Yes,
Treatment, But . . .
Elliott
Currie
ref:
October 99 Heroinsight
ELLIOTT
CURRIE is a criminologist at the Center for the
Study of Law and Society at the University of California,
Berkeley. His most recent book is Crime and Punishment
in America (Herry Holt).
Michael
Massing has written thoughtfully about the follies
of American drug policy in the past, and I'm sympathetic
to many things he says in this piece. It's true
that progressives have often been unhappily divided
over what to do about drugs, and that there has
been an inadequate appreciation of the costs of
drug abuse itself as opposed to the costs of the
drug war among some on the left. And certainly,
like most people I know, I think we need to shift
toward more treatment and prevention, less incarceration
and interdiction. But I find Massing's argument
here less than convincing as a manifesto for a progressive
drug policy, for a number of reasons.
One
is the tendency to treat the several `main schools'
of drug reform as if they were mutually exclusive,
and in the process to caricature them. Since I'm
probably one of those Massing has in mind when he
talks about the `root causes' school (I'm delighted,
by the way, to think that there's a whole school
of us out there), I'll focus on that, though I think
the problem also applies to his discussion of legalisation
and harm reduction.
There's
more than a little straw-manning here; adherents
of the `root-causes school' are said to believe
that we must `first' deal with poverty and other
social ills before we can do anything else about
drugs, and then are accordingly dismissed as politically
quixotic. But nobody I know actually says that.
Certainly I don't. When I wrote a book about drugs
a few years ago, I said we need a multi-layered
approach; we need better treatment, more harm-reduction
programs, selective decriminalisation, more creative
adolescent prevention efforts and much more all
in the context of a broader `strategy of inclusion'
that would systematically tackle the misery and
hopelessness that, as study after study shows, has
bred the worst drug abuse in America and elsewhere.
That strategy involves investing in, among other
things, family support centres, apprenticeship programs,
paid family leaves, high-quality childcare and a
lot else.
I
didn't say we should provide these things instead
of drug treatment, and I don't know anyone who has.
For the life of me, I can't fathom how this amounts
to a `prescription for paralysis.' I'm frankly mystified
by the argument that says we should talk about drug
treatment rather than job training or a decent housing
policy or family support. (Nor, for that matter,
is it really clear that massive investment in treatment
facilities is more politically feasible than, say,
investment in better school-to-work programs.) why
not acknowledge that we need to move on all of these
fronts in a comprehensive attack on drug abuse?
Massing's
answer is, in part, that doing so would take us
beyond the purview of `drug policy.' Yep, it would;
that's precisely why we need to do it. To say we
can successfully attack the drug problem through
`drug policy' alone is like saying we can solve
the illness problem through the healthcare system
alone which we increasingly understand is the wrong
way to think about health and illness. Or like saying
that we can eliminate crime through the criminal
justice system alone, which has helped to give us
the biggest prison system in the world. It isn't,
after all, differences in the availability of treatment
that account for the wide differences in chronic
hard-drug abuse between countries why, for example,
crack utterly devastated inner cities in the United
States but had a far more muted impact in other
industrial countries like Canada, Australia and
the Netherlands.
So
rather than counterposing separate `schools' of
reform, we ought to be crafting an approach to drugs
that operates on several levels at once. In that
approach, of course, treatment should have a very
important place. But we need to think about treatment
more critically than Massing does.
It's
true that drug treatment was unfairly maligned for
a long time; it's also true that the public treatment
system is sorely underfunded in many places. But
that doesn't mean that throwing money at the existing
treatment system amounts to a progressive drug policy.
As it stands, the treatment available ranges from
the highly effective to the utterly bogus. It needs
to be reformed as well as expanded, and reformed
in ways that make it more user-friendly for those
who need help and more capable of addressing the
complex social needs that addicts bring to treatment.
Drug
treatment does indeed work under some conditions,
but it works much better for some people than for
others. Great numbers of addicts, moreover, including
many of those with the most serious problems, never
go into treatment at all not because no treatment
exists but because they don't want it. Of those
who do go, great numbers drop out, especially in
the `therapeutic community' programs, which often
boast, on the surface, the best records of success
(this tends to inflate our assessments of the effectiveness
of treatment, which are typically based on the fraction
of addicts who not only enter it but actually complete
it). Nor is this lack of enthusiasm mysterious:
Much of what passes for treatment today is woefully
inadequate at best and deeply alienating at worst.
It's often worst of all for women and the young.
I used to work in a drug treatment program. Some
of the `treatment' I saw I wouldn't wish on anybody
nor would spend a dime of the public's money to
buy more of it.
Treatment
works best when it's linked to broader efforts to
improve addicts' lives. And that suggests, again.
why it's so unhelpful to separate treatment from
social intervention from `root causes.' Over and
over again, the research on treatment tells us that
what makes long-run success likely is the realistic
opportunity for a better and more stable life: a
steady job, a family, a home, a future. Without
that, treatment is all too often a revolving door.
So treatment programs need to be linked to job training
and placement, to family support, to housing advocacy.
The best programs do this now, and in these comprehensive
programs it's very difficult to define where `treatment'
leaves off and intervention into `root causes' begins.
What
progressives ought to be supporting, in short, is
not `treatment' but those models of treatment that
really work to change addicts' prospects over the
long haul, and that embody humane values that we
can wholeheartedly support. My guess is that Massing
wouldn't disagree with that, but if I'm right, I
wish he'd say so. And I think these caveats are
especially crucial now, because we've seen a significant
turn toward treatment in the past few years. The
quick spread of treatment-oriented drug courts is
probably the biggest piece of that shift, but there
is also the remarkable Arizona initiative, which
substitutes treatment for prison sentences for low-level
offenders. Even `drug czar' General Barry McCaffrey
now says we should invest more in treatment. But
the new acceptance of treatment has rarely been
backed by much concern for whether the programs
we're offering are any good, and if so, for whom.
So
let us, by all means, work to close the `treatment
gap.'
