Punishment is the status quo for dealing with substance problems even though research shows rewards are more effective at helping people break free from addiction
I was giving a presentation on non-traditional addiction treatment approaches to the Orange County Drug Addiction Advisory Board when one of the board members asked a very relevant question: “The criminal justice system is using incarceration for drug offenses less and less frequently, what other sticks are we supposed to use to motivate people to change?” She was drawing on the age-old metaphor of the “carrot and stick” approach, which means using a combination of rewards (carrots) and punishment (sticks) in order to change behavior, to ask how we should go about getting people to quit using drugs if we can’t threaten them with jail time. This is especially relevant in California, where we recently legalized marijuana and have largely decriminalized personal drug use. But the idea that we need to focus on punishing people in order to get them to stop using substances is deeply flawed. Here’s why, and what we can do about it:
The drug war’s ugly history…
Our culture has a long tradition of using sticks more than carrots. Ever since Richard Nixon launched the “War on Drugs” in the 1970s and Ronald Reagan ramped it up in the 80s, this country has been no stranger to locking people up for drug crimes. According to the Sentencing Project, the number of people incarcerated for drug crimes increased over 1000 percent from around 41,000 in 1980 to 488,000 in 2014. Depending on the prison system, anywhere from 16 to 48 percent of prisoners are currently serving time for a nonviolent drug offense. You’d think that if sticks really worked at changing behavior then having all these people in prison for drug crimes would mean we’d have much fewer drug problems and less addiction in this country. But you’d be wrong: in 2014, the same year over 488,000 people were incarcerated for drug crimes, the annual death toll from drug-related overdoses peaked at nearly 48,000.
… And the failure of sticks
What’s wrong with the tried-and-true stick here? Why does punishment not seem to get people to stop using drugs? In the fascinating new book Unbroken Brain, addiction expert Maia Szalavitz argues that part of the problem is the inconsistency between the carrot and stick approach and our understanding of the addictive process (Szalavitz, 2016). She points out that addiction is often referred to as “compulsive drug seeking and use, despite harmful consequences,” meaning someone with a substance problem keeps using in the face of negative outcomes, such as health problems and family issues. Research has shown us that even animals, once trained to take drugs, ignore punishments like electric shocks to get more of the good stuff (Pelloux, Everitt, & Dickinson, 2007).
As Szalavitz writes, why would an addict, who keeps using “despite harmful consequences,” quit using at the threat of a punishment like incarceration, which is really just another harmful consequence? It makes no sense. It undermines the whole notion that we can use punishment to get people with substance problems to quit, and when we see that 65 percent of inmates meet the criteria for an addiction, the logic becomes even more absurd.
Substantial research demonstrates the failure of sticks to break addiction. In two different studies, injection drug users who were incarcerated were half as likely to recover from their addiction as those who were not (Szalavitz, 2016). Furthermore, while we’ve seen how incarceration rates quadrupled from 1980s to 2000s (mostly because of drug-related offenses), the rate of addiction in the same time period went up, not down—from 6.1% of Americans to 10.3% (Szalavitz, 2016). Across the board, it’s pretty clear that punishment in its many forms doesn’t get people to stop using drugs, and may even worsen their chances of recovery. So if it doesn’t work, what does?
The power of modest rewards
Just because sticks don’t work as well as we want them to, doesn’t mean we can’t play a role in helping people change their behavior. What we need to do is to begin relying on carrots more than sticks shift our understanding of the problem instead of seeking more opportunities for punishment. Carrots can take on many forms. Carrots can either be actual rewards or the removal of negative experiences, which still leave the person feeling better. This is known as negative reinforcement in learning literature and can be very effective. An example might be how your spouse or roommate nags you to do the dishes after dinner, so in order to get them to not bug you about it, you do the dishes as soon as you are done eating. There’s no punishment, but you essentially get a reward out of not being nagged. One study showed us that the promise of clearing up a convicted felon’s criminal record (a form of negative reinforcement) given their participation in a naltrexone treatment regimen can be an effective motivator for medication-assisted treatment (Marlowe, 2006). How amazing would it be if, one day, we could actually allow people to select the form of treatment they want to engage in while supporting their efforts by removing barriers to functioning?
Another form of giving rewards is something called contingency management (CM). CM is a long-studied approach that utilizes small rewards in an escalating manner in order to provide motivation for clients to engage in specific parts of treatment. It’s based on three simple principles (Kleiman, Caulkins, & Hawken, 2011):
- Positive rewards help change behavior more than punishment
- Increased personal empowerment helps likelihood of change
- Behavioral change happens more quickly when effects occur immediately after action
The research on CM is extensive and wide-ranging: it’s is great at getting people to show up for treatment and at motivating them to meet certain goals (submitting drug-free urine tests, completing homework, etc.). Clients are more likely to be abstinent while in treatment (although some of this is based on self-report or random drug testing—more on that here) and some effects last beyond treatment, for as long as 12 months!
The key to substantial change: motivation from within
It seems clear that carrots are at least as good, if not better, at getting individuals to participate in treatment and to engage in the behaviors we are looking for. But the question is how to drive the improvement long past the actual provision of treatment. As it turns out, there are a few ways of thinking about this problem. If at least a subset of those who are struggling with drugs and alcohol are going to be dealing with the issue in a chronic manner, maybe we need to rethink of treatment as a long-term process that is more like diabetes or hypertension treatment. Clients would have an intense initial course of action while following up with less frequent but ongoing checkups. Alternatively, for the many clients who are dealing with issues such as sleep problems, anxiety, PTSD and the like, treatment is going to have to resolve those underlying issues if long-term sustainable progress is to be expected.
That’s what makes the work we do at Alternatives so different—we don’t assume that everyone is the same JUST because they struggle with their drug and alcohol use. Instead, we utilize all the amazing tools available to us to figure out where they might be along this continuum of a problem, identify their own goals for the future and then work together to improve their life. We find that our clients are really motivated to get better because we’ve made them part of the process! Rooted in Motivational Interviewing methods but also relying on Cognitive Behavioral Therapy, mindfulness and so much more, we provide our clients with a toolkit that is all theirs, drawing on their own motivation for change instead of believing that we have the answer from the get-go. Over time, this prospect of change because a carrot in and of itself, so much so that neither external rewards nor punishment are even necessary to create motivation. Ultimately, our clients improve substantially because THEY are part of their own process from the very beginning!
Kleiman, M., Caulkins, J. P., & Hawken, A. (2011). Drugs and drug policy: what everyone needs to know. New York: Oxford University Press.
Madson, M. B., Schumacher, J. A., Baer, J. S., & Martino, S. (2016). Motivational Interviewing for Substance Use: Mapping Out the Next Generation of Research. Journal of Substance Abuse Treatment,65, 1-5. doi:10.1016/j.jsat.2016.02.003
Marlowe, D. B. (2006). Depot naltrexone in lieu of incarceration: A behavioral analysis of coerced treatment for addicted offenders. Journal of Substance Abuse Treatment,31(2), 131-139. doi:10.1016/j.jsat.2006.06.005
Pelloux, Y., Everitt, B. J., & Dickinson, A. (2007). Compulsive drug seeking by rats under punishment: effects of drug taking history. Psychopharmacology,194(1), 127-137. doi:10.1007/s00213-007-0805-0
Stitzer, M., Cunningham, C. S., & Hermann, R. (n.d.). Contingency management for substance use disorders: Efficacy, implementation, and training (A. J. Saxon, Ed.). Retrieved January 31, 2017, from https://www.uptodate.com/contents/contingency-management-for-substance-use-disorders-efficacy-implementation-and-training?source=see_link
Szalavitz, M. (2016). Unbroken brain: a revolutionary new way of understanding addiction. New York: St. Martin’s Press. pages 176-179