In his latest column for City Journal (“Treating” Drug Abuse, 25 August 2006), Theodore Dalrymple has excoriated an editorial in the August issue of the British Journal of Psychiatry that endorsed the use of a drug treatment technique called “contingency management treatment”, whereby drug abusers are rewarded for passing urine tests by, in one example, being given vouchers (“positive reinforcers”) to spend on retail goods and services.
Noting that the scheme is predicated on the notion that the consumption of drugs can be halted voluntarily, the inescapable conclusion must be that addiction “is not a disease in any reasonable sense of the word”. Ipso facto, if
it is not a disease, there can be no treatment for it, only “treatment.”
What is then left is plain and simple “bribery”; a moral hazard that the editorialist, psychologist Nancy Petry of the University of Connecticut School of Medicine, simply ignored or failed to see.
Dalrymple is a noted critic of the drug-abuse-as-a-disease paradigm and his column is a good summary of one of the main arguments against it; I must confess that I haven’t completely made my mind up about the issue yet, but he puts forward a compelling case to which I’d like to hear an effective rebuttal.
As for the scheme itself, while I haven’t read what she wrote - unfortunately it is only available to paying subscribers of the British Journal of Psychiatry - on the face of it I find it a little dubious. If we follow the logic of the program itself – that it is indeed a matter of personal choice – then yes, it stands to reason that absent these financial rewards it is still possible to abstain from drug consumption; more difficult perhaps, but possible.
By advocating this method a much better financial incentive, namely the huge amounts of money the drug abuser could save but not spending money on the drugs themselves, is being missed. While vouchers are an overt positive reinforcer, I would argue that the less obvious – at least initially - but relatively larger amount of self-same goods and services that could be purchased absent the drug expenditure is what should be constantly reinforced by the relevant drug counsellors; this exercise in self-empowerment will surely have much far-reaching positive effects than expedient measures from without, without the costs being imposed on others.
While by no means is kicking drugs simply a matter of flicking an on/off switch - destructive patterns are hard to break - the desire for a healthier, happier drug-free existence - a prerequisite for going clean – and its subsequent realisation is the real incentive and main positive enforcer at work, combined with a supportive environment, family and friends. Without this determination, are not all other efforts doomed to fail?
