Decarcerating America

by Ernest Drucker

  Soon after moving into an apartment, Steve began exploring the idea of not using heroin. He and his therapist discussed heroin as his medicine. He met with a psychiatrist and was prescribed antianxiety and antidepressant medications. Eventually he quit using heroin and speed. He did continue using pot and alcohol, however, and he and his therapist focused on a substance use management plan.

  As treatment continued, the focus turned to treatment of his PTSD symptoms. He decided that he wanted to try somatic treatment; he learned grounding techniques and started practicing meditation. Although he greatly reduced his alcohol intake, he was still struggling with it and had occasional relapses with meth. Eventually he came around to a moderation approach to drinking that involved a lot of education and the development of a detailed drinking plan. He dedicated himself to moderation, and significantly reduced his alcohol use. When episodes of overdrinking occurred, the events and the emotional states leading up to the episode were explored and plans made to anticipate future episodes.

  Now, six years later, Steve does not use heroin or speed. He smokes a small amount of pot daily which helps him with pain management. He drinks moderately two to three times a week, with an occasional (every few weeks) episode of heavy drinking. His PTSD symptoms are significantly reduced and well managed through somatic therapy and psychiatric medications. He recently moved to a supportive housing apartment that is more appropriately suited to his physical needs. He volunteers at an LGBTQ youth drop-in center, has connected with state vocational rehabilitation, and is taking computer programming classes. Steve has achieved far more than “any positive change.” He has become a changed person.

  Challenges to Harm Reduction

  Many concerns have been expressed both about harm reduction as a philosophy and about its implementation. Concerns fall into several categories, but typically they are driven by the belief in the United States that addiction is a disease, that drugs’ sole property is that they are dangerous, and that lifelong abstinence from psychoactive substances is the best (and only) way to live. Here are a few categories of concern and our responses to them.

  People fear that we are “enabling” continued substance use. When people say this, they mean that harm reduction enables people to keep using. First of all, none of us has the power to enable or prevent others to do anything. We can only do our best to influence healthy decision-making. Harm reduction recognizes that many people are going to use drugs, and it enables people to do so more safely.

  What if someone keeps using, having risky binges or relapsing? This is typically a signal that the deeper conflicts and underlying pain that are driving the use have either not been identified correctly or they have not been adequately addressed. Instead of kicking people out of treatment for relapsing, or refusing to work with them if they are using, treatment should continue to engage clients in discussions of safety and motivation. As long as people are showing up, they are working on their problems. To kick people out for exhibiting the very behavior that got them to treatment in the first place makes no sense and only leaves families and communities on their own with the problem.

  People believe that abstinence is the only way in part because it’s what we’ve been taught. It’s scary to see a person who has serious problems keep on using, even if he or she is making progress. But abstinence is not the only way. Many people pull themselves back from problematic use to a healthier pattern.

  Second, people believe that harm reduction is opposed to abstinence. This is not true. Abstinence is a part of the harm reduction continuum. It is a very effective harm-reducing option, and many people end up choosing it for one or more of their drugs. It just is not the only option. And in many cases abstinence is not necessary, since many people successfully resolve their issues with substances without quitting.

  Drug Use After Prison

  Adopting harm reduction as its guiding philosophy and strategy for reentry would enable the criminal justice system to remove abstinence as a condition of probation and parole and instead focus its attention on activities that harm other people or property. If the criminal justice system required its contracted treatment providers to accept people as they are, omit the abstinence-only requirement, work with all underlying conditions, and offer a menu of options for change, this would lead to much more effective treatment and better lives. We would have a system that practices client-centered care, honors self-determination, removes barriers, encourages trust, and thereby enjoys cooperative relationships, rather than enduring resistant ones, with people under its supervision and in its care.

  Harm reduction is the most compassionate and realistic drug treatment model developed to date. Embracing harm reduction models and objectives would allow the entire treatment and legal system to help people who use drugs to make lasting and sustainable change and to exit the criminal justice system. As a system, either we can choose to maintain the status quo, so that only those willing and able to be abstinent can stay out of jail, or we can choose to meet these individuals “where they’re at,” facilitating healthier decisions and living better lives.

  Notes

  1. V.J. Felitti, “The Origins of Addiction: Evidence from the Adverse Childhood Experiences Study,” Praxis der Kinderpsychologie und Kinderpsychiatrie 52 (2003): 547–59.

  2. N.A. Miller and L.M. Najavits, “Creating Trauma-Informed Correctional Care: Balance of Goals and Environment,” European Journal of Psychotraumatology 3 (2012).

  3. N. Wolff and J. Shi, “Childhood and Adult Trauma Experiences of Incarcerated Persons and Their Relationship to Adult Behavioral Health Problems and Treatment,” International Journal of Environmental Research and Public Health 9, no. 5 (2012): 1908–26.

  4. R.C. Kessler, “The Epidemiology of Dual Diagnosis,” Biological Psychiatry 56 (2004): 730–37.

  5. Ibid.

  6. D.J. James and L.E. Glaze, “Mental Health Problems of Prison and Jail Inmates,” Bureau of Justice Statistics, Department of Justice, 2006, NCJ 213600.

  7. National Institute on Drug Abuse, “Drugs, Brains and Behavior: The Science of Addiction,” 2014, http://www.drugabuse.gov/sites/default/files/soa_2014.pdf.

  8. Substance Abuse and Mental Health Services Administration, National Survey of Substance Abuse Treatment Services (N-SSATS): 2013. Data on Substance Abuse Treatment Facilities (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014).

  9. Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014).

  10. R.H. Moos and B.S. Moos, “Rates and Predictors of Relapse After Natural and Treated Remission from Alcohol Use Disorders,” Addiction 101 (2006): 212–22.

  11. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, Treatment Episode Data Set (TEDS): 2002–2012. National Admissions to Substance Abuse Treatment Services (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014).

  12. R. Ryan and E. Deci, “Self-Determination Theory and the Facilitation of Intrinsic Motivation, Social Development and Well-Being,” American Psychologist 55 (2000): 68–78.

  13. P. Denning, “Therapeutic Interventions for People with Substance Abuse, HIV, and Personality Disorders: Harm Reduction as a Unifying Approach,” In Session: Psychotherapy in Practice 4, no. 1 (1998): 37–52; P. Denning, Practicing Harm Reduction Psychotherapy: An Alternative Approach to Addictions (New York: Guilford, 2000); J.R. Gordon, “Harm Reduction Psychotherapy Comes out of the Closet,” In Session: Psychotherapy in Practice 4, no. 1 (1998): 69–77; J. Little, “Treatment of Dually Diagnosed Clients,” Journal of Psychoactive Drugs 33, no. 1 (2001): 27–31; J. Little, “Harm Reduction Group Therapy: The Sobriety Support Group,” in Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems, ed. A. Tatarsky, 310–46 (Northvale, NJ: Jason Aronson, 2002); G.A. Marlatt and S
.F. Tapert, “Harm Reduction: Reducing the Risks of Addictive Behaviors,” in Addictive Behaviors Across the Life Span: Prevention, Treatment and Policy Issues, ed. J. Baer, A. Marlatt, and R.J. McMahon, 243–73 (Newbury Park, CA: Sage, 1993); G.A. Marlatt, Harm Reduction: Pragmatic Strategies for Managing High Risk Behaviors (New York: Guilford Press, 1998); D. Rothschild, “Treating the Resistant Substance Abuser: Harm Reduction (Re)emerges as Sound Clinical Practice,” In Session: Psychotherapy in Practice 4, no. 1 (1998): 25–35; A. Tatarsky, “An Integrated Approach to Harm Reduction Psychotherapy: A Case of Problem Drinking Secondary to Depression,” In Session: Psychotherapy in Practice 4, no. 1 (1998): 9–24; A. Tatarsky, ed., Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems (Northvale, NJ: Jason Aronson, 2002).

  14. S.E. Collins et al., “Current Status, Historical Highlights and Basic Principles of Harm Reduction,” in Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors, ed. G.A. Marlatt, M.E. Larimer, and K. Witkiewitz, 3–30 (New York: Guilford Press, 2012); E. Drucker et al., “Harm Reduction: New Drug Policies and Practices,” in Substance Abuse: A Comprehensive Textbook, 5th ed., ed. P. Ruiz and E. Strain (New York: Williams and Wilkins, 2011); E. Drucker et al., “Treating Addictions: Harm Reduction in Clinical Care and Prevention,” Journal of Bioethical Inquiry 13, no. 2 (2016): 239–49; P. O’Hare et al., The Reduction of Drug Related Harm (London: Routledge, 1992).

  15. World Health Organization, Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among Injecting Drug Users (Geneva: World Health Organization, 2004).

  16. E. Wood et al., “Attendance at Supervised Injecting Facilities and Use of Detoxification Services,” New England Journal of Medicine 354, no. 23 (2006): 2512–4.

  17. W. Miller and S. Rollnick, Motivational Interviewing: Preparing People to Change, 3rd ed. (New York: Guilford Press, 2013).

  18. P. Denning and J. Little, Practicing Harm Reduction Psychotherapy: An Alternative Approach to Addictions, 2nd ed. (New York: Guilford Press, 2012).

  19. Two excellent reviews of the research on successful controlled drinking and on harm reduction therapy demonstrate the vast potential for non-abstinence approaches to eliminate the harm of substance use. M.E. Saladin and E.J. Santa Ana, “Controlled Drinking: More than Just a Controversy,” Current Opinions in Psychiatry 17, no. 3 (2004): 175–87; D.E. Logan and G.A. Marlatt, “Harm Reduction Therapy: A Practice-Friendly Review of Research,” Journal of Clinical Psychotherapy 66, no. 2 (2010): 201–14.

  20. Denning and Little, Practicing Harm Reduction Psychotherapy, 2nd ed.; S. Kellogg, “A Struggle for the Soul of Addiction Treatment,” 2014, www.substance.com/a-struggle-for-the-soul-of-addiction-treatment/13798; A. Tatarsky and S. Kellogg, “Harm Reduction Psychotherapy,” in Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors, ed. G.A. Marlatt, M.E. Larimer, and K. Witkiewitz (New York: Guilford Press, 2012), 36–62.

  21. I. Thaca, “One Junky’s Odyssey,” Harm Reduction Communication 5 (Fall 1997): 28–30.

  22. E.J. Khantzian, “The Self-Medication Hypothesis of Addictive Disorders: Focus on Heroin and Cocaine Dependence,” American Journal of Psychiatry 142 (1985): 1259–64; E.J. Khantzian, Treating Addiction as a Human Process (Northvale, NJ: Jason Aronson, 2007).

  23. C.A. Draizen, “Your Letters [Letter to the Editor],” Harm Reduction Communication 5 (Fall 1997): 26–27.

  24. National Institute on Drug Abuse, “Drug Facts: Heroin,” 2014, www.drugabuse.gov/publications/drugfacts/heroin.

  25. N.E. Zinberg, Drug, Set, and Setting: The Basis for Controlled Intoxicant Use (New Haven, CT: Yale University Press, 1984).

  26. Ryan and Deci, “Self-Determination Theory”; Miller and Rollnick, Motivational Interviewing.

  27. Ryan and Deci, “Self-Determination Theory.”

  28. B.E. Lozano and R.S. Stephens, “Comparison of Participatively Set and Assigned Goals in the Reduction of Alcohol Use,” Psychology of Addictive Behaviors 24, no. 4 (2010): 581–91; B.E. Lozano, R.S. Stephens, and R.A. Roffman, “Abstinence and Moderate Use Goals in the Treatment of Marijuana Dependence,” Addiction 101 (2006): 1589–1597; B.E. Lozano et al., “To Reduce or Abstain? Substance Use Goals in the Treatment of Veterans with Substance Use Disorders and Comorbid PTSD,” American Journal on Addictions 24 (2015): 578–81; M.B. Sobell and L.C. Sobell, “Guided Self-Change Model of Treatment for Substance Use Disorders,” Journal of Cognitive Psychotherapy 19, no. 3 (2005): 199–210.

  29. W. White and W. Miller, “The Use of Confrontation in Addiction Treatment: History, Science and Time for Change,” Counselor 8, no. 4 (2007): 12–30.

  30. Tatarsky and Kellogg, “Harm Reduction Psychotherapy.”

  31. S.H. Kellogg, “On ‘Gradualism’ and the Building of the Harm Reduction-Abstinence Continuum,” Journal of Substance Abuse Treatment 25 (2003): 241–47.

  32. T.L. Mayo, Words to Live By (Sarasota, FL: Pinnacle Press, 1996).

  33. Zinberg, Drug, Set, and Setting.

  34. D. Bigg, “Substance Use Management: A Harm Reduction–Principled Approach to Assisting the Relief of Drug-Related Problems,” Journal of Psychoactive Drugs 33 (2001): 33–38; Denning and Little, Practicing Harm Reduction Psychotherapy, 2nd ed.

  14

  Prisons to Ploughshares

  New Economies for Prison Towns

  ERIC LOTKE

  “This is one of the largest employers in the North Country. We need to fight this tooth and nail.”

  —New York State senator Betty Little, October 2013 New York, May 20131

  “We need the jobs.”

  —Lake County commissioner Dan Sloan, trying to reopen the North Lake Correctional Facility in Baldwin, Michigan, April 20132

  “We cannot replace those jobs with jobs that are already in the community. . . . Jobs aren’t there to fall back on. And the income’s not there to fall back on.”

  —President of AFSCME Local 2758, Toby Oliver, regarding the closure of Tamms Correctional Center in 20123

  Mass incarceration seems to be crumbling under its own weight. Even as the federal government reverts to blood and soil, states are exploring different solutions. “Tough on crime” is giving way to “right and smart.” Former drug warriors are promoting sentencing reform, and “treatment not jail” is popular at the polls. That’s a good start. But a crucial element is missing.

  Most of the attention is on what I call the push side. Too many people are being pushed into prison, for too many years. The push side is the heart of the agenda for justice reform: sentencing and parole reform, treatment not jail, supportive reentry, geriatric release, and so forth. Some reforms go beyond the justice system to matters of poverty, education, and mental health—problems that lead people to crime and drugs in the first place. Such reforms are vitally important, of course, but they affect only the push side of the system. They’re about why people go to prison, who gets incarcerated, and for how long.

  What’s missing is the pull side. Too many rural communities rely on prisons for jobs. They want to pull people in, and more are better. “Prisons are viewed as the anchor for development in rural areas,” explained New York State’s corrections commissioner, Thomas Coughlin, in 1990.4 Farms and factories have closed; prisons are the new economic centerpiece.5 From the corrections staff to the local shopkeepers, most people in a prison town have an interest in keeping that prison open. The mayor and the state representative can be expected to take their side. Patrick Mulhern, mayor of Cresson, Pennsylvania, put it this way regarding the closure of Cambria State Prison near Pittsburgh in 2013: “It’s going to hurt the restaurants, the hardware store, every business place here is going to be affected. Five hundred employees in one fell swoop—that’s an awful lot.”6 And serious money is indeed at stake.

  The Bureau of Justice Statistics estimates state and federal spending on corrections as $58 billion in 2012.7 Annual operating costs for a single prison range from $20 million to $60 million, depending on its size and secur
ity level. Reformers often point to cost savings as an object for reform, surely a desirable goal.

  But spending is only one way to look at that money. Money is not only spent, it is earned. The $20 million spent to operate a prison counts as income in the host community. It is paychecks for corrections officers as well as prison nurses, electricians, administrators, and food service providers. It is revenue for businesses where corrections personnel buy their food and get their hair cut. Removing that money may be a savings from the state’s point of view, but it is a loss from the community’s point of view. Typically it is a loss with nothing in line to replace it. Regarding closure of the Chateaugay state prison in New York, an Adirondack Daily Enterprise editorial titled “Say No to Closures” wrote, “While saving the state money is a good thing, it’s not so good for the North Country. Jobs will be lost, the local economy will suffer, and abandoned real estate will deteriorate all while drug problems spread.”8

  The past thirty years have made it clear that prisons do not work for rural economic development.9 State money comes in, but little more. Prisons are not investments that attract other investments, like an airport, college, hospital, or factory. To the contrary, other enterprises appear to avoid a prison town. Thus the loss of a prison leaves a hole in the local economy.

  “Prisons as a conscious economic development strategy for depressed communities forge a fateful, symbiotic bond between depressed communities in urban and rural America,” observed filmmaker Tracy Huling in 1999.10 Her film Yes, in My Backyard tells the story of Greene County, New York, which starts as a thriving farm community with a small manufacturing base and ends with half the working population employed as corrections officers.11 The natural economy disappeared and was replaced by state subsidy via the Department of Corrections.

  As reform moves forward, entire towns and communities stand to lose their livelihoods. We can expect them to resist. The reform agenda needs to take this resistance seriously. As a political matter, we want the host communities to embrace the change, not to fight it. Justice reform is more likely to succeed if it reduces the demand for prisons as well as the supply of prisoners.