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On Substance Abuse Treatment

being a collection of thoughts and supporting materials regarding Substance Abuse, the Treatment process, and other related topics

(Note: I live and work in Kansas. My opinions and references are to the situation as it exists in this state. I am not familiar with the situation in other places.)

In the real world, I am a probation officer. I work in a work-release type correctional facility. We have been providing substance abuse treatment for our clients for over a decade. We’ve ‘known’ for a long time that active substance abusers just simply don’t stay crime-free. Since reducing recidivism, or at least keeping people out of prison, is one of those things we are supposed to be accomplishing, reducing substance abuse seems like a pretty smart thing to do. So we have been providing substance abuse treatment because we believe it is the right thing to do. Current research suggests that what we ‘knew’ to be true as a matter of common sense, has validity. Substance abuse treatment has now become an integral part of our strategy to provide maximally effective, cost-effective correctional supervision in the community. Over the past few years, I’ve had plenty of time to think about the process. I can’t say as how I have any original ideas about it, but I don’t see treatment in traditional terms.

In a lot of respects, the terminology used to discuss treatment defines the treatment. (OK, mabye that’s obvious.) One of the reasons I like the term ‘Substance Abuse’ is that it points out the hypocritical nature of our differing attitudes towards alcohol and drugs in this country. Substance “abuse” (a bad thing) implies that there is such a thing as substance “use” (if not a good thing, then at least a tolerable thing). Clearly this is our societal attitude toward alcohol. We are in the midst of a media blitz encouraging us to ‘drink responsibly.’ There is, however, no government campaign to get folks to smoke dope (or smoke crack or shoot heroin) responsibly. Alcohol use is tolerable, drug use (or at least use of drugs not officially prescribed and therefore a source of corporate profit) is categorically bad. In some other countries, especially in Europe, while the official rhetoric may be that drugs are categorically bad, the issue of drug use is often treated more as a public health problem than as a criminal problem. Proponents of this approach refer to it as a ‘harm reduction’ strategy. (See for example, this ‘position paper’ on drug law enforcement from the Internation Harm Reduction Association.) Dealing with the problem outside the legal system (and thereby not clogging up the legal system with people for whom the primary problem is addiction and not hard core criminality) would seem to be a more practical, cost-effective strategy than what we as a nation are doing now. (Sounds strange coming from a guy who makes a pretty fair living off a clogged up legal system, no?)

Generally, in my work I like terminology to be as blunt and descriptive as possible. Traditional treatment programs usually refer to their clients as ‘addicts’ and ‘alcoholics’. The terms are hard, cold and pointedly stark. In public discourse, the term ‘substance abuser’ is generally used. I’ve heard other, softer euphemisms of various levels of usefulness right down to the classic “Sobriety-Challenged” (generated by people who strive to protect everyone from the stigma associated with derogatory labels — which, if you think about it isn’t really the primary issue if you are looking at doing time in prison).

I think the term ‘substance abuser’ is probably the lesser of the various evils when it comes to this sort of thing. I know softening the language to protect people from stigma is the ‘politically correct’ thing to do, but I much prefer the terms ‘addict’ and ‘alcoholic’ to the softer variations. Addiction is a hard, cold, nasty business which is potentially, and very often literally, a matter of life or death. ‘Sobriety-challenged’ sounds a lot like ‘near-sightedness;’ an inconvenience in an otherwise healthy individual. Unfortunately, the differing legal status of the substances involved contributes to an unbalanced view of the relative undesireablity of being and addict or an alcoholic (i.e. there is less social stigma attached to alcoholism since alcohol is legal).

While this may or may not be a functional viewpoint for society at large, in the correctional arena this distinction is largely irrelevant, as nearly all probationers are prohibited from the consumption of alcohol and non-prescribed drugs. In spite of the prohibition, most alcoholics in the correctional system try to retain the societal bias that alcoholism is somehow less of a problem than drug addiction. (One of the most difficult types of client we get is the individual convicted of multiple DUIs. In genereal they don’t believe they should be in the system, because they aren’t really criminals.) So, while I may prefer the terms ‘addict’ and ‘alcoholic,’ the term ‘substance abuser’ is more functional in our environment. (By the way, I am aware that my use of the term ‘client’ is euphemistic for felon or convict or offender. I admit to the inconsistency. My only excuse is that it is mandated terminology at my work, so its pretty much force of habit.)

Also at issue is the inherent quibbling that goes along with pinning the labels ‘alcoholic’ or ‘addict’ on members of the correctional population. Traditional treatment programs seem to be unable to function if the client won’t admit to their addiction. (Yes, I know that is a gross overgeneralization.) In years past I have seen clients get kicked out of treatment programs because they wouldn’t admit that they were addicts or alcoholics. The amount of time wasted in this process in treatment just doesn’t justify the expenditure of energy. And, frankly, I have philosophical and pragmatic problems with some definitions of addiction. So, it seems more expedient and more honest in a way to be a bit more simplistic about it:
· The Judge said you can’t use alcohol or drugs.
· You did anyway.
· To date, you can’t or won’t quit using alcohol or drugs
· This is a problem that will get you sent to prison.
· We define that problem as ‘Substance Abuse’.
· Therefore, you are a ‘substance abuser’. End of story.
From there we move directly to ‘What are you going to do now.’

I have serious problems with the ‘disease concept’ of addiction. I also have serious problems with 12-step programs. I am not now, nor have I ever been a member of AA, NA, CA or any 12-step program. I don’t know the steps or traditions or much of any details about them. I suspect they work well for persons who are motivated to change and are temperamentally suited to them. That, however, is not a description of our clients. And I am only really interested in what works best for our clients.

There is a significant body of research that says that among the best approaches to getting criminals to change their behavior are programs that fall into the categories of ‘cognitive skills’ and ‘cognitive restructuring.’ The same research shows that these kinds of approaches are effective at changing substance abusers’ behavior. This is hardly surprising, given that the two populations overlap significantly. Research also shows that treatment programs need to target ‘dynamic’ factors. (For a short introduction to these concepts see Offender Rehabilitation by James Bonta. Or, see the work of Andrews, Bonta, Gendreau, Hoge and others, especially “The Psychology of Criminal Conduct” by Andrews and Bonta. [it may be out of print by now]) Traditionally it has been considered crucial to find out how the client got to where they are today. Things like the client’s age of first substance use, the fact that they were beaten as a child are all ‘static’ factors. No amount of effort expended in treatment can change them. Thus, we focus on things that can be changed; beliefs, thoughts, attitudes. Not that static factors can be completely ignored, but spending an inordinate amount of time discussing them tends to reinforce a client’s self-pity, belief that they are a victim and that their addiction is not their fault. As opposed to ‘How did you get here?’ our emphasis is on ‘What are you going to do now?’

One of the biggest problems we face is that a great many people out in the real world believe that substance abuse is purely and simply an issue of will. As I understand it, that was one of the issues that caused AA to be as it is: the idea that being an alcoholic was a bigger issue than just simply being weak and spineless and that the ideas behind AA were, in part, a way to get past the stigma and move on to doing something about the problem. From there, we get to the ‘disease concept.’

My personal philosophical problems with the ‘disease concept’ of addiction are relatively minor compared to the practical problems the concept introduces into the correctional arena. The idea that alcoholism (and drug addiction) is a disease has been around long enough that it has worked its way into the popular cultural vocabulary. There are very few corrections professionals who will (openly, at least) dispute the disease nature of addiction. However, this begs the question of what we mean by ‘disease.’ I believe that when persons in the treatment community use the term ‘disease’ they are referring to an ongoing medical condition in much the same way the diabetes and epilepsy are diseases: controllable but not curable. Unfortunately, it appears to me (and keep in mind that this is my perception and I don’t have any proof of this) that most people (including most corrections professionals) who are not actively involved in substance abuse treatment hear the term ‘disease’ and immediately think of something like pneumonia: nasty but curable.

In the world of corrections this has profound consequences. It leads to situations where judges and probation and parole officers conclude that if a criminal has been to treatment they should be cured, and any further substance use on their part indicates willful violation of the conditions of parole or probation and should legitimately be punished with incarceration. So instead of going to additional or ongoing treatment, the criminal ends up in prison.

At the same time, in our quest to save money and be more ‘efficient’ (and believe me, if there was a way to paint sarcasm onto a web page it would be all over the word ‘efficient’) we have reduced the amount of money available to fund treatment programs and introduced a state-funded managed care system where ‘professionals’ screen clients and determine, in advance, how much treatment they need. (Actually, what they determine is how much treatment the State will pay for.) When I started in corrections 20+ years ago my clients could get into reasonably available publicly funded in-patient treatment programs of up to 90 days and it was not uncommon for their stays to be extended an additional 30 days or so. Now, ‘in-patient’ treatment is ‘up to’ (I need that sarcasm paint brush again) 7 days, after which time the client is moved to ‘reintegration’ (which means they go live in a dorm and get to get a job and pay rent). The whole system appears to amount to little more than detox and a sort of vaguely supervised living environment. That I think this is an unacceptable waste of money should be obvious. But that the Federal Government suggests the same is, I think, significant:

(from the National Institute on Drug Abuse’s publication Principles of Drug Addiction Treatment:
Individuals progress through drug addiction treatment at various speeds, so there is no predetermined length of treatment. However, research has shown unequivocally that good outcomes are contingent on adequate lengths of treatment. Generally, for residential or outpatient treatment, participation for less than 90 days is of limited or no effectiveness, and treatments lasting significantly longer often are indicated…

Successful outcomes may require more than one treatment experience. Many addicted individuals have multiple episodes of treatment, often with a cumulative impact.

(As a side issue, there is evidence from Britain that detox with no follow-up may in fact be inherently dangerous. And, no, I’m not saying that the programs in Britain described in the study are exactly like what we have here. But I don’t think it is a stretch to say that the sort of short-term one-shot-and-you’re-cured approach we seem to be moving toward isn’t the best idea we’ve ever had.)

Blunt and to the point: In corrections, we expect to send our clients to treatment once and have them cured. At the same time, publicly available treatment options have been reduced in length and intensity. It shouldn’t take a genius to put 2 and 2 together and come up with a viable explanation as to why a significant number of probation revocations in recent years were because the clients ‘relapsed’.

Where is this headed? I don’t know for sure. I do know that if we want to impact the number of clients sent to prison on probation violations, effective substance abuse treatment is a necessity. I also know that at least some of the powers that be in Topeka agree with my assessment of the situation (the part about needing effective treatment for offenders. I wouldn’t presume to think anyone else would agree with the rest of what I’ve said). Strangely enough, they seem to have come to this conclusion because of the State’s current budget crisis. Apparently they believe the cost of long-term treatment for offenders (from the fiscal notes for Senate Bill 123) would be significantly less than sending the offenders to prison (partly because the cell space for the projected prison population in the next couple of years doesn’t exist and would have to be built). We will see how Senate Bill 123 plays out once it goes into effect.

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