Drug Treatment: The Case for Coercion

**By Sally L. Satel, M.D.**

####### Yale University School of Medicine

**Oasis Clinic, Washington, DC**

*In this article, Dr. Sally Satel makes the case for coercion in drug
treatment, and outlines the successes drug courts have realized in
having drug involved offenders not only enter, but also remain in
treatment for substantial periods of time. Dr. Satel argues that coerced
treatment, specifically that found in drug courts, is far more effective
in reducing criminality and drug abuse precisely because participants
are retained for substantially longer periods than in voluntary
treatment. Dr. Satel discusses the history of coerced drug treatment,
outlines different approaches to it, and presents the evidence of
coercion's effectiveness. Drug courts are discussed as a successful
coerced treatment modality. Dr. Satel concludes that coercion has shown
that addicts need not be internally motivated at the outset of treatment
in order to benefit from it, and that coercion itself is a crucial tool
in the rehabilitation of addicts through drug treatment.*

*Dr. Sally Satel L. is a practicing psychiatrist and lecturer at Yale
University School of Medicine. Dr. Satel also serves as staff
psychiatrist at the Oasis Clinic in Washington DC, and as an adjunct
scholar at the American Enterprise Institute. In addition to publishing
widely in medical journals, Dr. Satel's articles have appeared in* The
National Drug Court Institute Review, The New Republic, City Journal
*(of the Manhattan Institute),* The Los Angeles Times*,* The Wall Street
Journal*,* The New York Times*,* SLATE*,* The Public Interest, *and* The
Women\'s Quarterly*. Dr. Satel is also the author of the book,* Drug
Treatment: The Case for Coercion *(1999, American Enterprise Institute
Press).* *Dr. Satel attended college at Cornell University, received an
M.S. from the University of Chicago, and an M.D. from Brown University.*

#### ARTICLE SUMMARIES

###### Coercion Necessary

**\[1\]** Coercion is the best chance available for increasing addicts'
quality of life and that of the society in which they live.

###### Drug Courts Successful

**\[2\]** Drug courts have proven especially successful in retaining
participants in treatment and thereby reducing substance abuse and
criminality.

###### National Results

**\[3\]** National treatment studies indicate that 1) length of time in
treatment predicts success, and 2) coerced patients stay in treatment
longer.

###### Drug Court Retention

**\[4\]** Drug court retention rates exceed retention rates for public
sector treatment programs.

###### Social Contracting

**\[5\]** Social contracting has great therapeutic potential for both
participants and the community as a form of coercive treatment.

###### Contingency Management

**\[6\]** Contingency management employs sanctions and incentives
similar to drug courts, and evidences success as well.

###### Participant Motivation

**\[7\]** Participants need not be internally motivated at the outset of
treatment to benefit from it. Without coercion, patients cannot be
retained in treatment.

###### Drug Courts Provide Lesson

**\[8\]** Drug courts provide an important lesson to other institutions:
coerced treatment success helps both participants and community
resources.

INTRODUCTION: WHY COERCION?

To judge by the character of the present debate over national drug
control policy, an observer would never guess how completely the
participants agree about some very important issues. The debate is
dominated by its extremes, opposing camps that deride each other's
arguments. On one side, the "drug warriors," as their critics label
them, want to stamp out drug use altogether: They advance strict
controls on drug production and harsh punishments for trafficking. At
the other end of the continuum, drug legalizers condemn the abolitionist
strategy as costly, punitive, and unrealistic, promoting in its place a
regime of relaxed controls plus regulation for some or all drugs.

Yet all assent to two crucial points. First, many drug addicts need drug
treatment if they are to lead productive and satisfying lives. Second,
the more treatment available to each of these addicts, the better. The
White House's Office of National Drug Control Policy estimates that the
nation's present treatment capacity can accommodate only half the
country's 3.5 million addicts (Dargan, 1998; *Psychology of Addictive
Behaviors*, December 1997), and there is need to narrow the gap.

These agreed-on propositions have not been acknowledged for what they
are: starting points from which to work towards a policy consensus. The
reason for this avoidance is a large, uncomfortable fact: even if we
close the so-called treatment gap, the most promising way -- perhaps the
only way -- to put enough addicts into treatment for enough time to make
a difference entails a considerable measure of coercion. This is a
proposition massively supported by the empirical data on drug treatment
programs, yet it runs counter to some of today's most powerful political
and cultural currents.

In the context of treatment, the term coercion -- used more or less
interchangeably with "compulsory treatment," "mandated treatment,"
"involuntary treatment," "legal pressure into treatment," and "criminal
justice referral to treatment" -- refers to an array of strategies that
shape behavior by responding to specific actions with external pressure
and predictable consequences. Coercive drug treatment strategies are
already common. Both the criminal justice system and the workplace, for
example, have proven to be excellent venues for identifying individuals
with drug problems, then exerting external leverage, from risk of jail
to threat of job loss, and providing powerful incentives for individuals
to start and stay in treatment.

**\[1\]** *The aim of the examination is to make the case that unless we
acknowledge the necessity for coercive strategies, we will lose the best
chance we have for treating addicts in ways that will bring about a
significant increase in the quality of their lives and that of the
society in which they live.*

# The Effectiveness of Coerced Treatment

Data consistently show that treatment, when completed, is quite
effective. Indeed, during even brief exposures to treatment, almost all
addicts will use fewer drugs and commit fewer crimes than they otherwise
would, which means that almost any treatment produces benefits in excess
to cost. But most addicts, given a choice, will not enter a treatment
program at all.

Moreover, evidence shows that addicts referred to treatment through
court order or employer mandates benefit as much as or more than their
counterparts who enter treatment voluntarily. Research over the past
thirty years has firmly established that individuals who remain in
treatment for longer periods of time are more successful, maintaining
sobriety and committing fewer crimes.

A massive amount of data, assessing roughly 70,000 patients since 1967,
emerged with two clear findings. First, the length of time a patient
spends in treatment is a reliable predictor of his or her post-treatment
performance. Beyond a 90 day threshold, treatment outcomes improved in
direct relationship to the length of time spent in treatment, with one
year generally found to be the minimum effective duration of treatment
(Pescor, 1943; Simpson and Sells, 1983; Hubbard, et al., 1989; Simpson
and Curry, eds., *Psychology of Addictive Behaviors* vol. 11; Center for
Substance Abuse Treatment, 1996). The second major finding was that
coerced patients tended to stay in treatment longer.

Looking at the most recent studies brings home how effective coerced
treatment is (specifically that found in drug courts) compared to
voluntary treatment.

Drug courts, which are coercive in nature, have proven especially
successful in sustaining participants in treatment. An American
University survey of the 200 oldest drug courts found that 70 percent of
those offenders who entered the programs remained active in treatment at
the end of one year (American University, 1998). Steven Belenko, of
Columbia University's Center on Addiction and Substance Abuse, came to a
similar conclusion finding that "about 60 percent of those entering drug
courts are still in treatment (primarily out patient drug-free) after
one year" (Belenko, 1998).

In comparison, those addicts who do enter a program voluntarily rarely
complete it. About half drop out of the treatment program in the first
three months (Langenbucher, et al., 1993). Further, 80 to 90 percent of
voluntary participants leave treatment by the end of the first year
(Langenbucher, et al., 1993). Among such dropouts, relapse within a year
is generally the rule (Langenbucher, et al., 1993).

**\[2\]** *Clearly, coerced treatment, at least as used by drug courts,
is more effective in retaining participants for substantially longer
periods than voluntary treatment and therefore is far more effective in
reducing criminality and drug abuse.*

In short, if treatment is to fulfill its considerable promise as a key
component of drug control policy, whether strict or permissive, addicts
must not only enter treatment but stay in treatment for substantial
periods of time. Clearly, the coercion provided through drug courts is
proving a more effective treatment modality than voluntary treatment.

**A BRIEF** **HISTORY OF COERCION IN DRUG TREATMENT**

This article begins by recounting the story of early formal efforts to
rehabilitate drug addicts and by drawing from the lessons of those
efforts. It will proceed to explore modern approaches to coercive
treatment and examine the effectiveness of those approaches. It will
then look at the future of coercive treatment and, finally, suggest ways
in which to integrate the theory and practice of coercive treatment into
current policy.

# The Rise of Coercive Treatment

The nation had a perceived drug problem for some 50 years before
coercive treatment strategies developed in response. The first wave of
cocaine, heroin, and morphine addicts was inadvertently created during
the 1880s through the early 1900s, first by well meaning physicians,
later by hawkers of patent remedies. Most of the resulting "medical
addicts," as they were called, were genteel women, personified by the
heroin-addicted mother Mary Tyrone in Eugene O'Neill's *Long Day's
Journey Into Night*. They did not evoke moral censure.

Very different were the addicts who emerged over the first two decades
of the 20^th^ century. These were poor male "pleasure" addicts, harshly
condemned as a social menace (Jonnes, 1996). In response, the Treasury
Department, in 1919, cracked down on physicians who prescribed cocaine,
heroin, and morphine. States imposed and enforced criminal penalties for
use. Officials in big cities, fearing that the hundreds of male addicts
thus deprived of their prescriptions would turn in desperation to
violent crime, established opiate clinics to dispense morphine and
heroin. By 1920, some 40 such clinics were established.

Some of the clinics were worse than ineffective. The most notorious,
like the Worth Street Clinic in New York City, were corrupted by
diversion of drugs and presented the spectacle of bedraggled dope
fiends, as they were portrayed, loitering around the neighborhood.

The best-run of these facilities, like those in New Haven, Connecticut,
Los Angeles, California, and Shreveport, Louisiana, did reduce
drug-related crime and illicit trafficking, but were still unable to
point to addicts whom the clinics had cured of their addiction (Musto,
1987; White, 1998). The Shreveport clinic, however, did keep a close eye
on its 198 patients, maintained meticulous records, and required that
its addicts hold jobs and keep up their physical appearance or be cut
off from the clinic. This requirement, historian Jill Jonnes notes,
"probably weeded out most of the 'sporting' addicts and other unsavory
types who so frustrated the New York doctors" (Jonnes, 1996, p.55).

In time, the federal government extended its policy of total drug
abstinence to the clinics, which had all closed their doors by 1925 when
the medical staffs were threatened with indictment by federal
authorities. With the end of this short-lived clinical era, treatment
for opiate dependence was largely unavailable between the early 1920s
and the end of the Second World War. Though relatively few new addicts
emerged during this period, those who had become afflicted in the early
1900s tended to remain opiate-dependent. In particular, a growing
population of aging addicts came to inhabit federal prisons, to which
addicts convicted of selling or possessing drugs were routinely sent.

**Narcotics Farms**

As early as 1919, when governments began reining in physician
prescribing of opiates, the Narcotics Unit of the Treasury Department
urged Congress to set up a series of federal narcotics farms where users
could be confined and treated (Inciardi, in Leukefeld and Tims, eds.,
1988). It was only in 1935, though, in response to the problem of aging
addicts, that the U.S. Public Health Service opened a facility in
Lexington, Kentucky. Three years later, another federal farm was
established in Fort Worth, Texas. These facilities received both
criminal violators and addicts who enrolled in treatment voluntarily.

The Lexington facility was a hospital-prison-sanitarium in which medical
and moral approaches to treatment converged. It was located, as Jonnes
has described it,

> on 1,100 acres of rolling bluegrass. . . an Art Deco campus-like
> affair with barred windows. In its early years, Lexington was
> literally a working farm operated by patient-inmates with chicken
> hatcheries, slaughter houses, four large dairy barns, a green house
> and a utility barn. When not farming, inmates could work in sewing,
> printing or wood working shops (Jonnes, 1996, p. 111-12).

The facilities did not, however, succeed in providing a wholesome and
salutary rural respite. According to Jonnes, the "effect of going to KY
\[as patient-inmates called the Lexington farm\] for most addicts was to
expand their network of addict pals." The doctors were dedicated but
frustrated, often noting that their patients would likely relapse upon
returning to the inner cities from which they came.

The data confirmed the doctors' impressions. According to a report by
the U.S. Comptroller General, approximately 70 percent of the hospital's
voluntary patients signed out against medical advice before completing
the six-to-12-month treatment program; and within a few years, 90
percent had relapsed (U.S. Comptroller General, 1971). Most who remained
in treatment did so under legal pressure from a court.

Still, though the farms are generally considered to have been failures,
they generated useful clinical information. Most important, several
follow-up studies of the participants indicated that addicts who after
treatment were supervised under legal coercion had better outcomes than
those not so supervised. A follow-up of over 4,000 addicts, six months
after discharge from treatment, found that those on probation or parole
were more than twice as likely to remain abstinent as voluntary
patients, probably because the former had compulsory post-hospital
supervision (Pescor, 1943). A longer-term follow-up of the same
population confirmed the critical role of post-hospital surveillance: it
found that of those serving more than 12 months of parole, 67 percent
remained drug-free a year after discharge, while the figure for
voluntary patients was only four percent (Vaillant, 1966).

The data showed, in sum, that some kind of post-discharge supervision
was needed. The information also yielded the lessons that (a) a
six-to-12-month treatment stay was too brief, (b) the need was for
intensive vocational services rather than psychological services aimed
at personality change, and (c) the threat of reinstitutionalization had
teeth.

# *Therapeutic Communities*

After World War II, organized crime was able to reactivate the old
heroin trafficking routes disrupted by the war, and inner-city
physicians began to encounter the next generation of heroin addicts.
Therefore, the 1950s saw a resurgence of interest in the treatment of
addiction -- and, in particular, the emergence of the notion of the
self-regulating therapeutic community (TC), an idea enthusiastically
welcomed by clinicians and policymakers who were heartened by early TC
success stories and demoralized by the gloomy results of previous
treatment efforts.

The idea of a therapeutic community was exemplified by Synanon, a
residential facility established by former alcoholic Charles Dederich in
Santa Monica, California to treat both alcohol and heroin addicts.
Synanon was followed by the establishment in New York City of Daytop
Village and, in 1967, Phoenix House. The latter, a residential center on
the Upper West Side, was founded by psychiatrist Mitchell Rosenthal,
inspired by the efforts of six former addicts who were trying to keep
themselves clean and enlisted his help.

Modern therapeutic communities immerse patients in a comprehensive 18 to
24-month treatment regimen built around the philosophy that the addict's
primary problem is not the drug he abuses, but the addict himself.
Though psychiatric orthodoxy holds that addiction is a discrete,
self-contained "disease," the therapeutic community's approach
recognizes drug abuse as a symptom of a deeper personal disturbance. The
strategy for rehabilitation is to transform the destructive patterns of
feeling, thinking, and acting that predispose a person to use drugs.

In this effort, the primary "therapist" is the community itself, not
only peers but staff members, some of whom are graduates of a program
themselves and can serve as role models. The dynamic is mutual
self-help; residents continually reinforce, for each other, the
expectations and rules of the community. For meeting community
expectations, residents win rewards -- privileges like weekend passes or
increasing responsibility, culminating in leadership roles. If a
resident defies the rules, he or she loses privileges and must perform
the least desirable chores. All residents must work -- above all so that
they learn to accept authority and supervision, an ability vital to
their future success in the work force.

Researcher George De Leon has identified three stages in a resident's
attitude towards such communities (De Leon, in Leukefeld and Tims, eds.,
1988; De Leon, Melnick and Kressel, 1997):

\(1\) compliance: adherence to rules simply to avoid negative
consequences such as disciplinary action, discharge from the program, or
reincarceration;

> \(2\) conformity: adherence to the recovery community's norms in order
> to avoid loss of approval or disaffiliation;
>
> \(3\) commitment: development of a personal determination to change
> destructive attitudes and behaviors.

Those who negotiate the commitment stage have excellent outcomes. De
Leon, in a long-term follow-up study of addicts admitted to Phoenix
House, found that after five to seven years, 90 percent of those who had
graduated were employed and crime-free, while 70 percent were drug-free
(De Leon, Wexler and Jainchill, 1982).

However, the graduates constituted only 20 percent of De Leon's sample.
Generally, half of voluntarily committed patients leave therapeutic
communities prematurely within the first 90 days, generally considered
to be the threshold at which individuals form an independent commitment
to a treatment program. Perhaps one in five to one in ten fully
completes a program (De Leon, in Leukefeld and Tims, eds., 1988; De
Leon, Melnick and Kressel, 1997; Anglin and Hser, in Inciardi, ed.,
1990).

These dropout rates are not hard to understand. In the early months of a
program, residents of a therapeutic community often rebel against the
rigid structure, loss of status they enjoyed on the street, and
deprivation of getting high. Ambivalence about relinquishing drugs is a
powerful psychological force pulling patients back to the street. Even
patients with strong motivation experience flagging resolve, momentary
disillusionment, or intense cravings. If a patient succumbs to these
pressures, he or she may have gained some benefit from even the brief
exposure to treatment but is at high risk for relapse into drug use and
crime.

De Leon therefore sees legal pressure as the initial force that can
literally get patients through the door into treatment and keep them
there until they internalize the values and goals of recovery. Coercion
alone cannot do the job: one researcher put it that "if contact with
therapy does not bring its own rewards, the potency of coercion will
decline precipitously, and could ultimately work against treatment
goals" (Marlowe, et al., 1996). But the threat of consequences like
incarceration, the loss of a job, or some other aversive event can
sustain an ambivalent or flatly resistant patient during the early
months of treatment until those rewards -- newly learned skills, a
transformed self-concept, social maturation, and optimism about the
future -- ultimately inspire him or her to change.

Thus, it is of interest that in De Leon's Phoenix House sample, it did
not matter statistically to a patient's chances of "graduating" whether
he or she had enrolled voluntarily or had been mandated to treatment (De
Leon, Wexler and Jainchill, 1982). This similarity did not mean, in De
Leon's view, that compelled treatment made no difference; it was the
opposite. The compelled patients began with worse prognoses, because of
their legal involvement and their higher incidence of antisocial
personality disorder and low motivation (De Leon, in Leukefeld and Tims,
eds., 1988; De Leon, Melnick and Kressel, 1997; Leukefeld and Tims,
eds., 1988; Anglin and Hser in Inciardi, ed., 1990). Counteracting these
disadvantages, though, was the fact that individuals who had court cases
pending or had been legally referred to the community spent, on average,
more days in treatment than voluntary patients did (De Leon, in
Leukefeld and Tims, eds., 1988). The relatively bad prognosis was made
up for by more treatment days. "Retention in treatment," De Leon
therefore concluded, "is the best predictor of outcome, and legal
referral is a consistent predictor of retention."

### Methadone Clinics

The postwar period also saw, in the early 1960s, a renewed receptiveness
to the idea of drug maintenance. The number of heroin users was
increasing, and the treatment available to New York City's 100,000
heroin addicts, half of those in the nation, remained limited to
hospital-based detoxification and the Daytop Lodge therapeutic
community. A few years earlier, a joint committee of the American Bar
Association and the American Medical Association had called for
restoring physicians' freedom to prescribe heroin and for the
establishment of an experimental clinic for this purpose. In 1963, both
the New York Academy of Medicine and President John F. Kennedy's
Presidential Commission on Narcotics and Drug Abuse (the Prettyman
Commission) made similar recommendations (Musto, 1987; White, 1998).

Marie Nyswander and Vincent Dole, physicians at New York's Rockefeller
Institute, set out to develop new pharmacological approaches to treating
heroin addiction. They hypothesized that suppressing the physiological
craving for the drug was the key to treating the addiction, and they
sought a replacement or "substitution" drug that would, unlike heroin
and morphine, not wear off within a few hours. Ideally, a long-acting
medication would stabilize individuals so that they could hold down a
job and function normally.

Nyswander and Dole chose methadone, a long-acting synthetic opiate
developed by German chemists searching for an inexpensive morphine-like
medicine during World War II. Addicts could take methadone orally and
needed to do so only once a day in order to prevent withdrawal and
craving. Moreover, because methadone worked by blocking opiate
receptors, patients would not experience euphoria even if they took
heroin in addition.

Dole started six patients on methadone in 1965. Around the same time,
the U.S. experienced an influx of heroin from the Golden Triangle of
Burma, Laos, and Thailand, fueling an epidemic that peaked in most
American cities between 1969 and 1972. By 1969, almost 2,000 New York
City addicts were enrolled in Dole's maintenance clinic, and by 1970 the
city had expanded the clinic system to serve 20,000 voluntary patients
(Lowinson, et al., in Lowinson, Ruiz and Millman, eds., 1992).

Although there are not many studies of the relationship between
compelled treatment and methadone therapy,

However, over 20 years ago, M. Douglas Anglin of UCLA conducted an
important study of whether addicts coerced into drug treatment differed
from voluntary patients in their responses to treatment (Anglin, in
Leukefeld and Tims, eds., 1988; Anglin, 1988). Anglin divided some 600
methadone-maintenance patients according to whether they were subject to
high, moderate, or low levels of coercion. The 19 percent in the "high
level" category were under official legal supervision, including
required urine testing, and perceived their entry into treatment as
motivated primarily by the legal system. Another 19 percent, moderately
coerced, were under active legal supervision and either were having
urine tests or perceived coercion as the reason for their entry into
treatment. Finally, 62 percent of the sample, under a low level of
coercion, were not under legal supervision and not subject to monitoring
via probation or parole. The majority of these reported feeling no legal
pressure, even as minor as a fear of arrest, impelling them towards
treatment.

When Anglin compared the three groups, he found that all of them showed
substantial improvement when measured on narcotics use, crime, and
social functioning. Once again, compelling patients to accept treatment
did not bar clinical progress and, given the relatively poor prognoses
of those involved, probably aided such progress.

The same lesson emerged from a more recent experience with methadone
treatment at the Southeast Baltimore Drug Treatment Program. A research
team led by psychologist Michael Kidorf of Johns Hopkins University
noted that unemployment was a common problem among inner city drug users
and lamented that "standard drug abuse treatment services appear to have
only small effects on employment" (Kidorf, et al., 1998). In response,
the Baltimore clinic, like its predecessor clinic in Shreveport some 70
years before, instituted the once-again-innovative requirement that its
methadone patients be employed for at least 20 hours a week in order to
receive methadone and related services. Patients were given two months
to find employment or enroll in job training or community service
programs. If they did not, they received five weeks of intensive
counseling; those who did not obtain employment after counseling were
tapered off methadone.

Because these patients had been enrolled in the same clinic before the
requirement went into effect, their performance prior to the new rule
could be compared with the same population's performance afterwards.
Before the requirement, despite enhanced counseling with vocational
training, none had managed to secure either paying or volunteer
employment. By two months after the imposition of the requirement,
however, 75 percent of the sample had secured and maintained verified
paid employment, volunteer work, or education.

### Civil Commitment

Compelled treatment showed its potential in the California Civil Addict
Program, created in 1961 as the first-implemented statewide civil
commitment program in the country. Serving mostly heroin addicts, the
program flourished during the 1960s (McGlothlin, Anglin and Wilson,
1977). The California Department of Corrections ran the program,
providing high-quality treatment by specifically recruited and specially
trained corrections personnel.

During the program's most active years, its protocol included an average
of 18 months of inpatient treatment out of a total commitment period of
seven years. After 18 to 24 months in residential treatment, patients
spent up to five years closely supervised by specially trained parole
officers with small caseloads who monitored patients closely and
administered weekly urine toxicology tests. For any narcotics use
violation discovered by these tests, the officers had authority to take
action, up to returning patients for treatment to the institutions from
which they had been discharged.

This program became the venue for an unfortunate natural experiment:
During the program's first two years, judges and other officials
unfamiliar with its procedures mistakenly released about half of the
committed population after only minimal exposure to the inpatient part
of the program. Dr. Anglin's research team took advantage of this
circumstance, selecting a sample of individuals who had participated in
the program's inpatient treatment for a sustained length of time and
comparing it with a matched sample of individuals who had been
erroneously released. The team compared the two groups on their
self-reported percentages of time spent on drug use and criminal
activity, then verified the data through arrest records and urine
specimens taken at follow-up interviews.

By one year after the premature release of half of the study population,
the two groups had sharply diverged. Individuals who had been
prematurely released were more than twice as likely as those who had
completed 18 months as inpatients to use narcotics. During the
subsequent years of outpatient supervision, narcotics use declined for
both groups; but the decline for those who had been kept as inpatients
averaged 22 percent, while the figure for the discharged group was only
seven percent.

Criminal activity followed a similar pattern. Before commitment, both
groups had devoted about 60 percent of their time to such activity. A
year after one group had been prematurely discharged, the figure for the
treated group was 20 percent while the figure for the discharged group
was 48 percent. At the end of seven years, criminal activity among the
treated group had undergone a further reduction of 19 percent, but the
reduction figure for the discharged group was only seven percent.

New York followed California's model, with a crucial and deleterious
difference. Prompted by California's success, New York began its own
civil commitment program in 1966. New York had the advantage of that
year's federal Narcotic Addict Rehabilitation Act, which aimed to link
criminal justice agencies to community-based treatment programs. The Act
provided for compulsory treatment for addicts charged with certain
nonviolent federal crimes; for treatment instead of sentencing for those
convicted of such crimes, and for voluntary commitment of drug users not
involved in criminal proceedings. The Act also began what was to become,
in the 1970s, massive federal funding of treatment programs.

However, New York -- unlike California, which mandated addicts to
rehabilitation -- allowed addicts to choose between treatment and
incarceration. Those who chose the former were treated in residential
settings developed during those years by the state Narcotics Addiction
Control Commission, but this phase of treatment lasted only about nine
months. Inpatient treatment was followed by parole-like supervision for
another two to four years. Unfortunately, supervision was loose, and a
high percentage of patients went AWOL. Governor Nelson Rockefeller was,
not surprisingly, discouraged. "Let's be frank," he said in his 1973
Address to the Legislature; "we have achieved very little permanent
rehabilitation, we have found no cure" (Rockefeller, Annual Address,
January 3, 1973).

# Resistence to Coercion

EVIDENCE OF THE EFFECTIVENESS OF COERCED TREATMENT

Until recently, treatment has been only marginally effective. It wasn't
until the last 50 years or so that coercive treatment entered the
treatment field and has since been proven as an effective method of
treatment.

An estimated 60 percent of the cocaine and heroin used in the United
States is consumed by the five million Americans who are supervised by
or incarcerated within the criminal justice system. Moreover, offenders
who abuse drugs are more likely than non-abusing offenders to return to
crime following release from incarceration (Taxman, 1998; Bureau of
Justice Statistics, 1995). Therefore, there is considerable potential
within the criminal justice system for reducing drug abuse and related
crime through mandated treatment. Evidence indicates that diversionary
and in-prison treatment programs, though currently available to only
some 15 percent of offenders, have a benefit beyond the crime-reducing
effects of incarceration or probation as usual (National Center on
Addiction and Substance Abuse, Columbia University, 1998; Harlow, 1998;
Bureau of Justice Statistics, U.S. Department of Justice, 1997). Results
from several categories of criminal commitment show that treated
offenders have lower rates of recidivism. Though these studies do not
always directly measure post-treatment drug use, crime itself can
reasonably be used as indirect evidence of drug involvement, since the
two activities are so highly correlated. Conversely, declines in drug
use are accompanied by declines in crime, particularly income-generating
crime (Speckart and Anglin, 1986; Nurco, Kinlock and Hanlon, in
Inciardi, ed., 1990; Chaiken, in Johnson and Wish eds., 1986).

# National Outcome Studies

The first evaluation of this network of community-based programs began
in 1968 when the National Institute of Mental Health funded a proposal
by Saul B. Selis, Director of the Institute of Behavioral Research at
Texas Christian University, for the Drug Abuse Reporting Project (DARP).
Data collection began in 1969 and lasted four years, following about
44,000 patients enrolled in 52 federally funded programs. The project
followed subgroups for five and 12 years following discharge from
treatment.

In 1974, the Institute transferred control of the project to the newly
created National Institute on Drug Abuse (NIDA). NIDA subsequently
funded two more large studies, the Treatment Outcome Prospective Study
(TOPS), which followed 12,000 patients who entered treatment between
1979 and 1981, and the Drug Abuse Treatment Outcome Study (DATOS), which
followed 11,000 patients who entered between 1991 and 1993. More
recently another federal agency, the Center for Substance Abuse
Treatment, undertook the National Treatment Improvement and Evaluation
Study, of 4,400 patients who entered the project between 1993 and 1995.

Taken together, these studies assessed roughly 70,000 patients, of whom
40 to 50 percent were court-referred or otherwise mandated to
residential and outpatient treatment programs (Simpson and Sells, 1983;
Hubbard, et al., 1989; Simpson and Curry, eds., *Psychology of Addictive
Behaviors* vol. 11; Center for Substance Abuse Treatment, 1996).

**\[3\]** *Two major findings emerged from these huge evaluations. The
first was that the length of time a patient spent in treatment was a
reliable predictor of his or her post-treatment performance. Beyond a
90-day threshold, treatment outcomes improved in direct relationship to
the length of time spent in treatment, with one year generally found to
be the minimum effective duration of treatment (De Leon, in Leukefeld
and Tims, eds., 1988; De Leon, Melnick and Kressel, 1997).*

The second major finding was that coerced patients tended to stay
longer. (On this second point, DARP was an exception, finding no
correlation between criminal justice status and either time spent in
treatment or improvement. One can say only that DARP's compelled
patients stayed as long as, and did no worse than, voluntary patients.)

To evaluate these findings, it is important to know whether addicts who
entered treatment under legal coercion were meaningfully different from
other patients. The findings from these studies are mixed. Some show
that legally coerced addicts had a relatively unfavorable pre-admission
profile -- more crime and gang involvement, more drug use, worse
employment records\-- than their non-coerced counterparts. Other studies
detected little difference other than the particular offense that
triggered the mandate to treatment (McGlothlin, in DuPont, Goldstein and
O'Donnell, eds., 1979).

In the DARP study, the baseline characteristics of voluntary and legally
referred patients were similar. Because the subjects were relatively
homogeneous on these dimensions, being primarily young, male, inner-city
"street addicts," more than 80 percent with at least one previous arrest
and over half previously incarcerated, the authors speculated that legal
status was unlikely to have been a very discriminating variable.

The TOPS study, by contrast, discovered some differences. True, legally
mandated and voluntary patients had similar drug use patterns, previous
criminal justice involvement, and number of prior treatment episodes.
But the legally mandated patients were younger than their voluntary
counterparts and more likely to be male. When researchers looked
specifically at patients who reported that the criminal justice system
was the primary source of their referral to treatment, they found that
these legal referrals were not only younger but used mainly alcohol and
marijuana rather than "harder" drugs. The authors speculated that the
legally mandated patients were "caught" earlier in their careers, that
they were incarcerated too recently to have re-established their habits,
or both.

Though the studies do not present a consistent picture of pretreatment
characteristics of legally mandated patients, they make it reasonable to
conclude that even legally coerced addicts having relatively unfavorable
prognoses can benefit from treatment as much as voluntary patients do,
since the latter often remain in treatment for a shorter period of time
(McGlothlin, in DuPont, Goldstein and O'Donnell, eds., 1979).

A 1990 report from the Institute of Medicine summarized that "contrary
to earlier fears among clinicians, criminal justice pressure does not
seem to vitiate treatment effectiveness, and it probably improves
retention" (Gerstein and Harwood, eds., 1990). Thus, while there is
conflicting evidence as to whether a legal mandate brings individuals
into treatment earlier, coercion can almost surely be credited with
derailing many an addiction career once individuals have been brought
into treatment (Collins and Allison, 1983; Anglin and Hser, in Tonry and
Wilson, eds., 1990).

Of special significance, in light of the importance of the length of
treatment, is the fact that all four national outcomes studies showed
high rates of attrition among patients, with half dropping out inside of
90 days. For these early dropouts, the benefits of treatment disappeared
within the year. With substantial, durable change rarely occurring in
less than a year or two of treatment, the high dropout rate makes
retaining patients in treatment a pressing challenge.

Some researchers have hypothesized that the key to retention is to match
each individual patient with the proper type of treatment. Though in
principle such matching makes clinical and economic sense, there is
surprisingly little tested information about such attempts. Two
prospective studies by A. Thomas McLellan of the University of
Pennsylvania suggest that tailoring patient care can indeed make a
difference (McLellan, et al., 1993; McLellan, et al., 1997; Hser, 1995).
McLellan assigned patients to programs according to particular
psychiatric, medical, or family needs and found better outcomes for
these patients than for those without such treatment. One of the
national outcomes studies, DATOS, similarly found that even severely
drug dependent patients were more likely to be abstinent at their
one-year follow-up if they had received support services targeted to
specific needs.

However, these findings are not uniform. The American Society for
Addiction Medicine has developed widely used criteria for placing
patients in specific treatment modalities; but the few studies assessing
the validity of these criteria have not found an effect on outcomes
(McKay, McLellan and Alterman, 1992).

Thus far, it appears that "patient matching," while it may be one means
of assigning patients to treatment, is no substitute for length of
treatment. It is length of exposure to treatment that powerfully
predicts patient success, no matter what the treatment setting. The
federal Center for Substance Abuse Treatment, in a recent study
examining the relationship between these two variables, compared one
sample of addicts who had ten months of residential care followed by two
months of outpatient care with another sample that had six months of
residential care followed by another six months of outpatient care.
Regardless of the treatment scheme to which patients were assigned,
those who completed the entire 12-month treatment period had the best
outcomes. And those most likely to complete the course of treatment were
patients under probation, parole, or pre-trial supervision (Nemes, Wish
and Messina 1998).

# Prison-based Programs

According to a 1997 survey of state departments of corrections sponsored
by the Corrections Program Office, approximately 70 percent of all state
prison inmates are in need of substance abuse treatment (Office of
Justice Programs, 1998). Reporting states indicated, however, that only
15 percent complete a prescribed substance abuse treatment program
before their release from confinement (National Institute of Justice,
1996).

About 12 percent of prisons have intensive treatment programs based on
therapeutic community principles (Lipton, 1998), lasting from six to 15
months and open to nonviolent offenders who are within 18 months of
eligibility for work release or parole. Within the prison, these
offenders are segregated from the rest of the inmate population, in
order to maintain the integrity of the program and to protect
participants from other prisoners.

In a comprehensive review of the prison-based programs of the 1970s and
1980s, Falkin and co-authors concluded that in-prison therapeutic
communities are effective (Falkin, Wexler and Lipton, in Gerstein and
Harwood, eds., 1990). Examining programs such as New York's Stay'n Out
(which they praised as a national model), Oregon's Cornerstone Program,
and others, the authors found that the treatment experience, optimally
for nine to 12 months, was strongly correlated with successful
subsequent parole. For example, violations of parole occurred among 50
percent of the offenders who stayed less than three months in Stay'n
Out, among 39 percent of those who stayed longer than three months, and
among only 15 percent of those who completed the program.
Reincarceration rates within three years of release from prison were
significantly lower for Stay'n Out participants, no matter how long they
participated, than for matched offenders who had expressed interest in
being treated but did not meet technical eligibility requirements.

Similarly, Cornerstone graduates had a 36 percent reincarceration rate
over a three-year follow-up period, while the figure was 63 percent for
parolees-as-usual. The graduates' relative success occurred despite the
fact that they had begun with more severe criminal and substance abuse
histories than the control group.

# Work Release Programs

In 1987, the Delaware Department of Corrections established the Crest
program, the first therapeutic community work-release center in the U.S.
(Inciardi, et al., 1997). Offenders who had been released from prison
after participating in the Key program, a prison-based therapeutic
community for drug-involved offenders at a maximum security prison,
entered the Crest Center for three months of on-site treatment, three
months of additional treatment, and job training, also within a
therapeutic community.

Led by the Center's director, James Inciardi, researchers from the
University of Delaware's Center for Drug and Alcohol Studies compared
four groups of mostly male participants: Key participants who did not go
on to Crest, Crest participants who had not gone through the Key
program, Key and Crest combined, and a control group that had been
incarcerated without treatment, then gone on to conventional work
release. The Key and Key-Crest groups had begun with higher levels of
drug abuse and longer criminal histories. The Key-only group was older
and less likely to be white.

The study found that the longer one's tenure in treatment and the closer
to time of release the treatment was received, the better the
post-release outcome. Overall, the therpeutic element of the
prison-parole combination appears to reside more heavily in the parole
phase than in the incarceration phase.

At an early follow-up, in-prison treatment was found somewhat more
beneficial than no treatment. By 18 months, however, there was no
significant difference between the Key and control groups in rearrest
rates and urinalysis-confirmed drug use. By contrast, at 18 months
Crest-only participants maintained an advantage over the control group.
In addition, at the six-month follow-up, the Crest group was as
successful as the Key-Crest group; but by 18 months, the Key-Crest group
was superior, with 77 percent arrest-free and 47 percent drug-free among
Key-Crest participants, while the figures were only 57 percent
arrest-free and 31 percent drug-free among the Crest group.

The Key-Crest combination outranked all the others, with nearly half the
individuals drug-free at 18 months, three times the figure for the
control group, while Crest-only participants had an intermediate
likelihood of being drug free.

# Treatment Alternatives to Street Crime

TASC, established as a federal program in 1972 as one of the first
initiatives of the Nixon administration's war on drugs, was moderately
successful in cutting the number of street crimes committed by addicts.
TASC was meant to serve as a bridge between the criminal justice and
treatment systems. It functioned as a diversion program for drug
abusers, diverting them from jail or prison by identifying non-violent
addicted criminals and referring them to treatment in the community.
TASC assigned arrestees to case managers who were to get them into
treatment and send progress reports back to the courts. The program, now
supported primarily by state and local governments, subsequently
expanded to supervising probationers and to post-sentencing disposition.

TASC has been the subject of a number of evaluations. Most are postive;
others are partly so. In one such study, the TOPS project compared a
subgroup of TASC-referred patients with a group of voluntary,
unmonitored patients involved in the criminal justice system (Collins
and Allison, 1983). Comparing patients' drug use one year before
treatment to their drug use after the first three to six months of
treatment, the TOPS researchers found that the TASC patients' use had
declined by 81 percent; the comparable figure for the control group was
74 percent. Predatory illegal acts had declined by 96 percent for the
TASC group but only 71 percent for the control group.

The Education and Assistance Corporation analyzed results from the
Brooklyn, New York TASC program (Education and Assistance Corporation,
1995). Of 173 felons placed in treatment in 1992, 71 percent remained in
the program for at least two years. At 29 months after completion of the
program, the group's rearrest rate was nine percent. This was much lower
than either the 25 percent rearrest rate among offenders from a control
program or the 28 percent rearrest rate among the general inmate
population in New York State correctional facilities.

In Texas, a study found that seven percent of TASC-referred offenders
were incarcerated during an 18-month observation period, compared with
28 percent of offenders who did not enter treatment or who stayed less
than three months (Criminal Justice Policy Council, 1995).

Finally, researchers at UCLA and RAND studying five regional sites
compared TASC offenders mandated to treatment or to surveillance,
including urine testing and case management, with a control group of
offenders who received standard probation with little supervision
(Anglin, et al., 1996). The TASC and control groups were similar on most
demographic, drug, and criminal-record variables. At six months after
patients' entry into the study, the researchers measured
police-confirmed new arrests and technical violations and unverified
self-reports of drug use.

The findings varied across the sites. In three places, TASC patients
showed greater reductions in all three outcomes. In some places there
was no difference on one or another outcome. At two sites, Birmingham,
Alabama and Portland, Oregon, the researchers actually found more
criminal involvement and technical violations among TASC patients -- but
the authors attributed this phenomenon to the fact that the TASC
offenders were being watched more closely and were thus more likely to
get caught. (The authors also thought that the figures on self-reported
drug use among TASC patients might be artificially low because heavily
monitored groups may be more likely to minimize their reporting of
punishable behavior.)

# Diversion from Prison

In 1990, the office of the Kings County (Brooklyn) District Attorney
developed the Drug Treatment Alternative to Prison program in response
to the increasing pressure of drug-related commitments on the state
prison system (by the mid-1990s, drug offenders would constitute nearly
one-half of admissions to state prisons). The program diverts
non-violent drug felons to long-term, community-based residential drug
treatment at about two-thirds the cost of incarceration. Like drug
court, the program offers dismissal of charges in return for an
offender's completing treatment under close judicial supervision. Also
like drug court, DTAP may be chosen by offenders for reasons having
little to do with a desire to become drug-free. For some, the program is
a way to avoid incarceration; for others, it promises an expunged
criminal record.

The Vera Institute of Justice in New York City has conducted an
independent evaluation of DTAP (Young, 1996). Vera found that
participants began with more severe pre-treatment deficits -- in
education, employment, and legal involvement -- than those of offenders
placed in other diversion programs. Yet DTAP's overall retention rate at
one year was 64 percent, two to four times higher than that of
residential programs in general. At one year, 11 percent of DTAP
participants had been rearrested, half for drug offenses; by comparison,
drug offenders sent to prison are more than twice as likely to be
rearrested within a year of release, with more than half those arrests
drug-related. Fewer than five percent of ex-prisoners are rearrested
while in treatment, but dropouts have high rates of re-offense, ranging
from 80 to 92 percent, with an average time before return to custody of
only one week.

Drug Courts

Drug courts, one of the more successful modalities of coerced treatment,
offer nonviolent offenders, the majority with a criminal history, the
prospect of dismissed charges if they plead guilty and agree to be
diverted to a heavily monitored drug treatment and testing program
overseen by a judge. While in the TASC model judges do not have direct
contact with treatment personnel, a drug court is a hub from which
services such as treatment, case management, and vocational training
radiate (Tauber, 1997).

Drug courts originated in southern Florida in the late 1980s, when the
area was hit hard by cocaine-related arrests that flooded courtrooms and
overwhelmed jails. Addicts out on probation were quickly rearrested for
new drug-related crimes, and the revolving door to the justice system
seemed to be spinning out of control. Drug courts promised a way to
break the cycle by "reserving" jail and prison beds for dangerous
offenders while sending criminally involved addicts to treatment. The
first one opened in Miami in 1989.

Enthusiasm about drug courts has spawned an entire drug court movement.
Today there are over 500 drug courts in operation, up from about 20 in
1994. An estimated 200,000 individuals have been enrolled in drug
courts. As of June 2000, every state has at least one drug court in
operation. California, where nearly a quarter of all state prisoners are
incarcerated because of a drug offense, has over 100 drug courts
(American University, June 2000).

Though the accumulated evidence of drug courts' effectiveness has yet to
reach a critical threshold, because there has been only a handful of
independently evaluated studies, the early data look promising. Over 70
percent of drug court participants have been incarcerated at least once
previously, almost three times more than have been in drug treatment
(Belenko, 1998); thus for many offenders, drug court is the route of
entry into rehabilitation. In almost all drug courts, retention in
court-ordered drug treatment is consistently several times greater than
involuntary treatment.

A survey by the Drug Court Clearinghouse at American University first
emphasized the element of coercion in drug court participation. Though
80 percent of offenders offered the drug court option chose to take it,
many saw it as simply an expeditious way to get their charges dropped.
Indeed, some actually said they planned to return to drugs after they
"went through the motions" in the program (Cooper, et al., 1997; Satel,
1998). Yet, the survey also found that drug courts reported completion
or graduation rates of 48 percent. Rearrest rates, primarily for drug
crimes, varied according to graduates' characteristics and degree of
social dysfunction but averaged just four percent after one year from
graduation. Even among those who failed to finish the program, rearrest
rates one year after enrollment ranged from 28 percent down to five
percent. By contrast, the Bureau of Justice Statistics reports a 26 to
40 percent rearrest rate for individuals convicted of drug possession
who are traditionally adjudicated (Bureau of Justice Statistics, U.S.
Department of Justice, 1992).

A General Accounting Office report found that the average retention rate
of drug court programs was a highly respectable 71 percent. Even the
lowest retention rate that the GAO found in a drug court, 31 percent,
exceeds the average one-year retention rate of some 15 percent for
non-criminal addicts in public sector treatment programs (U.S. General
Accounting Office, 1997). This comparison is even more impressive in
light of the fact that the criminally involved addict is generally
considered the hardest to treat in conventional settings. The GAO report
also found, like other studies, that the longer a participant stayed in
drug court treatment, the better he or she fared.

**\[4\]** *Even more important is a* *recent* *study conducted by the
National Center on Addiction and Substance Abuse at Columbia University*
*reviewing 59 drug court evaluations from across the nation.* *This
study revealed that,*

"drug courts, compared to other treatment programs, provide more
comprehensive supervision and monitoring, increase the rates of
retention in treatment, as well as reduce drug use and criminal behavior
while participants are in the program. \[Additionally,\] drug courts are
handling more serious offenders, where many have been unsuccessful in
treatment, have a myriad of physical and mental health needs. Further, a
number of drug courts have had success in reducing recidivism following
program participation." (Belenko, 1999).

Evaluations of particular drug courts also show good results. The
Portland, Oregon drug court was evaluated in 1998 by the State Justice
Institute (Finigan, 1998), which made careful efforts to match drug
court participants with other arrestees with similar demographic
characteristics and criminal histories who either had refused drug court
or were ineligible for administrative reasons. Two years after
adjudication or leaving the program, on outcomes measures such as
rearrest and conviction, those who did not enter drug court were at
least as likely to be rearrested for felonies as those who did. Among
those who did enroll, those who finished less than three months in the
program were twice as likely as graduates to be rearrested. Even among
individuals who did not finish, those who completed at least three
months had significantly fewer arrests than those who did not.

Maricopa County, Arizona's drug court was the subject of a 1996
evaluation by RAND, which found that among a sample randomly assigned to
the drug court, rates of rearrest for any crime were significantly lower
than for those randomly assigned to probation alone (Deschenes, et al.,
1996).

A recent review of the Broward County, Florida drug court found that
drug court graduates were half as likely to be rearrested for a felony,
and one-third as likely to be rearrested for a drug felony, as
demographically similar offenders who were eligible for drug court but
had instead chosen and completed probation (Terry, 1998).

An independent evaluation found the Dade County, Florida drug court
superior to disposition as usual (Goldkamp and Weiland, 1993). Between
June, 1989 and March, 1993, the Dade County program enrolled 4,500
defendants, 20 percent of all arrestees in the county who were charged
with drug-related offenses. During that same period, 60 percent of the
enrollees graduated or remained in the program. A year after graduation,
only 11 percent were rearrested in Dade County on any criminal charge.
By contrast, the rearrest rate was some 60 percent for a matched sample
of drug offenders in 1987, two years before institution of the drug
court. Furthermore, the time that elapsed between graduation and first
re-offense was two to three times longer in the drug court group than in
the non-drug court group.

The District of Columbia conducted an experiment in coerced abstinence
as part of a drug court demonstration project funded by the federal
Center for Substance Abuse Treatment through the National Institute of
Justice (Harrell and Cavanaugh, 1997). Between 1992 and 1995, the
District's Pretrial Services Agency randomly assigned arrestees to three
different pre-sentencing tracks. In the "sanctions track," urine samples
were obtained twice weekly, and arrestees were subject to increasingly
severe penalties for missing or dirty urine samples. No formal treatment
was provided, though individuals could seek it or could go voluntarily
to Narcotics Anonymous.

The second, "treatment track" was an intensive, day-long treatment
program. The judge was kept informed about participants' performance but
did not impose sanctions frequently or reliably. Finally, for the
control group on the "standard track," urine samples were collected
twice a week, but there were no predictable consequences for missed or
dirty samples (Harrell and Cavanaugh, 1997).

The Urban Institute analyzed the first 850 of 1,223 defendants to reach
sentencing. They found that "treatment track" participants were twice as
likely to be drug free in the month before sentencing as those in the
"standard track," by 27 percent versus 12 percent. But "sanctions track"
participants, subject to frequent urine testing and known consequences
for violations, were three times as likely as "standard track"
participants to be drug free during the same month, by 37 percent versus
12 percent. At six months after sentencing, rearrest rates for crimes of
any kind were two percent for "sanctions track" participants, four
percent for the "treatment track," and six percent for "standard track"
participants.

Thus, the researchers found that certainty of consequences was
psychologically powerful. "The reason the sanctions track people did so
well," said senior researcher Adele Harrell, who conducted focus groups
with study participants, "is because they knew what the judge would do.
And he did it." Harrell also credited the "swiftness of the penalties --
they had to report to court immediately for a test failure -- and their
fairness." One participant summed up to Harrell, "\[Y\]ou get a dirty
urine, man, you're going to jail. They're letting you know. . . you know
the chances."

At least a dozen similar pilot programs and initiatives are in place, in
cities in Arizona, California, Colorado, Connecticut, Michigan, and New
York. Maryland's "Break the Cycle" program requires clinics to report to
probation or parole officers within 24 hours after an addict has failed
or skipped a drug test (as of July, 1998). Project Sentry in Lansing,
Michigan, in operation for 25 years, provides comparable testing, mostly
short-term, for drug-involved offenders on probation or pre-sentencing
release. Offenders are tested three times a week, and drug use results
in progressively more severe sanctions, beginning with three days in
jail for the first positive or missed urine test, ten days for the
second such failure, 20 for the third, and one month for each
thereafter.

An evaluation of 5,000 participating offenders by the Michigan Office of
Drug Control Policy found that 75 percent remained drug free and were
not arrested during the six-to-12-month observation period (Peterson,
1997).

In Coos County, Oregon, probationers' positive drug tests have dropped
since the Drug Reduction of Probationers program, began in 1988
(Kleiman, in Mead, ed., 1997). This program, too, is built around
certain, swift responses to positive tests -- immediate arrest and two
days in jail for the first violation, ten days for the second, and 30
days for the third. Oregon officials found that prior to implementation
of the program, 43 percent of all probationers tested positive for
drugs. Within about six months after implementation, the figure was down
to ten percent.

# THE FUTURE OF COERCIVE TREATMENT

# 

# 

# 

carceration rate over a three-year follow-up period, while the figure
was 63 percent for parolees-as-usual. The graduates' relative success
occurred despite the fact that they had begun with more severe criminal
and substance abuse histories than the control group.

# 

Social Contracting

**\[5\]** *Contracting confers advantages on individuals when they
manifest a desired behavior, and penalizes them for violating
expectations. For instance, addiction-impaired doctors, nurses, lawyers,
and pilots may be allowed to keep their jobs or licenses "in exchange"
for abstaining from illicit drugs or problem alcohol use under the close
monitoring of a state professional society. Recall the public service
announcement, "Help an Addict: Threaten to Fire Him," made popular in
the late 1980s by the Partnership for a Drug Free America. Employers who
follow that directive have established employee assistance programs
providing treatment for workers. With good effect, the military
threatens drug and alcohol abusing soldiers with dishonorable discharges
unless they abstain.*

Most addicts admit being pressured into treatment by external forces
such as health, employment, social relationships, financial conflicts,
and emotional disturbances. Researchers estimate that only a small
minority of addicts in treatment enrolled solely on personal initiative,
unpressured by others (Weisner, 1990; Anglin, Brecht and Maddahian,
1989; McLellan and Weisner, in Bickel and DeGrandpre, eds., 1996). Thus
the therapeutic potential of contracting, for job security or other
social opportunities, is considerable.

# 

# 

# 

Increasingly, public agencies are fighting to adopt a quid pro quo
strategy towards drug abuse. In 1996, a federal judge ruled in favor of
the New York City Housing Authority's efforts to obtain expedited
court-ordered evictions in cases involving drugs and other threatening
behavior. Previously, such evictions had taken two years or more to
carry out. The Legal Aid Society of New York City argued against the new
eviction procedure, filing court papers on behalf of tenants (without
ever having consulted one) despite overwhelming tenant support for the
Authority's plan (Saffran, 1998).

In Dallas, Alphonso Jackson, president of the city's Housing Authority
from 1989 to 1996, asked tenants to agree to undergo drug testing as a
condition of living in the special Self Sufficiency Program within
Dallas public housing. He was made a defendant in numerous lawsuits on
the issue filed by the ACLU and legal aid organizations (Jackson, 1998).

The Doe Foundation in New York City, which operates the Ready, Willing
and Able training program, became the target of a similar lawsuit after
it took over a Harlem men's shelter in 1996. The shelter, at the time of
the takeover, was described as a "lawless crack den" (Seigel, 1997). The
foundation began requiring applicants to the shelter to be drug-free as
a condition of acceptance and, once enrolled as trainees, to be drug
tested routinely. In addition, the foundation required that residents
work in street cleaning and house painting operations. Initially, 62
percent of the residents tested positive in scheduled, pre-announced
tests. Nine months later, only two percent were testing positive in
random tests.

In 1997, the Coalition for the Homeless and Legal Aid sued the
foundation. What raised these advocates' ire was the requirement that
residents work as a condition of participation. Even though the programs
pay each participant, the Coalition denounced them as "tools for slave
masters."

These plaintiffs could look for a precedent to a 1995 trial court
opinion by Justice Helen Freedman in Manhattan (Hellman, 1997). She
ruled that residents of public family shelters could not be obligated to
follow rules and regulations such as drug testing, curfews, and job
training.

The fight over drug testing has engaged other public bodies as well. The
ACLU has fought efforts by public high schools to perform random drug
tests on students, even those that would first require consent from
parents. This controversy went all the way to the Supreme Court, which
ruled such policies Constitutionally permissible (American Civil
Liberties Union, 1998).

Despite the challenges, many not-for-profit homeless shelters and
churches require abstinence as a condition of receiving services. As we
have seen, there is even a state-funded methadone clinic, in Baltimore,
that requires patients to be employed and drug-free as a condition of
remaining in the program.

Courts, too, are experimenting with various forms of social contracting.
Over the years, judges have noted that a high percentage of child abuse
and neglect cases involve substance abuse by parents; a 1996 report by
the National Committee to Prevent Child Abuse puts the figure at up to
80 percent (National Committee to Prevent Child Abuse, 1996).
Accordingly, a few cities -- Pensacola, Florida; Kalamazoo, Michigan;
Kansas City, Missouri; Reno, Nevada; and New York City -- have recently
established family drug courts. Though little information is as yet
available on outcomes, these new institutions are notable because they
are determined to use incentives such as child custody, visitation
privileges, and the removal of children from homes as leverage to compel
parents to comply with drug treatment and remain drug free.

Welfare reform legislation, too, has stimulated many states and
localities to revise their procedures for awarding benefits. For
example, Montgomery County, Maryland now denies benefits to applicants
who refuse to undergo drug testing.

With estimates of problem substance abuse among welfare recipients
estimated to be between 15 and 30 percent (though, according to the
Legal Action Center, some states put the figure as high as 50 percent),
the efficiency of surveillance and sanctioning procedures will be put to
the test (Legal Action Center, 1997). Although social services
organizations do not yet capitalize on their built-in potential for
leverage, more will be doing so as the public demands more civic
responsibility from beneficiaries.

# Contingency Management

**\[6\]** *The goal of this technique is to intervene in an addict's
life with an arrangement of environmental consequences -- rewards,
punishments, or both -- to systematically weaken drug use and strengthen
the skills necessary for abstinence. The underlying behavioral theory,
operant conditioning, holds that the act of using drugs can be modified
by its consequences.*

The earliest contingency management (CM) studies were conducted with
alcoholics. Miller and colleagues, for example, examined the question of
whether CM could be used to reduce public drunkenness (Miller, 1975).
They selected 20 alcoholic men from the city jail in Jackson,
Mississippi and randomly assigned them to an experimental or control
group. Men in the experimental group, if they reduced their drinking,
could earn housing, employment, food, and medical care through
co-operating local social service agencies. Men in the control group, by
contrast, received these services whether they were drunk or sober. The
researchers assessed the men's alcohol intake objectively, via breath
alcohol levels or observation of gross intoxication.

Over the course of the two-month study, arrests in the experimental
group decreased by 85 percent. In the control group, they did not
decline at all.

In the past decade, researchers have begun studying CM in depth. Though
sample sizes tend to be small and follow-up limited in duration, the
findings are so consistently promising that CM merits close review.
Stephen Higgins and colleagues at the University of Vermont have
produced a detailed summary of CM studies involving abusers of heroin
and cocaine (Higgins, Tidey and Stitzer, in Graham and Schultz, eds.,
1998); a few representative studies are described below.

Higgins and his colleagues conducted numerous CM trials with cocaine
addicts (Higgins, et al., 1991; Higgins, et al., 1993; Higgins, et al.,
1994). In a 1994 study, 40 patients were randomly assigned to either
ordinary treatment or treatment plus vouchers. The vouchers, assigned a
monetary value and exchangeable for retail items, were awarded on a
schedule of increasing value with each consecutive clean urine sample
submitted; conversely, a cocaine-positive sample would reset the value
of the vouchers at their initial low level.

At the end of 24 weeks, 75 percent of the voucher group remained active,
compared with only 40 percent of the no-voucher group. For the voucher
group, the average duration of continuous cocaine abstinence, documented
by urine tests, was 12 weeks; for the non-voucher group it was six
weeks. At nine and 12 months after entry into the study, self-reported
cocaine use remained significantly lower in the voucher group.

A similar study took place in Baltimore, conducted by Ken Silverman and
colleagues at Johns Hopkins University and involving 37 inner city
methadone maintenance patients who concurrently abused cocaine
(Silverman, et al., 1996). During the 12-week study, all patients
received standard counseling. A group of 19 received vouchers contingent
on cocaine-negative urine tests, while 18 received vouchers on a
schedule linked to that of the experimental group but dispensed
independently of urine test results. The parallel dispensing of vouchers
to the two groups was meant to uncouple the effects of voucher receipt
itself from its meaning as a reward predictably dependent on urine test
results.

At the end of the three-month study, the experimental group had
substantially reduced cocaine use, but the comparison group remained
largely unchanged. About half the patients exposed to the contingent
vouchers had achieved between seven and 12 weeks of continuous
abstinence; by contrast, less than five percent of the control group had
attained as much as three consecutive weeks of abstinence.

Though there was a rebound resumption of drug use after the contingent
vouchers were discontinued, as in most other CM studies, the
experimental group performed significantly better at all stages of
follow-up.

Intensified CM techniques have had results even for subgroups resistant
to voucher incentives. To examine such populations, Silverman and his
colleagues chose a sample of intravenous cocaine-abusing patients, many
of them also HIV-positive, who had failed a standard CM voucher
experiment (Silverman, et al., in Harris, ed., 1996). The researchers
ran these individuals, in randomized order, through three different
nine-week voucher regimes -- one in which the total redeemable value of
vouchers that could be earned was high, one in which it was low, and one
in which it was zero.

The findings were dramatic. Not a single patient in the zero-value
voucher program achieved more than two weeks of abstinence. Only one
person did so in the low-value program. But in the high-value voucher
program, 45 percent attained at least four weeks of sustained abstinence
(Silverman, et al., in Harris, ed., 1996).

The major drawback of these CM studies -- patients' tendency to resume
drug use, albeit at a lower level, when the contract is withdrawn --
also reveals the major potential of CM for entitlement reform. The
backsliding of patients in the studies was probably due in part to the
short duration of these research projects: a mere few months is not
enough time to enable a patient to learn the new skills, secure the
employment, and attain the measure of personal growth needed to live
drug-free. Entitlement reform need not be limited by such constraints.

Jesse Milby of the University of Alabama sought to apply CM in a
situation that approximated real-world conditions (Milby, et al., 1996).
He randomized 176 homeless, crack-addicted individuals to receive
ordinary or enhanced care. Members of the enhanced group, after two
months of daily intensive therapy, were eligible to participate in a
work-therapy program refurbishing condemned housing and, for a modest
rental fee, to live in this housing. Participation was contingent on
submitting twice-weekly clean urine tests.

After six months, this group had achieved significantly greater
improvement in employment status, days of homelessness, and cocaine use
than the usual-care group.

At Seattle's Harborview Medical Center, psychiatrist Richard K. Ries
directs a clinic for mentally ill substance abusers (Reis and Comtois,
forthcoming). Clinic patients are asked to sign over their Supplemental
Security Income checks to the outpatient clinic, which then acts as the
patients' "representative payee," managing bank accounts on their
behalf. The clinic covers rent and other basics. Patients, by complying
with treatment, are allowed to "earn back" discretionary funds and
ultimately, when they demonstrate ability to manage money responsibly,
to control the passbooks to their bank accounts.

Ries and his colleagues compared treatment outcomes between patients in
the incentive program and those attending the clinic as usual. Over a
three-month period, sicker patients were significantly more likely to
attend treatment sessions as their healthier counterparts and were just
as likely to participate in job training sessions and stay out of the
hospital and jail.

Studies such as these suggest that with drug abusing individuals,
manipulating benefits to reinforce positive social behavior could
provide a partial solution to the perverse incentives that entitlements
often provide. Street ethnographers have long known that addicts
routinely purchase drugs with welfare payments and food stamps; more
recent quantitative reports have described a persistent temporal pattern
in which receipt of monthly benefits is linked to increases in emergency
room visits for intoxication and overdoses and in hospitalizations for
psychosis among cocaine-abusing schizophrenics.

Thus the Veterans Administration has instituted a CM project that would
distribute veterans' service-connected benefits contingently to mentally
ill substance abusers (Rosenheck, 1998). Conceivably, federal disability
payments, welfare benefits, and other forms of cash entitlement could be
dispensed in accordance with CM principles.

**CONCLUSION**

**\[7\]** *Coercion has been applied in the service of rehabilitating
addicts for over 70 years. The experience has yielded a powerful
clinical lesson: addicts need not be internally motivated at the outset
of treatment in order to benefit from it. Indeed, addicts who are
legally pressured into treatment may outperform voluntary patients,
because they are likely to stay in treatment longer and are more likely
to graduate. Without formal coercive mechanisms, the treatment system
would not attract many of the most dysfunctional addicts and surely
could not retain them.*

But, though official bodies, especially criminal justice organizations,
are accustomed to wielding such leverage, they do not do so
systematically enough to yield maximum benefit (Taxman and Byrne, 1994;
Langan and Cunniff, 1993). Some judges will forego referral to treatment
altogether if they perceive an offender not to be motivated towards
rehabilitation (Belenko, Nikerson and Rubinstein, 1990). Other judges
express disappointment with the laxity of supervision addicts receive in
treatment, citing failure to follow up with the court, verify patient
participation, and perform drug testing -- the very surveillance
mechanisms that are necessary to retain unmotivated addicts.

**\[8\]** *Ironically, it appears that among current programs, with
their various mixes of treatment and coercion, the treatment component
has relatively less clout than other forces in shaping addicts'
behavior. That is why examples of combining treatment with external
monitoring, such as drug courts, are so encouraging. If more
institutions, like public housing or even disability programs, adopted
principles of contingency management, individuals would be likely to
remain in treatment longer and enjoy greater improvement. Such
behavioral gains would serve both addicts and the communities whose
resources they strain.*

A co-ordinated effort by social service agencies to track and monitor
drug use and enforce consequences for that use will be costly in the
short run. In addition, it will also require the creation of a certain
amount of new bureaucracy. Those facts make coercive strategies
unattractive even to those who are sympathetic to the need for
aggressive intervention. It remains true, however, that as a clinical
strategy, coercion is solidly promising. What is more, increasing our
capacity to leverage addicts into treatment will be important whether we
maintain our present policy of drug prohibition, decide on a policy of
outright legalization, or choose anything in between, since any one of
these policies will depend on drug treatment to rehabilitate addicts.

Addiction impairs participation in a free society. It interferes with
the ability to ensure one's own welfare, respect the safety of others,
and discharge responsibilities as a parent, spouse, worker, neighbor, or
citizen. Addiction is a behavioral condition for which the prescription
of choice is the imposition of reliable consequences and rewards, often
combined with coercion that keeps the addicted individual from fleeing.
To say this is not punitive; it is clinically sound and empirically
justified.

Every day, all people respond to contingencies, incentives, and
consequences. If we do not work, we do not get paid. If rent is not
paid, we are evicted. If children are mistreated, they can be taken
away. Meeting obligations in these circumstances is not the antithesis
of freedom but a prerequisite to it. No less is this true of individuals
with drug problems, though it is our job to structure the contingencies
before them in creative ways to help them regain their freedom. To date,
drug courts offer one of the more creative and effective means of
treating addicts involved in the criminal justice system.

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