bit of how it goes. We tell the individual on day one that it is their choice alone whether they use substances and to what degree they do so. We tell them we’re not going to assign them a goal, and that they shouldn’t jump into a lifelong goal. Then the rest of the learning materials are designed to show them how to re-analyze all of their options, and figure out for themselves whether a change would make them happier. That is to say, we show them they can change their wants, we show them how to do it, but we don’t tell them what to do – we leave it up to them, after arming them with the best possible information. In our retreats and other interactive forms of learning The Freedom Model, we give them something they haven’t been able to get anywhere else – a nonjudgmental, non-coercive environment and helpers to interact with, where they finally feel free to explore their options. We hope the rest of the world catches up with us, and stops trying to coerce and deter people from using substance. Because the only way a person can move forward happier is by following the goals they truly want, so they need to be allowed to develop their own goals.