Yes, Treatment, But…

Yes, Treatment, But…

Follow these links for the other articles in this forum: the original article by Michael Massing, and reponses by Peter Kornbluh andMike Gray–and Massing’s concluding thoughts.


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 legalization 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 multilayered approach; we need better treatment, more harm-reduction programs, selective decriminalization, 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 centers, 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 I 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” Gen. 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.” But let’s also insist on closing the equally consequential gap between the crummy reality of too much of the treatment we now have and the treatment we could have if we took treatment and its clients more seriously. And let’s insist on better living standards for the urban and rural dispossessed, so that we can truly reduce the demand for hard drugs–and the need for treatment–over the long haul.

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