Tag Archives: drugs

Substance Abuse and Social Capital

While the Donald Trump / Jeff Sessions administration is working to re-invigorate the war on drug users, a number of new studies look at relationships between social / cultural / economic capital on the one hand, and drug use, on the other. In my own research with criminalized women in the Boston area I witness the drug-encouraging perfect storm of poverty, marginalization, and the absence of meaningful opportunities for understanding how social inequalities cause suffering.

Despite popular articles (including this one in the New York Times) extolling drug treatment in prisons, newly emerging research suggests that locking up drug users is just about the worst thing we can do if we want to reduce drug-related deaths. By removing people from sources of social and cultural capital, we are exacerbating the very conditions that lead far too many Americans to abuse substances to begin with.

Opiate deaths in a former manufacturing community

A recently published qualitative study looks at factors contributing to drug overdose in the Monongahela Valley of Pennsylvania. This is a region that used to be a center of steel production but is now economically very depressed as manufacturing has shifted out of the area. The author interviewed people at a drug treatment program and found that they mostly spoke about lack of jobs and overall hopelessness in the local communities. The author concludes, “While state and county efforts to ameliorate overdose mortality have focused upon creating an open market in naloxone, this study suggests the need for interventions that address the poverty and social isolation of opiate users in the post-industrial periphery.”

To me, it’s interesting that the author makes the connection between poverty and social isolation for the “post-industrial periphery” but I think the same argument can be made for urban and suburban areas.  When people feel isolated and hopeless — and, of course, when mood altering substances are easily available — drug use can be quite attractive.

I suppose that the appeal of 12 step groups such as Alcoholics Anonymous and Narcotics Anonymous lies both in the sense of community (though, of course, it’s a constructed community that one loses as soon as one “relapses”) and the hope relayed by the success stories recited at meetings. Unfortunately, however, the hope and success (which is not as common as 12 step proponents like to claim) are limited to the specific context of the meetings. Commitment to sobriety does not change the economic reality of dead-end jobs, companies that do not have loyalty to employees, wages that don’t allow people to save money towards things like home ownership that truly bring hope, and so on.

Social capital and drug overdoses: a quantitative analysis

Another new study makes a similar point. In “Bowling alone, dying together: The role of social capital in mitigating the drug overdose epidemic in the United States” the authors used large-scale county-level data. The data show a pretty clear correlation between low social capital and high overdose death rates. The authors measured social capital in terms of the density of civic organizations, the percentage of adults who voted in elections, response rate to the census, and the number of non-profit organizations in the county.

While these measures are not perfect (in my opinion) they are suggestive. I’m particularly interested in the correlation between voting and drug overdose rates. In my own work I see a connection between substance abuse and the sense that one is stuck in world over which one has no power to make things better. Not just hopelessness but also powerlessness seem to drive at least some of the excessive drug use that we are witnessing around the country. In fact, according to the Sentencing Project, “one of every thirteen African Americans has lost their voting rights due to felony disenfranchisement.” Moreover, “A record 6.1 million Americans are forbidden to vote because of … laws restricting voting rights for those convicted of felony-level crimes. The number of disenfranchised individuals has increased dramatically along with the rise in criminal justice populations in recent decades, rising from an estimated 1.17 million in 1976 to 6.1 million today.”

What this study cannot get at is the variability of access to social capital within particular counties. I sometimes hear the women I have come to know speak with deep sadness about how other people seem to get the breaks while they just can’t catch a break. These women are likely to see their misfortunes as an individual failure or bad karma, but when I look at their life experiences I often see how identifiable policies forced them to be cut off from sources of social capital. Locked into jails, homeless shelters, rehab programs, low income housing and temporary jobs (at best), they are systematically excluded from the primary sources of social capital in our communities.

The women I know tell me that they want to help others, but even volunteer positions require criminal background checks. Many want to be part of church communities, but they find that churches drop them like hot potatoes when it becomes clear that they need more help than the congregations want to provide to any one individual.

Creating social and cultural capital: A revolutionary program in San Francisco

I’ll close here with a third article I read this week. This one highlights a program that addresses social and cultural capital in a very profound way. “Making the case for innovative reentry employment programs: previously incarcerated women as birth doulas – a case study,” documents a San Francisco program in which formerly incarcerated and low-income women were trained as birth doulas. 

According to the authors, “Realigning women within communities via birth support to other women also provides culturally relevant and appropriate members of the healthcare team for traditionally vulnerable populations. Doulas are important members of the healthcare workforce and can improve birth outcomes. Our work testing doula training, as a reentry vocational program has been successful in producing 16 culturally relevant and appropriate doulas of color that experienced no re-arrests and to date no program participant has experienced recidivism.”

Of course, not everyone is suited to be a doula! But the lesson from this project is far broader. Through participation in the program the women joined an on-going community, learned that they can be powerful agents in helping other women take control of their own births, and they not only acquire but also create meaningful social and cultural capital.

 

The Women of Can’t Catch a Break: January 2017 Update

Life is never boring for the women of Can’t Catch a Break. Over the past months they’ve faced serious health problems; they’ve struggled to care for their children and grandchildren; they’ve suffered at the hands of violent men; and they’ve remained trapped in an institutional circuit that often seems to present more hurdles than actual help. Yet that is not the whole story. Many of the women continue to build and draw upon social networks that provide them with places to stay, help with childcare, emotional support, and medical advice.

See Summer 2016 Update to catch up on the women and to help put the January 2017 update into context!

 

Andrea has not been well. Though trim and fit-looking (she’s an avid fan of exercise tapes), she’s been having trouble breathing and her body has been retaining fluids for almost a year. By December 2016, after a string of hospital stays, she was placed in a nursing home. When we spoke she told me, “I hate to tell you but my heart and lungs are not doing so well, so they brought me here. There’s nothing they can do for me at the other hospital.”

I’ve known Andrea for almost a decade and I still can’t tell whether it’s stoicism, fatalism, optimism and / or complete trust in modern medicine, but she was far more upbeat than I imagine that I would be in her situation. As always, she is comfortable staying in a medical institution — perhaps more comfortable than staying at home. Unable to read (she has had mild cognitive disabilities all her life), she finds navigating daily life on her own to be a challenge. In the hospital or nursing home she is looked after, there are professionals around who can explain things to her, and with her friendly demeanor she can always find a nurse or other staff person to chat with her for a bit. “I’m fine, Susan,” she told me. “I’m holding my own. I can still tell jokes and whatnot.”

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Carly (see “A New Home for Carly“) still has not received her baby back from DCF (child welfare department.) Without the baby, she is no longer eligible for the housing subsidy for her two bedroom apartment. For several months after losing her apartment she was on the streets. As of this writing she is couch surfing with a “friend”. (I put “friend” in quotes because Carly has a long history of being taken advantage of and even robbed and raped by so-called “friends”).

Since the baby was taken away, she has become extremely distressed, tormented by hostile spirits, suspicious of conspiracies to hurt her and to steal her baby, and hospitalized (voluntarily and involuntarily). During one hospitalization, “I was shot full of drugs – of Haldol. That’s why I won’t go back there.”

Through all of this, she remains focused on getting her baby back and attends frequent meetings and appointments with social workers, court-appointed psychologists, lawyers, and doctors. She carries around a large pack with her everywhere she goes. The pack contains “all the papers that prove that the baby is mine and that I took care of her properly. I have her umbilical cord, her footprint from the hospital, and records showing she had her infant check-ups.”

I have spent a great deal of time with Carly and honestly cannot figure out how much of what she does and says has to do with her deeply held belief in the active presence of good and evil spiritual powers in this world; how much may be symptoms of mental illness — even psychosis; and how much may be simple naivete. I can say that from what I’ve seen she took proper care of her baby, but I acknowledge that Carly likely tries to show me that she is stable and competent. I don’t envy the DCF workers, psychiatrists and judges who ultimately will decide whether the child is better off with Carly or in foster care.

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Daisy remains limited in her ability to care for herself, but both of her children have stepped up and are able to help her out. Her son has arranged for a supermarket to deliver food to her at regular intervals. She is not up to cooking (she is allowed to use the kitchen in her rooming house), but can prepare simple breakfasts and frozen meals for her lunch and dinner. She continues to enjoy the program for disabled adults that she attends three days each week, and considers the other people there to be her friends. And, “I do my laundry every single weekend.” She sees her daughter at regular intervals and her son and his wife took her along on a road trip to Ohio to visit her in-laws for Thanksgiving.

She does feel lonely much of the time (on the days she does not go to her program she rarely talks to anyone), and spends more time than she’d like cooped up in her room watching television.

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Francesca (see “The Bitch at the Welfare Office“) is still living in a working-class suburb with her son and younger granddaughter. She is busy raising the child and has landed a part-time job at a local supermarket. She does not earn enough to be independent, and continues to rely on her son and boyfriend (she has been in several serious relationships during the past year) for financial support. Unfortunately, that support comes with strings attached. In the case of her son, the strings are expectations that she take on the lion’s share of child care. In the case of her boyfriend, the strings are a matter of exerting control over her time and activities. But overall she is happy with her current life and posts encouraging comments on Facebook at least once a day.

One of Francesca’s greatest assets is her ability to nurture social ties. Over the years she has maintained a strong relationship with the mother of her older grandchild. That relationship is paying off now as the two women help one another with child care. All in all, Francesca has managed to create a safe, cozy and loving family and home for her granddaughter.

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Ginger (seeThe New Price of Freedom“) is back in touch with me on a regular basis! In the summer and early fall she was living on the streets. When I ran into her she told me she was smoking a lot of crack and staying with her “trans mother” (an older woman who had helped her come out as trans when Ginger was in her teens.) A mutual friend told me that he saw her fish around in the garbage and take out a cup and then sit down on the sidewalk with the cup in front of her to panhandle.

A few weeks later she called me from a “safety” phone that she had been given by an agency that helps homeless people. She had moved in with her Aunt after “a homeless man from the Boston Common hit me in the head.” She had a concussion and spent three days in the hospital. When we got together for coffee she told me that she actually had been beaten up three times by the same homeless man who called her “ugly names” because she is trans. When she went to the police they told her they wouldn’t do anything because they told people to stay out of the Common at night. She also had her ID stolen. When she went to meet with a housing advocate he told her that she needs to get her ID first. For Ginger, this is a pretty overwhelming task, involving visits to various offices and paying fees that she cannot afford to pay.

Throughout late fall and early winter she has stayed off crack, resumed her beloved weekly bingo games, and returned to the excellent doctor who has helped her with anti-depressants and hormones over the years.

In November she moved in with an old boyfriend who lives in a rooming house (SRO) but, “We got into a domestic dispute. He hit me over the head with a lamp.” I asked her if she called the police. She said she couldn’t “because I’m a known trespasser [in his building] and they’d arrest me.” For now, she is staying with his brother and trying to move forward on getting her own housing.

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Isabella (see “Failure by Design: Isabella’s Experiences with Social Services“) continues to grieve for her late husband. Over the past months she’s lived in several different apartments, each of which turned out to be problematic. She has come close to getting a job but in the end things have fallen through. She continues to help out friends and acquaintances who need to get into detox or who need help managing their methadone regimes or other drug-related health problems.

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Joy continues to cycle through psychiatric wards throughout the Commonwealth of Massachusetts. In September I visited her in a locked psychiatric ward where she’d been taken after attempting suicide. She told me that she had overdosed. “I just tried to end it. But someone found me and here I am. I woke up in the hospital with tubes everywhere. They told me I almost died. … I had not used drugs for a long time. I got high that one night to kill myself.” The person who found her called 911, and then stole her phone.

A long chain of miserable events had led her to the point of wanting to end her life. Both of her parents have been unwell and may not be able to care for her daughter for much longer. She did not have a place to live and had been staying with a man who constantly criticized her and told her that she can’t do anything right. And she’d spent the previous month in prison. “A drunk woman started fighting with me [in the street.] I slapped her to get her to let go of my hair, and the police arrested me. I was still on probation from [an old] charge of soliciting a police officer [for sex] so they locked me up. I asked them to take me to a hospital and the police refused. When I saw the judge after a month he said to me, “You’ve been in my courtroom at least twenty times. I see that you have paid all but $260 of your restitution and fees [on old charges]. That’s enough. I’m releasing you on time served and remitting the remaining payments. Your probation is terminated.” Joy plead guilty (she told me she didn’t know why) “and that was that. I was released.” Unfortunately, on that same day a former boyfriend who had beaten her up (badly) was in court on the domestic violence charge. Because she had to come to court for her own hearing she was not able to go and testify at his hearing, and he was released. She asked to be able to go and testify but “I was told that wouldn’t be possible because I had to appear at my own hearing.” After he was released, Joy said, he told people that he would track her down wherever she went. She is terrified of him.

While we chatted at the hospital I noticed that her eyes were puffy and her speech slightly slurred. She said she was given Librium to help detox from alcohol – she had begun drinking over the summer and had become addicted. She’d also been put on Haldol and a few other psychiatric medicines.

Her hospital caseworker joined us and we talked about where Joy would go after the hospital releases (at some point in the next few days.) The caseworker had been tasked with setting up Joy’s outpatient therapy, not with finding her a residential program. Joy made her own call to a rehab program she’d been in previously and was told that they couldn’t take her unless she detoxes there first. “But I’ve already detoxed here! They told me to get high and then come to detox and then I could get into the program.” The caseworker confirmed that this is indeed the case, and told Joy that, “You need to do what you need to do to get into a program.”

We asked the caseworker about getting Joy into a group home under the auspices of the Department of Mental Health (DMH). The caseworker explained that group homes only accept people coming from state mental hospitals and Joy is not sick enough to need to go to the state mental hospital. I pointed out that Joy has repeatedly tried to kill herself. She replied, “Joy is high functioning and does not fit the criteria for a state hospital. What you need to do, Joy, is go to a homeless shelter. They will work with you to help you save money so that you can get an apartment. You need to get a job and then the shelter will reserve a bed for you. You need to go to your outpatient appointments and see the doctor. It’s a lot of work but you have to do it. It’s up to you to do the work.” Incredulous, I pointed out to the caseworker that Joy cannot get a job or an apartment. She has three felony convictions, has been homeless since age 18, and has already been in just about every shelter and program in the state.

We then asked what will happen if no placement is found for her when she is discharged. “You will be given two weeks supply of your medication and we’ll set up an appointment for you with an outpatient psychiatrist.” Joy pointed out that it takes longer than two weeks to get an appointment.

The caseworker was not being mean-spirited. Rather, she was a very young woman with no concept of the realities of life faced by someone like Joy. My sense is that she truly believes that if Joy tries hard she’ll make things work.

By November Joy was in another locked ward in another hospital – her third of the fall. When we spoke on the phone her speech was slurred from the medication they gave her. “They are discharging me today – couldn’t find a program or placement. They’ll pay for a taxi.” She told me that she would be going back to [the emotionally abusive] man she’d been living with when she’d tried to kill herself in September. She knew this wasn’t a good solution, “but I have nowhere else to go.”

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Kahtia (See “Prostitution, Decriminalization and the Problem of Consent“)

Throughout the first part of the fall Kahtia was doing well – volunteering everyday at a soup kitchen and attending multiple AA and NA meetings each week. With pride in her voice, she told me how many people the soup kitchen feeds each day and how much the staff appreciates her dedicated work. Most important, the family court judge told her that if she continues doing what she has been doing she will get her daughters back from DCF custody in a few months.

Her daughters were not doing as well. They had been taken away from their third foster home because the foster mother hit one of them. Now in foster home number four, one of the girls had become very introverted. The new foster mother took them for haircuts, which she is not supposed to do without Kahtia’s permission. “She gave them yuppy hair cuts. I mean, they look cute but it’s not what I would have done.” Kahtia expressed concern that the girls will become accustomed to living in a wealthier household and will resent her when they come back home to her.

Later in the fall Kahtia called to tell me that, “I am going through the worst thing in my life. DCF entered a charge of sexual and physical abuse against my husband [the girls’ father]. They haven’t told me any details and they’ve canceled home visits for the girls.” The story, as best as she can figure it out, is this: Quite a while ago, before she lost the girls, they told her that “Daddy touched me”. She took them to the hospital where they were examined but there were no physical signs of rape and no follow-up inquiry. Several months into their foster care time they said the same thing – that “Daddy touched me” (apparently referring to the same incident.) The girls spoke with their therapists but nothing more was said and nothing else happened. Then, almost a year later, in their third foster home, they mentioned it again. “They sent them to a  trauma specialist – I don’t even know what that is – and now the whole thing is under investigation. I don’t know why they talked about this now. Did something new happen in foster care that triggered them to say this? I don’t know what is going on. I don’t know if my husband really did hit or sexually abuse the girls. I feel guilty for not protecting them. Or if the whole thing is made up by DCF? I don’t know. I’m devastated, Susan, especially, you know, because I was a victim of incest and of rape.” She told me in tears, “All I ever wanted was a family, a husband and my children, a house with a white picket fence and a dog in the back and a cat on the window sill.”

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Melanie‘s doctors seem to have stopped looking into her medical problems and are concentrating solely on her PTSD. She has been placed on Disability (SSDI), which does not please her. But she is allowed to work part-time and has arranged to return to the shelter where she had been working, albeit as a “relief” staff rather than a shift supervisor.

Her big news is that — after several tries — she passed her test for her learner’s permit. She feels that she is able to drive, but because of her learning disabilities she’d “bombed” the written test. This time she was allowed to take the test with pencil and paper (instead of on the computer), and the person who administered the test was nice, which allowed Melanie to relax and focus on filling in the right answers. “I feel that everything is coming together!”

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Tonya (see “Knowledge is Power“) is still living in the same apartment. She is dedicated to raising her son and helping out with her grandchildren. Much of her time and resources are eaten up by  family members who come to her for a place to stay and assistance of various sorts.

Her son is now in school and there is no role for her there as a volunteer. “I need something to do but don’t know what to do.”

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Vanessa, now a grandmother, is staying at a homeless shelter. She has not had stable housing for several years. She looks forward to holidays when she can come stay with her mother for a few days. Other than those visits, she seems to be holding steady — no major disasters but no progress in terms of housing or employment.

 

To read previous updates click on:  Summer 2016  New Years 2016   Summer 2015   Christmas 2014 / 2015    Fall 2014 

 

 

Eulogy for Nicole

By Maureen Norton-Hawk, co-author Can’t Catch a Break.

If you were to meet Nicole you would never imagine that she had been battling a drug addiction for years. I can still see her sitting cross-legged on the lawn at the Common during one of our meetings.  Her long auburn hair framed her slender face as she chatted away, oftentimes not pausing between sentences.  She would talk about her love of making jewelry, her efforts to start a business, and the antics of her tiny dog. She was young, attractive, energetic and kind. Her desire to volunteer with the elderly was just one of many expressions of her deep desire to help others.

Unfortunately her giving nature made her vulnerable to those who would exploit her.  The combination of her youth and desire to please others made her an easy target to be used and abused physically, emotionally and economically by traffickers, boyfriends and some family members.

Nicole tried to stay off heroin, and succeeded for substantial periods of time. “I don’t want any more heroin. I want to live, I don’t want to die,” she declared shortly before her death.

Nicole died with a needle in her arm. Even the drug she ran to for relief took advantage of her.

I’d like to think that you are making beautiful jewelry in heaven. Rest in peace, Nicole.

For more on drug-related deaths see ““White Women, Opiates and Prison”   “The Opioid Epidemic: Just the Facts Please”

For previous eulogies see  “Orange-frosted Hostess Cupcakes”   “Eulogy for Elizabeth”

 

Like the “Girl Who Hides a Razor Blade in Her Mouth,” Coerced Addiction Treatment Has Many Victims

This article was originally published on April 13, 2016 by The Influence.

Kahtia “acted out” from a young age. At least that’s what the counselors involved in her case said. The reality, Kahtia recounts, is that she wanted to get away from the horrific sexual abuse in her home. By age 12 she was in residence at a juvenile treatment institution. By age 13 she was tired of being locked up.

After running away she had a few good years, during which she was adopted by a New York City gang whose leader had heard impressive stories about “the girl who hides a razor blade in her mouth to protect herself.” Later on she contributed to the gang through some high-priced prostitution and exotic dancing at upscale clubs. “Then,” she explains, “I was dealing drugs and became my own best customer.” The high-end sex work descended to street work, and Kahtia spent the next 15 years or so in and out of prisons and jails.

By the time I met her in 2008 (I have come to know her as part of an ongoing project with formerly incarcerated Boston-area women) she was spending far more time in treatment programs than in jail. Over the years, Kahtia has been sent by the courts, social workers, child welfare workers and doctors to residential treatment both in and out of jail, to outpatient multi-service clinics, gender-sensitive therapeutic groups, methadone treatment and ubiquitous 12-step programs.

What Should “Alternatives to Incarceration” Mean?

As a national consensus seems to be building around the idea that people who use drugs problematically are mentally ill and need treatment rather than incarceration, Kahtia’s experiences shed needed light on the concept as well as the practicalities of the “alternatives to incarceration,” which are garnering more enthusiasm than critical examination around the country.

Conceptually, the term “alternatives to incarceration” takes for granted that we are talking about ways to handle criminals who otherwise would need to be incarcerated—that incarceration is a reasonable baseline against which to measure “alternatives.” In light of the over-representation of Americans of color and low-income Americans in jails and prisons, however, it’s necessary to be careful about any sort of presumption of correlation between criminality and incarceration. In fact, about a third of people locked up in the US are awaiting trial; that is, they have not been convicted of a crime. Another third are locked up because they violated the terms of probation or parole; that is, the “criminal” act was not sufficiently egregious to require imprisonment but a subsequent action—often simply not showing up for a meeting with a parole or probation officer, or failing to keep up restitution payments or money owed in court fees—was the reason for incarceration. And 97 percent of federal and state criminal prosecutions are resolved by plea bargain—often accepted by defendants out of fear that if they don’t accept the deal they will be locked up even longer—rather than by trial.

Logistically, most alternatives to incarceration involve various sorts of intensive monitoring. This includes electronic bracelets, probation, parole and drug courts. Kahtia, like many other women I know, explains that all of these are a “set up” to be sent to prison. The terms of the supervision tend to be so extensive and rigid that, in her experience, everyone is bound to violate the terms. In her case, her last incarceration—four years ago—was triggered by the parole violation of having a “dirty urine.” When she added up the jail time and the time she was on parole, the total came to more months than she would have served if she’d been sent to jail to begin with.

Criminalization and Medicalization: Two Sides of the Same Coin

For the past 40 years, the cultural logic behind the mass incarceration of drug users rested on framing drug use as a personal choice, with the implication that it is appropriate to punish drug users who could have “just said no” to drugs. A similar logic still lies behind nearly all treatment alternatives to incarceration.

The individualistic understanding of addiction that is the bedrock both of prisons and of most treatment programs has important consequences in terms of social policies. In both medical and correctional settings Kahtia has been told—repeatedly—that her problems are the result of the bad choices she has made: the wrong men, wrong friends, wrong ways of getting money and wrong drugs. Correctional staff and therapeutic staff alike have drilled her in the idea that her problem lies within herself, her flaws, her disease, her female propensity to be “too nice,” and her proclivity for “denial.” Neither while incarcerated nor in any treatment programs has she ever been told that her problems may be the consequence of the failure of the collective to address economic inequality, racism, or sexual violence.

Sociologist Peter Conrad explains that, “[S]ince the medical profession’s mandate to treat addiction is dependent on (and accomplished at the determination of) the state, medicine functions as a social control agent in the former’s behalf. The uneasy alliance between law-enforcement and medical systems has created a hybrid criminal-medical designation of addiction” (Conrad p. 144). For women like Kahtia medicalization and criminalization are two sides of the same coin. She has been treated by doctors and psychiatrists for the very same conditions (pain and fear) and with the same or similar psychotropic and pain medications for which she has been sent to prison.

The murky line between punishment and treatment has not been lost on some of the corporations involved in the prison industry. Correctional Healthcare Companies, for example, has expanded beyond providing medical services to prisons and now offers services for the “full spectrum” of “offenders” lives: “pre-custody, in custody, and post-custody,” a timeline that perhaps says more than the company intended about American understandings of criminality.

What Is Treatment?

Typically, treatment begins with a short (five- or seven-day) detox. Ideally, people are sent from detox to residential facilities. However, in Massachusetts, like in much of the country, that transition often does not happen because there are no appropriate long-term placements available. Kahtia has been through dozens, perhaps even hundreds, of detoxes. Francesca, a friend of Kahtia’s, describes detox as “spin dry”—people come in, dry out, and are spat out afterwards. Spinning dry is particularly problematic because tolerance for heroin or pain medication is lower right after detox, making post-detox a period of danger for overdosing.

While one might argue that this simply points to the need for more long-term residential facilities, it is far from clear that such facilities offer much of a solution. If residence is voluntary, many people will leave because like Kahtia, they have families whom they do not wish to abandon or because they are fed up with the many rules about making beds, eating times, dress codes, etc. that residential programs typically see as necessary to “recovery.” If residence is coerced, then we as a society are at risk of a mass return to the cuckoo’s nest.

Recently there has been more interest in opioid agonist therapies such as methadone and buprenorphine. To be clear, these drugs do not “cure” addiction but rather are used like insulin or other on-going treatments for chronic diseases. While many people find these therapies useful, others feel that they simply substitute one drug for another (Kahtia told me that she found detoxing from buprenorphine even worse than detoxing from heroin), put money into the coffers of pharmaceutical companies, and too easily are misused when people sell or trade their doses.

Kahtia currently is in an outpatient program that provides group and individual therapy, psychiatric medication and methadone. Unfortunately, the combination of psychiatric medication and methadone made her so groggy that the director of the day camp to which she sent her kids last summer reported her to child welfare services (DCF) for being on drugs. Eight months later her kids are still in foster care; in order to get them back Kahtia is required to attend a full-time program of therapy and classes.

While not all treatment programs prescribe psychotropic medication, virtually all incorporate—explicitly or implicitly—12-step ideology and practices. Treatment facilities tend to be plastered with 12-step slogans such as “Let Go and Let God” and “Cultivate an attitude of gratitude,” and formal AA/NA meetings typically are part of the treatment regime. With emphasis on admitting one’s powerlessness (Step One) and making moral inventories of one’s faults (Step Four), these programs do not seem to offer people like Kahtia a meaningful script for re-organizing their lives. Having been at the receiving end of physical, emotional and sexual abuse both as a child and as an adult, she already is quite familiar with her powerlessness. And having spent much of her life in correctional facilities, her faults have been inventoried more times than she cares to think about.

Most treatment programs in Massachusetts also include some sort of psychotherapy. Kahtia has been treated by multiple therapists in both conventional and gender-sensitive programs over the years. While Kahtia typically enjoys talking about her history and her problems, she is frustrated by the rapid turnover in therapists at community mental health centers, by the fact that therapy has been required by parole officer and caseworkers, and most of all by the fact that therapy addresses her attitude to life’s challenges but can’t address the challenges themselves.

But Does It Work?

Politicians, advocates and just plain folks tout treatment as if there is clear evidence that treatment for addiction works. Indeed, “work it til it works” is a popular 12-step slogan. But by the standards commonly accepted for medical and scientific research there simply is no substantial evidence that this is the case. Studies showing positive outcomes to treatment typically look only at participants who completed the program, do not track program participants for long enough time to establish meaningful rates of success, fail to control for confounding variables, or look at very small numbers of participants from the start. Indeed, a recent meta-analytic review of the effectiveness of continuing care for substance use disorders (the need for ongoing treatment is one of the few things that virtually everyone in the field seems to agree upon), the researchers concluded, “Limited by [the] small number of [methodologically sound] studies, analyses did not identify any significant moderators of overall effects.”

Studies of addiction treatment tend to focus on retention rate in programs rather than on how the program impacted participants after they finished. The notion of treatment being measured by sticking with the program rather than by actually being cured seems bizarre. In cancer treatment we wouldn’t consider long-term treatment to be good. Yet, in the world of addiction research we find studies like this one that conclude that “Consistent with a sustained benefit for 12-step exposure, abstinence patterns aligned much like attendance profiles.” Despite the researchers’ use of the word “benefit,” all that their study showed is that there is some correlation between attendance and abstinence. Their data do not show that one causes the other. (In other words, it could just as well be that people who are not using drugs—for whatever reason—are more likely to continue attending 12-step meetings.)

Every Statistics 101 student learns that correlation does not prove causation, that two phenomena can be related with one causing the other. Yet studies like this one on “engagement” in treatment seem to remember that wisdom only in the “Limitations” section at the end of the article.  After pages of numbers showing that people who remain engaged in treatment are also less likely to be arrested, the authors acknowledge that “clients with stronger motivation at entrance to treatment may have both higher engagement and better outcomes.”

Very few studies follow the people who have left the treatment program, though in many studies more than half of the initial participants have left before the end. And even the best studies, the ones that make efforts to follow-up with all participants, typically cannot find half or more of the participants thus have no idea what has happened to them or whether the half (or less) they have managed to find are in any way representative of the full participant cohort.

For example, an otherwise strong study that compared methadone with buprenorphine (Suboxone) looked at 1267 opioid-dependent individuals participating in nine opioid treatment programs between 2006 and 2009 and randomized to receive buprenorphine or methadone for 24 weeks. But perhaps the most important finding is that the treatment completion rate was 74 percent for methadone versus 46 percent for buprenorphine. The researchers have no idea what happened to the half of the participants who dropped out. In short, while the study ostensibly found better patient retention with methadone but lower continued use of illicit opioids with buprenorphine, it’s difficult to conclude anything meaningful about the efficacy of treatment.

Even the best studies, the ones that that make efforts to follow-up with everyone who started the study, typically limit the follow-up to three months, six months, or at the most a year or 18 months post-program. However, as in Kahtia’s case, it is common for people who use drugs to have periods in which they use heavily, periods in which they use occasionally, and periods in which they don’t use at all. And while I suspect it is likely that many forms of treatment do have a short-term positive impact on participants, without a double-blind random study in which some people are treated and some are not and then everyone is followed-up for a substantial period of time, we really cannot know which, if any, treatment modalities actually work.

The absence of evidence for the success of treatment programs is especially glaring when the treatment is coerced or carried out in a coercive situation. It may be tempting to believe that even if treatment doesn’t help everyone, at least it doesn’t hurt. Yet, as we’ve learned from past efforts to “cure” homosexuality, treatment that is ostensibly for the patient’s own good may be used to bring the “deviant” individual back into line when their ideas or behaviors challenge social hierarchies of race, gender, sexual orientation or class. Those of us old enough to remember Jack Nicholson’s performance in One Flew Over the Cuckoo’s Nest can attest to the reality that therapeutic interventions aimed at “getting inside” the patient’s head can carry heavy costs indeed.

A Real Alternative

As the treatment-industrial complex gathers steam, there is need for critical thinking regarding not only the effectiveness but also the goal of treatment. Is the goal necessarily abstinence (an ideology promoted by the 12-step movement), as opposed to temperance or moderate drug use? More broadly, is abstinence or even temperance really the ultimate aim, or is the true goal a life of purpose, meaning and dignity? In Kahtia’s case the absurdity is that she would now be considered a “success” by treatment researchers because she has not had a dirty urine in many months. But the reality of her life is that she spends all of her weekdays in various classes and groups, she is not able to work, she is always broke, and her kids are still in foster care with no set date for her getting them back. Is that a success story?

Last month President Obama gave a strong speech about drugs. Yet even this thoughtful man, a president who has demonstrated his ability to hold onto competing ideas and live with ambiguity, offered the same uncritical promotion of treatment that has started to replace the uncritical promotion of mass incarceration. There was, however, an intriguing kernel of insight in his allusion to his own drug use in his younger days and his implicit acknowledgment that not everyone who uses drugs becomes addicted. I would have liked him to examine his own experiences a bit more and move beyond his uncharacteristically superficial analysis that, “I was lucky because, for whatever reason, addiction didn’t get its claws into me.” Could it be that his strong political and social views and commitments—his deep belief that the world can be made better and that he can be part of that process—made drug use less appealing?

If so (and I think it’s pretty likely that this is so) then we should be talking about social factors in addition to medical ones.

If, as President Obama has articulated many times, reckless use of violence by the United States cannot cure the violence that plagues the Middle East, then surely he can recognize that uncritically escalating our use of medical treatment cannot cure the problem of America’s massive overuse of drugs. Just like we need to put more thought and resources into understanding why people become suicide-bombers and into preventing disaffected young people from joining terrorist organizations, we need to put more thought and resources into understanding why so many Americans feel the need to use large amounts of mood-altering and sense-numbing substances. At this point we barely know what prevention of problematic drug use would entail.


 

Suicide is Painful

The week that Robin Williams’ suicide hit every media outlet in the country, my friend Joy drove into the woods, shot herself up with enough heroin to kill a horse, and sat on a rock waiting to die. Unlike Williams, Joy survived (though the person who found her and called 911 first stole all of the cash from her wallet). And while I’m not surprised or even hurt that Joy’s intentional overdose has not received the media attention of Williams’ hanging, I do feel the need to acknowledge and share the knowledge of what led her to that rock and what happened after she was “rescued”.

The youngest daughter of a white, middle-class couple, Joy recalls that, “Until I was seven everything was normal – white picket fence, father went to work, mother stayed home with the children. Then everything fell apart.” Her parents divorced, her mother received custody and her mother’s boyfriend molested Joy and her older sister. Joy saw therapists and was given psychiatric medication throughout her childhood. Eventually she was removed from the home and placed into the child welfare system where she lived in various foster homes and juvenile programs. “None of these placements worked. I was an early drug abuser.” When I first met her crack cocaine was her drug of choice; a few years ago a boyfriend introduced her to heroin.

As an adult, Joy has never held a job that pays a living wage, never had secure housing, and never had custody of her daughter (her father is raising her daughter.) She suffers from impaired hearing, diabetes, insomnia, Hepatitis C, chronic hip and shoulder pain, lumps in several lymph nodes, and neuropathy in her feet. Joy’s sole legal income is her monthly SSI check of approximately $740, which she supplements through sex work. For the past twenty years she has moved among drug rehabilitation programs, motel rooms, shelters, jail and psychiatric hospitals. During the years I have known her she has been prescribed the following psychiatric medications: Trileptal, Seroquel, Neurontin, Abilify, Remeron, Buspar, Celexa, Wellbutrin, Neurontin, and Effexor.

…..

I’d last seen Joy a few months ago right after she was released from jail. She had been held while awaiting trial on a prostitution charge and then let go on “time served.” After losing track of her for a while, a few days ago I heard that she was in the locked psychiatric ward of a local hospital and I went to visit her. Although brightly painted and staffed by cheerful nurses, the ward gave off a “One Flew Over the Cuckoo’s Nest” vibe. Most of the patients were wearing hospital gowns, and since they are not allowed shoes they shuffled back and forth in the corridors in slippers or socks. Some gave off unpleasant odors; many had the blank “zombie” look of heavy psych medication.

Joy was delighted to see me (and delighted with the chocolate and magazines I brought). I asked her how she ended up on the ward. She explained that she’d been drifting around between stints of jail time and realized (not for the first time) that she needed to make a change in her life if she is going to survive and “be there for my daughter”. She made the decision try methadone and see if she could kick her drug use once and for all. The methadone clinic put her on a dose that was too low for the amount of heroin that she had been using, and she became extremely dope sick. “They moved up my dose but it wasn’t enough so I kept using dope together with methadone. I realized it wasn’t working and I already tried everything else – you know Susan I’ve been in so many programs that I could teach them — so I decided to end it all.” The last thing she remembers is feeling the heroin start to work. When she woke up in a hospital close to where she was found, she was told that she very nearly died and that the medical staff worked on her for a significant amount of time to bring her back.

…..

Two days later the hospital released her. She was told that they had tried to place her into the detox facility with which the hospital works, but that facility only takes people on Suboxone (another drug that is used to treat opiate addiction), not methadone. The nurse handed Joy a piece of paper with some phone numbers for her to call to find a detox program for herself, and told her to leave. Joy said to the nurse, “Are you kidding me? I tried to kill myself less than 48 hours ago.” The staff claimed they didn’t know that, but in that case she could stay in the hospital.

The next day they transferred her to the hospital at which I met her. Joy was assigned a doctor whom she liked, but after one day a “fill-in doctor” took that doctor’s place. The fill-in doctor looked at her chart and cut in half the medication for the neuropathy in her feet and stopped her anti-anxiety medication without talking to her or seeing her. A nurse told Joy that she’d try to speak to the doctor on her behalf, but the doctor made it clear that “I am the doctor and you’ll get the medication I give you.”

Joy was not assigned a therapist but was told to meet with a social worker who tried to find a rehabilitation program for her. Joy told the social worker that she had thrived at a facility she had been in a few years ago, but that program only lasted for five months, after which she was sent back to the streets.

Two days later when I called Joy told me that the doctor felt a large lump in her stomach and was sending her for an ultrasound later that day. Also, a lump on her neck had grown and she was being sent for a scan. I told her I’d drop by but I could only come in the morning. Because visiting hours start at 4:00 the nurse would not let me in (although Joy told her that I was the only person visiting her and that my visits help her want to live.)

Later that day Joy and I talked again on the phone. “It’s good you didn’t come, Susan, because they had me packed up and ready to go to a detox program in [another city]. I was literally going out the door when the program called and said they can’t take someone from a psych ward. So I’m just waiting for them to find a holding place for me where I can wait for a halfway house placement.” I asked her about the results of the ultrasound and scan. These tests had not been done nor had the doctor written up orders for them to be done at her next placement.

…….

The U.S Centers for Disease Control and Prevention (CDC) recently reported substantial increases in suicide rates among middle-aged adults in the United States. Based on National Vital Statistics System mortality data from 1999–2010, CDC researchers found that the suicide rate among American men aged 35–64 had increased 27.3 percent from 1999 to 2010, and among American women aged 35-64 the rate had increased 31.5 percent. A variety of theories have been proposed to explain these increases. Psychologist and author Bruce E. Levine notes that while it is popular to blame chemical imbalances in the brain for suicide, according to the CDC, “Possible contributing factors for the rise in suicide rates among middle-aged adults include the recent economic downturn (historically, suicide rates tend to correlate with business cycles, with higher rates observed during times of economic hardship).

One would assume that our current partiality to theories regarding the biological and chemical bases of mental illness would lead us beyond blaming the individual for his or her pain. But that is not the case – as witnessed by the estimate that nearly two-thirds of people sitting in jails and prisons are mentally ill.

And that is what I find so difficult to swallow.

Within forty-eight hours of Joy’s almost fatal suicide experience she had to fight to stop the hospital from releasing her to the streets where she’d surely be re-arrested for drugs, prostitution or simply loitering. Then she was confined in a locked ward where her visitors were limited and where she was prescribed different medication regimes by two different doctors (one of whom refused to listen to anything she or her nurses had to say). She knows she needs to stay off the streets but she has been told that there is no placement available for someone who is both suicidal and on methadone so the best she can hope for is a temporary “holding” facility until a place can be found in a slightly-less-temporary halfway house from which (as she and I know from her past experiences) she will be kicked-out if she “relapses”. And all of this happened in a very reputable treatment setting, which, Joy told me, is not all that different from jail.

…….

Now, it may be tempting to chalk Joy’s experiences up to bureaucratic run-around or an episode of particularly egregious institutional incompetence. But when the run-arounds and incomeptences are built into the laws, the regulations, the policies and rules and protocols, then they must be understood as manifestations of “the system” rather than as haphazard or idiosyncratic exceptions.

I don’t know if Joy will die from being raped or beaten by a trick, from a bullet one day when she can’t hear the police tell her to stand still, from whatever is causing the mass in her stomach and the lump on her neck, from the chaotic cocktails of prescription medication she receives, or from an unintentional overdose or another try at suicide. I don’t know if she’ll die in prison, a violent and oppressive setting that gives rise to high rates of suicide, or after her next prison release – a time in which suicide rates again rise. I don’t know if she’ll die in a detox facility or a homeless shelter. But each time I say good-bye to her, I have a sick feeling that this may well be for the last time.

You can read more about Joy in Can’t Catch a Break: Gender, Jail, Drugs, and the Limits of Personal Responsibility.

Civil Commitment: If You Build It They Will Come

Massachusetts General Laws Chapter 123, Section 35 permits the court to involuntarily commit to an inpatient substance abuse treatment someone whose alcohol or drug use puts themselves or others at risk. Last week the Massachusetts ACLU, together with Prisoners’ Legal Services and the Center for Public Representation, filed a class action suit in US District Court in Boston challenging the constitutionality of sending women committed under Section 35 to state prison.

Melanie

Melanie grew up in a close-knit, working-class Boston family. When she had her first child, “The hospital messed up my C-section and left staples inside.” She developed a painful infection, and was prescribed Fentanyl, Percocet and Klonopin. Her second child also was delivered by C-section, and again there were complications. Six surgeries and many pain clinic sessions later, Melanie muses, “Maybe I was hooked on meds, but nothing touched the pain.” At about that time an acquaintance suggested heroin, which successfully quelled the agony while opening up whole new sets of challenges. A year or so later she moved out of the house she shared with her children and husband and moved in with her parents because she didn’t want her kids to see her high on drugs. Maintaining a close relationship with them, she shuttled back and forth between the two households nearly every day for a year or so.

Melanie’s parents desperately wanted to help but were out of their depth. Finally one day, after she called them from the police station in a neighboring town to tell them that she had been picked up for shoplifting at a local pharmacy, they discussed with the police and the judge the best course of action. Her parents and the judge decided that given the absence of a criminal record and the presence of a supportive family (and, I surmise, the fact that she and her family are white) the judge did not charge her with shoplifting. Rather, he civilly committed her under Section 35.

For the purposes of Section 35, a substance abuser or alcoholic is defined broadly and rather vaguely as a person who “chronically or habitually” uses controlled substances or alcohol to the extent that “such use substantially injures his health or substantially interferes with his social or economic functioning . . . or . . . he has lost the power of self-control over the use of [controlled substances or alcohol].” Petitions for civil commitments can be made by a relative, guardian, police officer, physician or court official, or one can petition for commitment on one’s own behalf. While the law requires that the court call for a psychological assessment, it is unclear what that assessment means. In any case, there is no trial, no due process, and no possibility for appeal.

What Melanie’s parents didn’t know is that under Massachusetts law, a person can be committed under Section 35 to prison if there is no space available at a licensed substance abuse treatment facility. Melanie’s parents thought they were doing the right thing. They thought Melanie would receive treatment for her addiction and maybe even for her chronic pain. They were shocked to see her handcuffed and led out of the courtroom. Sick and vomiting, she sat in a holding cell at the courthouse for a full day. And then she was shackled and put on the bus to MCI-Framingham, the medium security women’s prison where she spent the next month.

According to ACLU staff attorney Jessie Rossman, upon arrival at MCI-Framingham, women committed under Section 35 are strip-searched, deprived of their personal possessions, and issued a prison uniform and number. Then they “are sent to the medical unit for detox – what [the Department of Corrections] calls detox, which essentially is just you being given a bucket. They are given over-the-counter drugs like Tylenol and Tums,” but no medication such as methadone, Suboxone or Vivitrol which are frequently used to facilitate detox. After detoxification in the medical unit, civilly committed women are sent to “The Mod”, a large room with bunk beds where women being held pre-trial are imprisoned. Unlike other prisoners they cannot visit the library, pray at the chapel, or participate in prison programs. Civilly committed women at MCI-Framingham cannot even access the addiction treatment programs available to sentenced prisoners. Ironically, the original reason for this policy seems to have been to discourage MCI to be used as a treatment facility.

“If you build it they will come”

By every measure, the MCI-Framingham “solution” to drug addiction is a disaster. The average length of stay for women sectioned to MCI-Framingham is longer than for women sectioned to the Women’s Addiction Treatment Center (a “staff-secured, but not locked” facility) licensed by the Massachusetts Department of Public Health to treat women who have been civilly committed. According to data compiled by the Massachusetts Women’s Justice Network, women sectioned to prison are less likely to be released to an outpatient facility and more likely to return to court (11% compared with 3%). Most damning, women of color are more likely than white women to be sectioned to prison rather than to the Women’s Addiction Treatment Center (31% compared to 9%).

The way out of this mess suggested by nearly everyone – judges, prison officials, public health officials, legislators, Governor Deval Patrick and most advocacy groups — is to fund and allocate more substance abuse treatment “beds” (that’s the term that is used) in non-prison facilities.

On the face of it this argument makes sense, but a bit of digging through the record indicates otherwise.

Massachusetts opened the Women’s Addiction Treatment Center in 2007 in order to provide an appropriate treatment setting for women committed under Section 35. In a classic instance of “if you build it they will come,” the Massachusetts Department of Public Health reported in a February 12, 2014 hearing held at the Massachusetts State House that the number of women committed through Section 35 dramatically increased over the following years, growing from 347 in FY 2006 to 1591 in FY 2012. At the same hearing, Department of Correction Commissioner Luis S. Spencer reported that the number of women committed to MCI-Framingham also continued to increase, going up from 221 women in 2007 to 310 women in 2012.

Spencer explained that many of the people committed under Section 35 are not only dealing with addictions but also with other mental health challenges as well as physical health problems including diabetes, heart disease, COPD, liver diseases, infectious diseases, Hepatitis C and dementia. Many have long histories of sexual victimization, self-injurious behavior, and psychiatric treatment. Brian Sylvester of the Massachusetts Department of Public Health estimates that 20% of those committed through Section 35 do not meet the criteria for commitment; rather, they are committed because no one knows where else to send them. People self-commit and are committed by others because there are insufficient spaces in detoxification facilities, because their insurance will not pay for detoxification or rehabilitation or even because they cannot afford housing. According to Sylvester, “Section 35 has become the catch-all for gaps in the system: substance abuse, mental health, criminal justice and medical.”

It is a travesty that drug users who have not been arrested, arraigned, tried or sentenced are sent to prison. And it is a travesty that needs to be seen in the broader context of local and national policies. The National Institute on Drug Abuse states in its Principles of Drug Addiction Treatment, “To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems.” But how (and the Institute does not ask this) can an individual’s vocational problems can be addressed when so many Americans work at jobs that do not pay a living wage, and when individuals with criminal records often cannot land a job at all? How can an individual’s social problems be addressed when poverty locks millions of people into communities with high rates of violence, when a quarter of American women experience sexual or intimate partner violence at some point in their lives? And how can an individual’s legal problems be addressed when the United States has the highest incarceration rate in the world?

As a nation we’ve gone the route of building more and more prisons in unsuccessful efforts to manage the devastation caused by economic and racial inequalities. I’m far from convinced that building more and more “staff-secured” treatment centers will prove any more successful.

You can read more on the confluence of punishment and treatment in Incarceration by Any Other Name: A Return to the Cuckoo’s Nest?

White Women, Opiates and Prison

Author’s note: Race is hard to write about; so is class; so is gender. I struggle with articulating — especially in a short essay —  two truths. Broad social forces and inequalities impact life experiences. And, each individual has her own unique life experiences framed by the particular ways in which class, race, gender, sexual orientation, ethnicity, nationality, citizenship status and other social categories intersect for her. I thank Robin Yang and Lois Ahrens for helping me try to get it right here. I accept sole responsibility for bits where I’ve missed the mark.

Black men have been the face of incarceration in America for decades, and black men continue to be locked up at rates far exceeding those of other gender and racial demographic groups. But, over the past few years, just as the pace of incarceration finally began to decline for men and for black women, incarceration rates have risen by 47.1% for white women. Opiate use seems to be driving much of that increase.

CDC Director Tom Frieden, in a 2013 briefing, announced that rates of opiate use, abuse, overdose and death are rapidly increasing among women. Aside from age (those in the 45-54 year age group have the highest rate of opiate related death), Frieden did not offer demographic details beyond the rather meaningless “mothers, wives, sisters, and daughters.”

Research published last week by the Boston Globe found that the number of babies born in Massachusetts with opiates in their system is more than triple the national rate, and that the numbers in Maine and Vermont are even worse. This research did not track race, but we do know that Maine and Vermont are two of the whitest states in the county – 95% white, Massachusetts is 84% white, and that many of the opiate hot spots in these states are poor, white communities. In Fall River, for instance, approximately 72% of residents have received a prescription for opiates, a rate well above the state average of 40 percent.

While the media seems shocked to “discover” that white women make illicit use of drugs, we really should not be surprised. Indeed, over the same years in which black men were the face of incarceration, white women were the face of medicine. White women take more prescription and over-the-counter medication, are prescribed more pain medication, undergo more cosmetic surgery, and make more doctor visits than any other major demographic group. White women are the greatest users of commercial holistic healing (alternative and complementary medicine). And white women are over-represented on pharmaceutical commercials and in high profile “war on illness” campaigns such as the pink ribbon breast cancer extravaganzas.

Just as higher incarceration rates do not necessarily mean that black men are especially wicked, higher medication rates do not necessarily mean that white women are especially sick. They do mean that white women tend to be portrayed as particularly in need of — and deserving of — expert medical care, and that the health challenges of white women are treated with more attention than the health challenges of other groups. Think, for instance, of how the natural aging process becomes seen as a medical problem (medicalized) when millions of prescriptions are written for hormone replacement therapy (HRT) for women who do not have any disease other than not being young. And think of the racial implications of these findings from a large government study released in the 1990s: HRT use among white women was 89% higher than among black women and white women were 54% more likely than black women to receive HRT counseling from their doctors.

Women – and especially white women – are prescribed more psychiatric medication (especially for depression and anxiety) than men. Jonathan Metzl, in Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs, traced advertisements for psychiatric medication in the American Journal of Psychiatry over a period of decades. He found that marketing to doctors disproportionately addressed women’s problems. Advertisements for Milltown and then Valium featured women’s unhappiness with their husbands, family responsibilities and sex, and offered medication as a way to make them more compliant with expected gender roles. Overwhelmingly, the pictures in these advertisements were of white women benefiting from treatment provided by white male doctors.

…..

What does all of this mean for white women’s experiences of opiates today? Continue reading White Women, Opiates and Prison

Our Prisons are Drugging Women

This piece originally appeared in Salon in August, 2013

A report issued earlier this month by the Center for Investigative Reporting revealed that doctors have sterilized as many as 148 women inmates in California prisons during the five-year period from 2006 to 2010. As a feminist and a mother, my initial response to the report was fury at the prison system for its blatant disregard of women’s rights and sadness for the women who will never again be able to carry, birth, nurse and raise their children. As a sociologist who works with criminalized women in Massachusetts, my second response (I am ashamed to say) was relief: Here in Massachusetts, with our top universities and progressive politics, such a thing would never happen.

Once I finished seething, crying and telling myself how lucky I am to live in Massachusetts, a slightly different picture began to form in my mind. Forced sterilization is an outrageous human rights violation, and prison rights advocates correctly argue that any sterilization performed on incarcerated women is by definition coercive. But this is only part of the story of how women in prison are controlled. In Massachusetts we may not sterilize incarcerated women, but we sure do drug them.

Having followed a group of 20 women post-incarceration for the past five years, I have become increasingly concerned with the use of medical procedures and treatments to “manage” the problems caused by social and economic policies and by overuse of incarceration.

I first met Elizabeth, a white woman in her early 40s, as a participant in a study I was conducting among women who have been incarcerated in Massachusetts. A decade or so earlier she had the misfortune of losing the sister with whom she had been especially close throughout her life. Devastated by the death of her sister, she struggled to keep up the smiling expression demanded in her job as a waitress. Told by her boss that her teary demeanor made the customers uncomfortable, she was let go. Without a job she was unable to keep up with her rent, and at the age of 32 she became homeless. Without a secure place to live, Elizabeth became a target for repeated robberies and sexual assaults.



Like many other homeless people, she was arrested for loitering, drinking in a public park and resisting arrest when a policeman she had called to protect her from assault decided to arrest her instead. In prison she was put on Thorazine and Lithium, medications that typically are used for psychosis (she has never been diagnosed as psychotic). Elizabeth explained, “This [the drugs they gave me] made me gain weight and made me into a [space cadet]. It’s not the right medicine. I’m not crazy, that’s for crazy people. I have PTSD and depression from being raped.” In a fog from the medication, Elizabeth lost privileges such as use of the prison canteen and was repeatedly confined to her cell for failing to cooperate with the orders of correctional officers. She was lucky; her cell mate spent two weeks in solitary confinement.

America’s astronomical rates of incarceration (the highest in the world) and America’s equally astronomical rates of psychotropic drug use (also the highest in the world) are two sides of the same coin. Both medicalization (the tendency to characterize social problems or conditions in medical terms and adopting a medical approach to address those problems) and criminalization construe social problems as the moral failings of individuals. This formulation draws attention away from the social miseries that lead to pain, disability, illness and the need to do whatever it takes to survive. When Elizabeth needed job security and affordable housing, what she received was a prison sentence and a cocktail of psychotropic medication.

Such medication certainly can be beneficial for people whose emotional distress or mental confusion interfere with their ability to stay safe, make sound decisions or experience pleasure or satisfaction in life. But the medications Elizabeth was prescribed actually diminished her capacity to make sound decisions and stay out of harm’s way. The issue for Elizabeth is that prisoners have very little – if any — power over what medication they receive, or are denied. Talk therapy is also much less accessible in prison than outside. And any treatment inmates get tends to emphasize individual pathology rather than acknowledging the social injustices that brought many women to prison in the first place.

While men are more likely than women to be caught up in the net of incarceration, women are more likely than men to be controlled through seemingly more benign medical practices. In Massachusetts in 2012, 56 percent of women inmates were treated with psychotropic medication while in prison. (In comparison, only 17 percent of male inmates were treated with psychotropic medication.) In prisons and jails across America, psychotropic drugs are used to subdue inmates. Ostensibly prescribed in order to treat inmates’ pathologies, these drugs often function to restrict autonomy in much the same way as shackles and solitary confinement; they can cause serious side effects including lethargy, seizures and menstrual irregularities; and they are liable to interfere with prisoners’ ability to participate in the preparation of their own defense cases.

I have reached out to various people in the Massachusetts penal system about these issues. Though none have been willing to speak on the record, most people who work in positions of power in the system in Massachusetts are well-intentioned and clearly understand that women inmates struggle with a variety of problems and barriers including histories of sexual abuse. They genuinely want to help women inmates improve their life situations. And they believe that psychotropic medications are a crucial part of that mission. Thus, in response to my questions about overuse of medications, I typically am told that they feel the problem is the underuse of medications.

Medical and penal interventions are often used in tandem to modify, reform, punish and control people – especially poor people and people of color – who are seen as lying outside of, or as threatening, social norms and power hierarchies. The vast majority of female inmates have experienced sexual abuse or assault (estimates vary from 70 percent to 90 percent). Whether through medical or penal practices, women are held responsible for dealing with the consequences of rape. While few people nowadays openly blame women for being raped, the fact is that a history of sexual abuse substantially increases a woman’s chances both of ending up in prison and of being treated with psychotropic medication while there. As Elizabeth learned the hard way, our national solution to “rape culture” is to “fix” women who have been assaulted rather than to change the social attitudes and policies that set women up for abuse.

In this wider context, forced sterilization inside of prisons is one – albeit particularly horrifying — instance of the use of medical procedures and treatments to “manage” marginalized women. In “Killing the Black Body: Race, Reproduction, and the Meaning of Liberty,” Dorothy Roberts documents how the forced sterilizations of the eugenics campaign of the early 20th century (a campaign meant to improve the human gene pool by preventing the “unfit” from procreating) functioned to keep women – and particularly black women – in check. More recently, coerced sterilization has raised its ugly head in public debates regarding the family cap for recipients of welfare (the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 allows states to deny mothers further financial assistance after the birth of another child) and in blatantly racist proposals to require contraceptive implants for mothers accused of using crack.

Women like Elizabeth face double jeopardy, first in their difficult life circumstances and then in the way they are treated once they enter into the criminal justice system. I do not claim that psychiatric medication (or sterilization, for that matter) is never appropriate. But when two of the most powerful social institutions — medicine and prisons – join forces, the threat of coercion is all too real. We rightfully express outrage when women in prison are sterilized, but our silence in the face of inappropriate medicalization could justly be called criminal.

For more on this theme: Incarceration by Any Other Name: A Return to the Cuckoo’s Nest?