Right Arguments, Wrong Audience
The addiction treatment industry just can't quit coercion. Mandated (forced) treatment is a staple topic here because the industry relies on it, both financially (guaranteed revenue) and politically (offering a "more humane alternative" to incarceration).
Today I'm looking at arguments against mandated treatment, specifically in context of the July executive order seeking to loosen standards for involuntary long-term commitment. The order explicitly aims to remove people from public space indefinitely because their (supposed) mental illnesses or addictions cause "crime and disorder." (See this earlier post for more on the order and its rationale.)
Rosalie Genova
So far, I hear two primary arguments against the order as pertaining to substance use, and both are right:
1) Mandated treatment rarely achieves its intended effect (patients stopping or reducing substance use), and increases risk of accidental overdose. People forced into treatment typically continue using--we shouldn't even call it "relapse" when someone never intentionally quit in the first place--and overdose becomes more likely when one's drug tolerance is lower due to a period of (forced) abstinence.
2) Our current substance use treatment infrastructure is already over capacity. Many people who want and voluntarily seek treatment are unable to access it. Shouldn't we solve that problem first, before trying to force anyone in? Where would we even find the space for all these new involuntary patients?
Who Is Listening
The right audience for these arguments: the treatment industry's well-intentioned true believers. I know these people exist because I used to be one of them. Many dedicated providers, affected friends and family, and people with lived experience– and remember these are overlapping groups– have a rigid understanding of what people with addictions need that is not ignorant or uninformed:
Rosalie Genova
True believers see coercion as regrettable, but sometimes necessary, to help people in active addiction begin to think clearly and regain control of their lives. In other words, taking away someone's autonomy to initiate treatment will actually restore their autonomy long-term. I am not claiming that this approach makes sense, but it really can come from good faith (and lived experience). Regarding Argument 1 above, misunderstandings on coercion can be corrected for those willing to learn. As to Argument 2, lack of capacity for quality treatment is already unacceptable to true believers. They especially object to someone who wants to enroll in treatment having to wait because a program is over-full with forced patients.
Who Isn't Listening
Most of the public, however, is not impassioned about substance use issues. They are not necessarily interested in the topic at all. They are worried about "crime and disorder," and often sad/confused/angry about addiction and overdose. They want these problems solved, but they are not watching closely to see how solutions are implemented.
Because the current treatment system is already so mandate-heavy, the vision of this executive order is a difference in degree but not in kind. This means logics that support our current practices can easily extend to support expanded involuntary commitment--doubling down on the current approach, which "works" in ways that have nothing to do with patient care.
So to be cynical, here's how I think the above 2 arguments will usually land:
1) People with addictions may not benefit from forced treatment, but they'll be out of sight, and we can say we tried. If they continue using substances or overdose, they can be blamed for not making use of the "help" they were offered. Patients' long-term benefit has never been the goal at an institutional level anyway--which is why we have no outcome data for most treatment programs today.
2) We always find more room to put people away. Capacity for meaningful treatment may be limited, but overcrowding and understaffing are already accepted (and good for the budget) in existing programs. And if the real objective is simply to lock people up, new facilities are popping up for that purpose all the time. If lots of new "treatment centers" open to accommodate patients swept off the streets, most of us will be content not knowing the conditions inside.
So what is the right argument, for a general audience, against the order to confine people indefinitely in so-called addiction treatment? Ideas are welcome! So far all I can think of is cost. However, cost arguments are also on the side of harm reduction, and that cause is losing ground on many fronts right now.
I hope to see more true believers turn into loud apostates.
