By Susan Collins

When big cities struggle with visible addiction, one solution that inevitably resurfaces is forcing people into treatment. In 2019’s “Seattle Is Dying,” locking people up for public drug use on an abandoned prison island was pitched as “an answer waiting for the right question.” And lawmakers across the nation are echoing this call. Forcing people into facilities where they can “get the help they won’t get themselves” seems to offer a mix of toughness, benevolence, and moral imperative that garners mass appeal.

I am not a politician or a pundit. I am seven years sober and have spent 30 years working in addiction treatment and research. Within my family and during my workday, I see that communities need safety, and people need more support. The status quo is unacceptable.

But “forced treatment,” also known as involuntary treatment, should remain an option of last resort, used only in extreme cases of grave disability or imminent harm to self or others. That is the position of the organizations clinicians look to for guidance, including Substance Abuse and Mental Health Services Administration (SAMHSA), the American Psychiatric Association, the UN, and the WHO.

That’s why Dr. Keith Humphrey’s New York Times op-ed, in which he asserts, “Forced treatment isn’t horrific. It’s a relief,” shocked me and many of my colleagues. Words matter. When echoed by lawmakers, they shape policy and public perception. And the public relies on experts to present the science carefully, especially when people are at their most vulnerable.

In his piece, Humphreys conflates various forms of “pressure” to get people into treatment, suggesting that there is little difference between involuntary treatment, “pressure” from friends and family, and mandated treatment imposed by a court. We need to be clear: Involuntary treatment, which some politicians and advocacy groups in Seattle have expressed interest in expanding, is not the same as these other, less coercive methods. Unfortunately, confusion around these concepts is being repeated by other scientists and journalists as well.

In the US, involuntary treatment is civil commitment, without consent, to treatment in a locked facility. Mandated treatment is different. It entails choices, albeit difficult ones, to engage in treatment and other milestones to avoid penalties, like incarceration or loss of child custody. Both involuntary treatment and mandated treatment are formal means of coercion. Neither is the same as “pressure” from family members. Blurring these types of coercion—as Humphreys’ op/ed did—confuses the science, makes it harder to make rational decisions about public policy, and takes the larger conversation off track.

Another unhelpful trope is that internal motivation to stop harmful alcohol and drug use is “rare” among people actively using substances. At least half of Americans with significant drug and alcohol problems have internal motivation so high they recover without formal treatment, much less “forced treatment.” Motivation is also dynamic; one-fifth of those who appear to have low motivation achieve recovery within months. Even brief voluntary interventions can strengthen motivation and spark change. In our own work with people with severe alcohol use disorder, internal motivation was surprisingly high and more strongly predicted positive outcomes than treatment attendance.

Humphreys also makes sizeable mistakes in quoting and interpreting the research on the efficacy of involuntary treatment and introduces red herrings around ideal comparison groups that obfuscate the scientific realities. For example, Humphreys’ desired “no treatment” control conditions are often not ethically viable and even cruel in the context of a randomized controlled trial in which people are experiencing severe symptoms. Arguably, voluntary treatment control conditions are more accurate “real world” comparison groups in randomized controlled trials because they represent the “system as usual” offerings – even with their gaps and problems.

When civil liberties are at stake, scientists cannot be careless. Fortunately, some colleagues have been meaningfully pushing back because the public deserves accurate information about involuntary treatment and its effects.

Decades of research on involuntary treatment are strikingly consistent and negative:

• After careful review of involuntary treatment studies, none show definitively positive findings— they’re only null or negative.
• A concerning number of studies show patients experience severe harms after involuntary treatment—including high rates of relapse, re-arrest, and overdose death after release.
• The larger research landscape reveals a gradient in which less coercive treatments are less harmful and more effective in creating safe, sustainable change than more coercive treatments.

Confident about this clear evidence, I was recently asked to share it with an audience that included state lawmakers. I assumed we would be on the same page. We weren’t. Upon reflection, I wondered if high-level research data fails to respond to the felt need for on-the-ground solutions in one’s own community. There is an understandable urgency to do something.

Our sense of urgency should open doors to more voluntary, evidence-based solutions, not more coercion. But many find those doors are locked or hard to locate. My well-resourced colleague had to send her child out of state for timely treatment. In my own clinic, administrative rules and bottlenecks block people from directly seeking care with me. And colleagues across the US have shared that treatment for substance use disorders is never made a priority, “because it doesn’t make money.”

So, from the research and my own clinical experience, I know the system isn’t working. Fortunately, decades of research and listening to people who use substances have generated evidence-based, voluntary solutions that are consistent with SAMHSA’s recovery framework. These must be funded and supported:

• Lower-barrier and community-based efforts—hotlines, self-help books, mHealth, mutual-help groups (12-step and SMART Recovery, among others), harm-reduction outreach and support—can help people curb harm and build recovery while staying in their communities.
• Justice-system diversion and sustained case management helps people experiencing homelessness move toward permanent supportive housing, recovery support, treatment, and jobs.
• Voluntary, evidence-based treatments for alcohol and substance use should be supported in both in-person and telehealth modalities. Access should be easy, timely, affordable, and aligned with patients’ values, culture, and needs.
• Patients need systemic solutions to ensure they don’t fall through the cracks. They tell us they need solutions to bigger problems beyond substance use. These include managing co-occurring trauma, psychiatric disorders and medical problems, finding affordable housing or permanent supportive housing, and getting work.

Even if all those options are adequately funded, coercive measures might still be necessary. But even in locked facilities, involuntary treatment should provide patient advocates and offer the least-restrictive evidence-based care possible. On release, patients should have immediate access to the voluntary recovery support listed above. Too often, community health workers fight to secure treatment, only to see patients discharged within days to no support at all.

I agree with Humphreys and many in the field that more US-based evaluation of involuntary treatment is needed. Washington State is one of the few that requires reporting on the outcomes of involuntary treatment. Early results are more promising than elsewhere, but critical data gaps remain, including data on overdose and death upon release.

And in the meantime, more states should publish evaluations of their existing systems, tracking long-term recovery, overdose, and cost, as well as qualitative accounts of patients’ experiences in their own words. At the very moment when some federal data systems are being scaled back or shut down, independent state-level reporting is all the more essential. Without rigorous, transparent data, we cannot judge whether coercive treatments deliver benefit or cause harm.

We cannot afford carelessness in our conversations shaping policy. Once we sort through the definitions of our terms and exhaustively examine the research,  it is clear that involuntary treatment should remain a rare, last-resort option for life-threatening crises. It cannot substitute for a fully funded spectrum of voluntary care or become a shortcut for bottlenecks, underfunding, or political point-scoring.

History may not repeat, but it rhymes. From institutionalization to the mass incarceration of the costly and failed War on Drugs, coercive solutions always promised a utopian safety they did not deliver. The siren song of “forced treatment” expansion as a broad-based solution may sound like a “relief,” but it is more likely to bring harm to patients and, ultimately, fail communities.

Susan E. Collins, PhD, is a licensed clinical psychologist and co-director of the HaRRT Center. She is a professor in the University of Washington School of Medicine’s’s Department of Psychiatry and Behavioral Sciences, an adjunct professor at the UW Department of Psychology, and an adjoint professor at Washington State University’s Department of Psychology

The views in this article are her personal views and not that of UW Medicine or Washington State University.