Out there in therapyville earnest clinicians have long been working hard to explain why treatment so rarely works. Following Freud and others they have lit on the notion that people who do not get better do not really want to get better. Or else, that they do not want to get better badly enough.
For this and other reasons, the question of involuntary commitment and involuntary treatment for psychosis has haunted the profession.
Ever since civil libertarians persuaded politicians and courts that psychiatric patients had the right to refuse treatment and to be sent on their way with a prescription for medication that was largely effective but was largely ineffective for those who refused to take it, the mentally ill have come to inhabit America’s streets and back alleys.
As I noted on my blog, many of those who engage in murderous rampages, whether in Aurora, CO or Sandy Hook, CT were examined by mental health professionals. Said professionals often wanted the patients to be committed involuntarily. Yet, patients did not want to be treated and certainly did not want to be committed, so the system had little choice but to let them go free.
Catastrophes ensued.
Now, Dr. Sally Satel and Kevin Sabet address the issue in a Wall Street Journal essay. They argue that forcing addicts into treatment does not diminish the effectiveness of treatment, but improves it.
The authors describe the treatment offered:
Patients received drug treatment, job training and education with transition services. Upon release, they were to spend up to five additional years being closely monitored and undergoing weekly urine toxicology tests.
As for the larger question, they explain:
Popular opinion holds that an addict cannot be helped until he or she wants to quit, and there is overwhelming agreement among experts that it is preferable for people to choose to enter care rather than be forced into it. But research has borne out the conclusion of a 1990 Institute of Medicine report that “criminal justice pressure does not seem to vitiate treatment effectiveness, and it probably improves retention.”
So, addicts rarely want to be treated. Left to their own will, they often drop out of treatment.
Most people who are addicted do not want to enter a treatment program. Data from the federal Substance Abuse and Mental Health Services Administration show that in 2022, a staggering 94.8% of people with a drug or alcohol use disorder within the past year “did not seek treatment and did not think they should get treatment.” Those who do voluntarily enter treatment usually don’t complete it. About one-third of voluntary patients drop out of treatment before completion, according to government data. Other studies show that up to 80% leave by the end of the first year. Among dropouts, relapse within a year is the rule.
If we were to allow addicts to choose or not to choose treatment nearly none of them would do so. Compared to those who were forced to continue treatment, those who dropped out often relapsed:
A natural experiment was born, allowing researchers to compare people who finished treatment with those who were inadvertently released. After reviewing records and interviewing almost 1,000 “out of control” heroin-addicted participants, the researchers found that, seven years after admission to the program, participants who were prematurely released went back to using heroin at more than twice the rate of those who completed 18 months of compulsory residential care.
Satel and Sabet argue persuasively for compulsory treatment.
Compulsory treatment offers a chance to rescue people earlier in their “careers” of drug addiction, when intervention can produce greater lifetime benefits. And mandated care can ensure that people remain in treatment and don’t drop out, which is consistently shown to be one of the best predictors of a successful outcome. The longer participants stay in care, the more likely they are to internalize the values and goals of recovery.
They add that addiction is less a disease and more a behavior. The point is worth emphasis:
Some critics say that compelling treatment for addiction is unethical because addiction is a disease. But it is not a classic, involuntary illness; it is a behavior that entails choice and responds to consequences. An approach known as “contingency management” offers people undergoing drug treatment a positive incentive by offering small rewards for meeting expectations; for instance, a negative drug test might earn movie tickets or gift cards.
Evidently, drug addiction is pervasive. Apparently, we do not have any ready fixes to it. And yet, we now know that involuntary treatment works, but that letting addicts decide on their own whether to undertake or to complete treatment, does not.
No one’s civil liberties are respected or enhanced by fostering drug addiction.
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