Addicted to Rehab

Allison McKim

• Editorial: Rutgers University Press
• Año: 2017
• ISBN:
  9780813587646
• Categoría: Ciencias sociales
• Categoría: Criminología

After decades of the American “war on drugs” and relentless prison expansion, political officials are finally challenging mass incarceration. Many point to an apparently promising solution to reduce the prison population: addiction treatment.
 
In Addicted to Rehab, Bard College sociologist Allison McKim gives an in-depth and innovative ethnographic account of two such rehab programs for women, one located in the criminal justice system and one located in the private healthcare system—two very different ways of defining and treating addiction. McKim’s book shows how addiction rehab reflects the race, class, and gender politics of the punitive turn. As a result, addiction has become a racialized category that has reorganized the link between punishment and welfare provision. While reformers hope that treatment will offer an alternative to punishment and help women, McKim argues that the framework of addiction further stigmatizes criminalized women and undermines our capacity to challenge gendered subordination. Her study ultimately reveals a two-tiered system, bifurcated by race and class.  
 

Chapter 1

Intake

Pathways to Treatment

Sarah ended up in rehab because of a doctor. A white woman in her late thirties, Sarah works as a nurse; she also wrote herself illegal prescriptions for the oxycodone-containing drug Percocet by using the name of a doctor who was both a colleague and a friend. Sarah funded her habit by stealing thousands of dollars from her father while managing his finances. Despite efforts to control the misuse of prescription opiates, it was a while before Sarah got caught. Finally, a suspicious pharmacist called the doctor whose name was on the prescriptions. Although he was unaware of Sarah’s actions, he covered for her to prevent her from losing her nursing license. He also called her husband. Together with her children, they lured Sarah home with a story about how her daughter had been injured and staged an intervention. The doctor promised not to report Sarah if she got help, and he recommended she go to Gladstone Lodge because that was where his own daughter had gone for treatment. After an arduous withdrawal in a detox clinic, Sarah was lucky to spend four weeks at the Lodge—the longest stretch of inpatient treatment that her insurance would cover. Sarah felt awful about what she had done, but she found solace at the Lodge, where she met four other nurses. Finding people in the same boat made her “feel like a person” and reassured her that she was “not so bad.”

Donisha also had a brush with medical authorities before coming to rehab, but hers was a more formal and coercive route. About the same age as Sarah, Donisha is a black woman whose pathway to rehab started after she gave birth and tested positive for an illegal drug. The hospital reported her to the city’s child protective services (CPS) agency, which placed her baby daughter in foster care. The family court overseeing the case required Donisha to complete one year of residential treatment at Women’s Treatment Services (WTS). This made her one of only three WTS clients who did not have a criminal justice mandate to be in the program. Donisha proudly described herself to me as a “voluntary” client, distinguishing herself from those with a “criminal” label. Indeed, she was technically voluntary. Yet Donisha was similar to her peers. She had been in prison before, long enough that the state had terminated her parental rights to two children, a situation that is common among incarcerated women.1 Moreover, if Donisha did not successfully graduate from WTS, she would lose custody of her new baby. While at WTS, she was eager to get a general equivalency diploma (GED) and job training and to be reunited with her daughter. However, these priorities came into conflict with those of WTS. Donisha said that the staff made her feel like a “fuck-up” and asked her to degrade herself. Eventually, she left the program without permission, which the criminal justice system terms “absconding.”

Although Sarah and Donisha both used drugs and broke the law, they took different pathways to rehab, ended up in different kinds of programs, and thus had different experiences in treatment. Charting what I call pathways to treatment reveals a great deal about WTS, Gladstone Lodge, and how we govern through addiction. In this chapter, I trace the processes by which women enter these two rehabs. The pathways concept captures the social relationships and institutions that push women to seek treatment, shape what kind of program they go to, and fund treatment. They are, in short, pathways for people, money, and power. Underpinning these pathways are larger systems of inequality and governance, such as patterns in employment, workplace benefits, criminal justice processes, the welfare state, and informal familial relationships.

I suspected that the women at the Lodge would be more privileged than those at WTS, but I was unsure how much the treatment practices would differ. What I found were two nearly distinct systems of treatment and client populations. Yet in interviews of staff members at WTS or the Lodge, I found that they often used the same language to discuss addiction and women’s needs. Concealed under this ubiquitous recovery lingo are two kinds of rehab programs whose different structures, services, and populations hint at their distinct social roles. This distinction may appear to be one of medicalization versus criminalization. However, neither program was especially medicalized. Moreover, the treatment system funnels people into rehab based not on a diagnosis of the nature or severity of their substance use, but rather on their socioeconomic status and relationship to the penal state. As a result, the pathways women take to Gladstone Lodge and WTS reveal addiction treatment to be a two-tiered system embedded in structures of racial, class, and gender inequality. These intersecting axes of inequality position people differently within systems of governance, sending them along different pathways.

Medicalization, Criminalization, and the History of Addiction Treatment

For WTS and Gladstone Lodge, it all started in the 1970s with nuns. Nuns founded WTS in a northeastern US city to serve as a halfway house for women leaving prison. It was not originally an addiction treatment program. In keeping with penal-welfarist ideas about rehabilitation, the nuns focused on teaching women blue-collar trades, but rather unusually these included traditionally male-dominated fields. Today, WTS is a nonprofit organization that has no religious affiliation—although a statue of the Virgin Mary still sits by the front door. Instead, it survived by formalizing its relationship with the state and tapping into the criminal justice system’s deep pockets. As ideas about why women commit crimes shifted away from social and moral explanations,2 WTS’s approach to rehabilitation also changed. The program no longer emphasizes reintegrating former prisoners into society through work or religion. Now, addiction provides the framework for understanding women’s deviance.

Located about a two-hour drive away from WTS, Gladstone Lodge is a for-profit, residential treatment facility that was founded in the 1970s by Bill and Faye, an older white couple who still own and run the program. They are recovering alcoholics who got sober in Alcoholics Anonymous (AA), and they remain deeply devoted to the twelve-step model of treatment. Both Catholic, Faye and Bill opened the Lodge on the grounds of a convent, in a building that had once housed tuberculosis patients. The nuns provided the only affordable space for the couple’s precariously funded business. While the Lodge is no longer in that location, statues of the Virgin Mary and other saints stand by the front door, echoing the entrance to WTS. This similarity was an unplanned and surprising coincidence in my research. However, the programs’ shared roots in religious outreach and their trajectories since then hint at how governing through addiction has expanded and at how the treatment field bifurcated as it became integrated with the penal state.

The 1970s were a moment of growth for addiction treatment programs. This was the era when the contemporary system of specialized addiction rehab programs took shape. Two factors contributed to this expansion. The first was an influx of government funding for addiction treatment; the second was that health insurers began to consider alcoholism an insurable illness.3 These two relationships—to state agendas (especially about the marginalized) and the private health-care system—have structured the treatment system since the earliest institutions devoted to treating addiction, the inebriate asylums of the late nineteenth century.4 Moreover the ambivalence of both the state and medicine has kept the addiction recovery field decentralized, semiprofessionalized, and estranged from mainstream health care. Since the days of inebriate asylums, this dynamic has reflected the shifting racial, class, and gender stigmas around substance use.

The nineteenth-century idea of inebriety marks the first effort to medicalize this problem and develop professional treatment. The notion that chronic substance abuse is a disease—meaning that people imbibe not because they want to but because they are compelled to do so—dates from around 1800, and it began in the days when early temperance advocates made alcohol the first problem drug. Before the mid-nineteenth century, Americans problematized drunkenness as a willful sin.5 For people with property, drunkenness itself was not a problem. Poor drunkards, however, were a problem because they could not support themselves. They were lumped in with paupers, orphans, and other groups considered to be dependent. Early Americans did not distinguish between being poor and being deviant—a merging that continues in some contemporary penal rehabs.6 Thus, poor drunkards fell under the purview of the newly emerging carceral institutions for managing poverty and deviance: prisons, workhouses, and lunatic asylums. But these institutions did not want drunkards or their moral stigma.7 Meanwhile, narcotics use was common in the nineteenth century, especially among middle-class women who, like Sarah, took opiates as medicine. However, women alcoholics received extra stigma for violating gender norms, and many were imprisoned for inebriety.8

Criminal and gendered stigmas continue to shape the construction of addiction and the treatment field, ultimately spurring its bifurcation along lines of class and race. Early temperance advocates pressed for voluntary pledges of abstinence, but as drinking became associated with immigrants and the urban poor in the late nineteenth century, the advocates’ approach shifted toward criminalization.9 At the same time, some members of the newly solidified medical profession attempted to claim ownership of this problem. They expanded the category of inebriety to include other drugs but applied it only to users who were white and well-to-do.10 The drunken poor and Chinese opium smokers remained sinners. Because the disease concept allowed drug and alcohol users to remain members of the moral community, early treatment programs were not a way of dealing with people who were considered to be social others. Consequently, most of the people in inebriate asylums were affluent men.11 At the time, treatment included everything from whole-grain cereal to cocaine.12 However, “moral treatment” was the dominant method and laid the foundation for rehab today. It involved removing patients from their environment to “well-ordered,” family-like institutions where they prepared to reenter middle-class life through learning self-control, praying, and engaging in productive work.13

Inebriate asylums disappeared rapidly after 1900. William White, a historian of addiction treatment, argues that their competition with temperance’s moral model and inebriety’s contested status within medicine left these institutions poorly integrated into the emerging penal welfare system, which supported the development of insane asylums and reformatories.14 In contrast to these organizations, inebriate asylums often failed to secure state funding or the backing of involuntary commitment laws. Early addiction treatments, therefore, operated on the outskirts of medicine with close ties to religious revivals, popular movements, and shady businessmen. Inebriate treatment fully collapsed after passage of the 1914 Harrison Narcotics Tax Act and Prohibition in 1919, when the problem moved decidedly into the realm of crime.15 Mariana Valverde argues that addiction remains quasi-medicalized because of this moral stigma, producing the low-status, stratified, and paraprofessional system of today.16

The end of inebriate asylums left few formal treatment options, a situation that persisted until the 1960s. People could go to a psychiatric hospital or buy supposed cures (usually full of alcohol) sporting names such as Howe’s Arabian Tonic and Mensman’s Peptonized Beef Tonic.17 With the criminalization of doctor-supplied opiate maintenance, the archetypal drug addict shifted from an ailing, middle-class white woman to a nonwhite, urban man who was orientalized as effeminate. This cemented the association of narcotics with racial minorities and gendered deviance.18 Criminalization did not eliminate treatment. The one treatment organization that expanded in the early twentieth century was the penal institution called an inebriate farm, where poor people spent their days in hard labor and faced sterilization under eugenics laws.19 There were few treatments for illegal drug users until the federal government created two penal institutions known as narcotics farms to alleviate prison overcrowding. The farms lasted into the 1970s but sought to exclude women altogether or limit their numbers. Because there are fewer of them, the added stigma of their gender, and their poor fit with male-dominated models of addiction, women are marginalized and underserved in the treatment field to this day.20

Into this treatment gap stepped AA. Founded in 1935, this group would forever change the construction of addiction and its treatment. AA began with two middle-class white men who had failed at numerous medical and religious cures for alcoholism. Drawing on Protestant self-help practices, AA bucked the authority of medical professionals and emphasized the power of groups of alcoholics—mostly white men in the early days—who came together to support each other’s sobriety. AA used the language of disease to account for why members felt unable to control their drinking when other people could. AA also sought to reassure outsiders that they were not morally prudish prohibitionists akin to members of the temperance movement. The goal of the disease language was to show that AA members did not blame alcohol. Instead, they blamed themselves.21 Given its deprofessionalized origins, AA’s success is nothing short of astonishing. It played a key role in promoting the disease concept and spurred the creation of private alcoholism rehabs in the 1950s, and its theories continue to influence scientific models of addiction.22

Neither Sarah nor Donisha would have ended up in rehab without the idea that addiction is a disease, but medicine played a small role in their treatment. The success of AA’s barely medicalized disease concept garnered state support for rehab outside medicine, including within penal institutions. In 1966, the Narcotic Addict Rehabilitation Act, a federal civil commitment law that permitted states to coerce individuals into rehab, created community-based treatment programs and opened the door for people other than physicians to treat addiction. In 1970, just before the punitive turn, the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act (referred to as the Hughes Act) poured more money into alcoholism treatment and research. Although drug and alcohol treatment remained separate until the 1980s, these two laws created the system we have today. Constance Weisner and Robin Room argue that this funding boom expanded the category of addiction and made treatment more coercive.23 In fact, by 1974, Senator Harold Hughes, who introduced the 1970 act, seemed disturbed by what he had created, calling it the “alcohol and drug industrial complex.”24 When funding and insurance coverage were expanded, it was members of twelve-step programs like Faye and Bill who were there to use it. As a result, nearly all contemporary rehabs still rely on twelve-step ideology and techniques.25

Gladstone Lodge and the Private Addiction Field

Gladstone Lodge is located in a picturesque rural area with a largely white and middle-income population. It runs two separate programs, one for men and one for women. New clients find that the large, two-story, multiwing building does not look fancy—especially the women’s unit. The building’s siding is old, and the colors are drab. Inside, faux-wood paneling, pictures of old white men, and a large lobby with a fireplace make Gladstone look like a fraternal organization’s clubhouse or a ski resort that needs renovation. One client even called the women’s unit “a dump.” Yet its isolated, bucolic location places the Lodge squarely in the nineteenth-century tradition of sending the errant to rural institutions, far from the corrupting influence of urban life, to foster health and moral reform. There are private homes around the Lodge but no sidewalks, and the nearest town is far away. It would take at least half an hour to walk to the closest commercial establishment, a roadside convenience store. In addition to its potential therapeutic value, isolation aids control. Staff members in the men’s program joked to me that they talked up the existence of bears in the woods so the “city boys” wouldn’t run off. Following the familial logic underpinning reformatories, Bill and Faye live on the property. Their house is so close that clients take a daily walk right in front of their lawn. Faye and Bill serve as managers, parental figures, and spiritual guides to the twelve steps. Given its setting, approach, and leaders in recovery, it is a classic addiction rehab program.

Both the Lodge and WTS are licensed by the state’s Department of Substance Abuse Services.26 However, the Lodge is a private-pay program, meaning it takes no government funding or public insurance like Medicaid. Thus, it has no formal relationship with the criminal justice or welfare systems. Its customers (staff members call them either “clients” or “patients”—the latter a term never used at WTS) pay with private health insurance or their own money. Because state funding and the penal system are so deeply involved in treatment, private-pay facilities constitute a minority of all rehabs. There is enormous variation in the cost and luxuriousness of private-pay programs. Some charge well above $30,000 a month and offer the look and services of a five-star hotel, including spas, acupuncture treatment, and equine therapy. In comparison, Gladstone Lodge is a modest and inexpensive program that costs $9,000 per month and offers few frills. Nevertheless, with a gym, a pool, and beautiful wooded grounds, it is a far cry from what women like Donisha find at WTS. The men’s and women’s programs at the Lodge are completely separate, operating in different buildings connected by a hallway. While Bill and Faye manage the whole organization, the two programs are staffed by different counselors. The men’s program is about three times bigger than the women’s (which is a typical ratio in addiction treatment).27 In fact, the Lodge could not survive if it offered only a women’s program, which with an average of around twelve clients was chronically under its maximum of twenty-four.

Pathways to the Lodge

To get clients, the Lodge contracts with insurance companies, employers, and labor unions (including those for police, steelworkers, steamfitters, utility, sanitation, and health-care workers). This means that a majority of its clients came through the union or employer pathway. Family pressure and resources create a second pathway. A smaller number of women take a third pathway: the state’s CPS system. Like some WTS women, they must go to treatment to retain custody of their children. I met only a handful of women who had no institutional or social network connection to the Lodge. They had found the program on the Internet. Work and family operate at three important stages of women’s pathways to treatment. First, employers, unions, and family members often propel women to seek treatment in the first place. Second, these networks also recommend the Lodge, as Sarah’s doctor colleague did. Finally, they help pay for treatment. While a couple of Lodge clients had criminal cases that drove them to rehab, CPS represents the only pathway the Lodge shares with WTS. Lodge clients never had the threat of prison hanging over their heads. Nevertheless, work-based pathways are no...