on coercion
TRANSCRIPT
International Journal of Drug Policy 16 (2005) 207–209
Editorial
On coercion
Coercion is controversial. The idea of using the legalsystem to get drug users into treatment tends to polarisedebate between those who present it as a solution to drug-related crime, and others who see it as an abuse of humanrights and of the relationship between client and therapist.Protagonists in this debate tend to talk past each other,with their different emphases on crime and civil liberties.In this editorial, we attempt to test these arguments, inthe hope of moving the debate beyond mutual incompre-hension. Our discussion builds on work we have done forthe QCT Europe project, a six-country study of the use ofquasi-compulsory treatment for drug-dependent offenders(seewww.kent.ac.uk/eiss/projects/qct-europe/).
We focus on three areas: the nature of coercion in drugttouthtmBfi
It may necessitate or ignore the consent of the individual toenter treatment. These differences are crucial. Where coer-cion is applied simply for drug use, this constraint on freedomexaggerates a prohibition that is already morally problem-atic. This problem recedes for people who have committedother crimes and are already at risk of losing their liberty. Butan important distinction remains between compulsory andquasi-compulsory treatment. In the first case, offenders maybe sentenced to treatment without their consent. Arrange-ments for this exist in Austria, Germany and the Netherlands.It may be better to call these arrangements compulsory place-ment in treatment, as they provide only for people to be sentto treatment centres, where the usual treatment involves dis-cussion. It is impossible to force people to engage fully in
, theas an
entlegal
ugttishAus-tems
reatment, human rights, and the role of coercion in attemptso reduce health and criminal harm. We argue that the elementf constrained choice in quasi-compulsory treatment for drugsing offenders is an important difference from compulsory
reatment for drug users. The former can be consistent withuman rights, whereas compulsory treatment is more likely
o breach them. Finally, we suggest that coerced drug treat-ent alone will not solve the problem of drug-related crime.y focusing resources on coercion, we risk diverting them
talking treatment. In quasi-compulsory treatment (QCT)offending drug user has the choice to enter treatmentalternative to another sentence, often imprisonment.
Arrangements for QCT vary widely. There are differtarget groups, treatment philosophies, approaches andeligibility criteria for United States, Irish and Australian drcourts, English Drug Rehabilitation Requirements, ScoDrug Treatment and Testing Orders and German, Swiss,trian, Dutch and Italian arrangements for QCT. These sys
rom other measures that may be more effective in improv-ng health and reducing crime.
hingnst. Todycanhenthat
rentilies
oksxt ofore,
h has
tioner-imeces.
can also differ greatly between states, towns or regions of thesame country. A major difference between US drug courtsand most QCT systems in Europe is that people with previ-o allye nt inm ther-l fend-e idee A,o sub-sa ith itsi ofv tate.I onlyu carep den-t on.I siser
d.
us criminal and drug possession convictions are formxcluded from treatment as an alternative to imprisonmeany US states, whereas QCT in England and the Ne
ands is specifically targeted at persistent drug-related ofrs, and is available to offenders who fall within a wligibility range in other European countries. In the USnly 39% of drug courts provided access to methadonetitution treatment in 1999 (Peyton & Gossweiler, 2001),nd the widespread emphasis on 12-step treatment, w
nvolvement of a ‘higher power’, has lead to criticismsiolating the constitutional separation of Church and sn England, opiate substitution treatment is more commsed, and much of the treatment is delivered through dayrogrammes. In Switzerland, Austria and Germany resi
ial placement in therapeutic communities is more commn the Netherlands low threshold facilities, which emphae-integration over therapy, are also used for QCT.
Coercion usually means forcing someone to do sometagainst their will. This everyday definition immediately ruinto problems when applied to drug users and treatmenwhat extent is the will of problematic drug users alreacompromised by their compulsion to use drugs? Howsomeone be forced to engage in treatment, especially wthat treatment includes honest talking? It may be arguedusing the law to coerce people into treatment is no diffethan the pressures that are put on drug users by their famand friends to seek help for their problems. This overlothe vital difference between pressure exerted in the conteintimate relationships, which the person can choose to ignand the impersonal pressure exerted by the state, whicagencies to deal with those who try to avoid it.
The potential for confusion is aggravated by the conflaof different kinds of legal compulsion in discussions of cocion. The law may be applied to people whose only cris drug use, or to those who have committed other offen
0955-3959/$ – see front matter © 2005 Elsevier B.V. All rights reservedoi:10.1016/j.drugpo.2005.04.004
208 Editorial / International Journal of Drug Policy 16 (2005) 207–209
Human rights issues in coerced treatment are distinct forcompulsory and quasi-compulsory treatment. Punishment forcrime is not against human rights (with restrictions of course),but enforced treatment is another matter. Treatment for drugdependence is only consistent with human rights when theperson gives their informed consent. This holds for any kindof therapy, and especially for pharmacological interventions.Doctors cannot administer treatment to an unwilling patient,unless it is proved that the patient is unfit to give informedconsent or that he or she presents so great a danger to them-selves and others that their liberty must be restricted. This hasnot been done in the case of problematic drug users who havenot been convicted of other crimes, although there have beensystems for civil commitment of drug users to treatment inthe USA and Sweden. Such systems are of questionable con-stitutionality (Rosenthal, 1988) and efficacy, and have beenpresented as a case study of how not to approach drug prob-lems (Inciardi, 1988). As Melissa Bull notes (in this issue),informed consent is a key element of good practice in diver-sion from imprisonment internationally (Bull, 2005).
QCT for offenders may be a constrained choice betweenentering treatment and another punishment, but it can still beconsidered to be an informed choice. The other punishment,which they face as an alternative to treatment, has alreadybeen justified by the person’s offence. The option of no pun-ishment and no loss of freedom is not on the table. So QCTc stric-t tivei theyo iated,r
manr it-t tment otherc tiono ivatel ss ofwC s,f hasn bilityt of theo erep enttP con-d putf1
t ofe onlyb eat-m pensu treat-m ct
the results of QCT across wide groups of offenders, let alonefor individuals, which makes the ethical argument more com-plex. It does mean that we can reject some arguments, suchas the suggestion that “the appropriate use of coercion mayincrease a client’s readiness for treatment” and so create bet-ter outcomes, even “as treatment lengths shrink and resourcesfor treatment dwindle” (Gregoire & Burke, 2004). Coercedtreatment is no substitute for high quality, easily accessi-ble treatment. Overall, drug treatment has been shown to beeffective in reducing health and criminal harms (Prendergast,Podus, Chang, & Urada, 2002). There is emerging evidencethat clients referred by the criminal justice system may be lesslikely to stay in treatment (Millar, Donmall, & Jones, 2004;Schalast, 2000), although the quality and characteristics ofthe treatment itself appear to be the strongest predictors forretaining and helping drug users (Fiorentine, Nakashima, &Anglin, 1999).
Increasing the range of coercive measures may have unin-tended, negative effects on the wider treatment system (Hunt& Stevens, 2004; Parker, 2004). Given our current state ofknowledge on ethics and effectiveness, we should not expandcoercion to the neglect of the creation and maintenance ofhigh quality drug treatment services that are open to all whoneed them. QCT is more likely to have a valid role whensuch services are already in place. In this situation (which ismuch closer to reality in countries such as Switzerland andt ereda seekt whos
rugt dc or-i whoc tive-n rug-d tmentp blemsa loy-m ltha even-t sedo tancef
A
byt andD 002-0 akent f ourp con-t d ourt
an be seen as an opportunity to substitute one form of reion of liberty for another, less palatable one. In qualitanterviews that we have done with people entering QCT,ften describe it as an opportunity that they have apprecather than as an imposition.
This is not to say that QCT is always consistent with huights. A recent report of the UK Parliament Joint Commee on Human Rights argues that extending coerced treao people who have not been charged or convicted ofrimes risks breaking Article 8 of the European Convenn Human Rights, which guarantees the right to a pr
ife, and includes the right to refuse treatment, regardlehether that refusal is in the best interests of the patient (Jointommittee on Human Rights, 2004). There are also case
or example in the US drug court system, where QCTot been based on due legal process (including the a
o contest charges, with adequate legal representation,riginal crime or of subsequent treatment failure), or wharticipants face harsher punishment for failing treatm
han they would have done for the original crime (Burns &eyrot, 2003). The treatment of these cases breaks theitions for QCT to respect human rights that have been
orward by the World Health Organization and others (Gostin,991; Hall, 1997; Porter, Arif, & Curran, 1986).
Both Hall and Gostin link the question of ethics to thaffectiveness. They suggest that coercive treatment cane justified if it is warranted by the outcomes of the trent in reducing harm to the person and to others. This op the unresolved debate about the effects of coercedent (seeStevens et al., 2005). We cannot reliably predi
t
he Netherlands than the UK and USA), QCT can be offs an opportunity to people who would otherwise not
reatment, without interfering with the treatment of thoseeek it voluntarily.
Finally, we should not look to coerced treatment (or dreatment generally) to providethe answer to drug-relaterime. It is at best a partial answer. It will reach only a minty of offenders (i.e. those who have drug problems andan be retained in treatment), and the long-term effecess of QCT with even this group is unproven. Those dependent persistent offenders targeted by coerced trearogrammes also experience a range of inter-related prossociated with housing, mental health, literacy, empent, social skills and family relationships. A public heapproach would emphasise primary and secondary pr
ion of both health and criminal harms. It would not be ban coercion, but on expanding opportunities and assis
or all to lead healthy and productive lives.
cknowledgements
Our work on the QCT Europe project is fundedhe European Commission’s Fifth Framework Researchevelopment programme (contract number QLG4-CT-21446). The views expressed in this article cannot be t
o reflect the views of the European Commission, nor oartners in this project (although we acknowledge their
ribution to research and discussions that have informehinking).
Editorial / International Journal of Drug Policy 16 (2005) 207–209 209
References
Bull, M. (2005). What comes first good policy or best practice? The rela-tionship between guidelines for the diversion of drug related offendersfrom the criminal justice system and the research literature.Interna-tional Journal of Drug Policy, 16(4), 223–234.
Burns, S. L., & Peyrot, M. (2003). Tough love: Nurturing and coercingresponsibility and recovery in California drug courts.Social Problems,50(3), 416–438.
Fiorentine, R., Nakashima, J., & Anglin, M. D. (1999). Client engagementwith drug treatment.Journal of Substance Abuse Treatment, 17(3),199–206.
Gostin, L. O. (1991). Compulsory treatment for drug-dependent persons:Justifications for a public health approach to drug dependency.TheMilbank Quarterly, 69(4), 561–593.
Gregoire, T. K., & Burke, A. C. (2004). The relationship of legal coercionto readiness to change among adults with alcohol and other drugproblems.Journal of Substance Abuse Treatment, 26, 337–343.
Hall, W. (1997). The role of legal coercion in the treatment of offend-ers with alcohol and heroin problems.Australian and New ZealandJournal of Criminology, 30(2), 103–120.
Hunt, N., & Stevens, A. (2004). Whose harm? Harm and the shift fromhealth to coercion in UK drug policy.Social Policy & Society, 3(4),333–342.
Inciardi, J. A. (1988). Compulsory treatment in New York: A brief narra-tive history of misjudgement, mismanagement, and misrepresentation.Journal of Drug Issues, 18(4), 547–560.
Joint Committee On Human Rights. (2004).Seventh report: Drugs bill.London: UK Parliament.
Millar, T., Donmall, M., & Jones, A. (2004).Treatment effectiveness:mentor
P omesliver?
P grvey,ce,Sub-r for
umanealth
P ofisting
Prendergast, M. L., Podus, D., Chang, E., & Urada, D. (2002).The effectiveness of drug abuse treatment: A meta-analysis ofcomparison group studies.Drug and Alcohol Dependence, 67(1),53–72.
Rosenthal, M. P. (1988). The constitutionality of involuntary civil com-mitment of opiate addicts.Journal of Drug Issues, 18(4), 641–661.
Schalast, R. (2000). Ruckfalle wahrend der Behandlung im Maßregelvol-lzug gemaߧ 64 StGB.Sucht—Zeitschrift f¨ur Wissenschaft und Praxis,46(2).
Stevens, A., Berto, D., Heckmann, W., Kerschl, V., Oeuvray, K., vanOoyen, M., et al. (2005). Quasi-compulsory treatment of drug depen-dent offenders: An international literature review.Substance Use &Misuse, 40, 269–283.
Alex Stevens∗School of Social Policy, Sociology and Social Research
European Institute of Social Services, University of KentKeynes College, Canterbury CT2 7NP, UK
E-mail address:[email protected]
Tim McSweeneyInstitute for Criminal Policy Research, King’s College
London, Strand, London WC2R 2LS, UKTel.: +44 207 848 1757; fax: +44 207 848 1770
E-mail address:[email protected]
Marianne van OoyenWODC, Ministry of Justice, P.O. Box 20301
ds5l
nngd6h
3046
Demonstration analysis of treatment surveillance data about treatcompletion and retention. London: National Treatment Agency fSubstance Misuse.
arker, H. (2004). The new drugs interventions industry: What outccan drugs/criminal justice treatment programmes realistically deProbation Journal, 51(4), 379–386.
eyton, E. A., & Gossweiler, R. (2001).Treatment services in adult drucourts: Report on the 1999 National Drug Court Treatment SuExecutive Summary.Washington, DC: Drug Courts Program OffiOffice of Justice Programs, US Department of Justice, and thestance Abuse and Mental Health Services Administration, CenteSubstance Abuse Treatment, US Department of Health and HServices (US Department of Justice and US Department of Hand Human Services).
orter, L., Arif, A., & Curran, W. J. (1986).The law and treatmentdrug and alcohol dependent persons—A comparative study of exlegislation. World Health Organisation.
EH 2500 The Hague, The NetherlanTel.: +31 70 386159
E-mail address:[email protected]
Ambros UchtenhageInstitut fur Sucht – und Gesundheitsforschu
CH 8031 Zurich, SwitzerlanTel.: +41 1448 11 6
E-mail address:[email protected]
∗ Corresponding author. Tel.: +44 1227 827fax: +44 1227 827 24
8 March 2005