Last week on the subway, I saw a man crouch down over an empty seat, proceeding to urinate — and possibly defecate. His behavior and ostensible intoxication were so extreme that it is possible that he mistook the subway seat for a toilet seat. It was a first for me. It gave me pause to consider how we got here, and what we can do to get out of here.
I am a psychologist who has amassed related experience on both sides of the U.S.-Canada border, the most relevant of which was completed in the late 1990s in New York and then again in the late 2010s in Toronto. The former was completed at Bellevue Psychiatric Hospital, where I worked intensively with “street people,” on a unit dedicated to mentally ill chemical abusers. The latter was completed at the Centre for Addiction and Mental Health, where I worked intensively with a similar population of adolescents and young adults.
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First, I wish to address the question of why people abuse drugs. Second, I wish to address the question of how to help them.
Different people abuse drugs for different reasons. Some people abuse drugs to feel more of something, such as happiness, exhilaration, or confidence. Some people abuse drugs to feel less of something, such as anxiety, loneliness, or shame. For many, it is some of both. Are many drug abusers victims of trauma? Yes. Are all drug abusers victims of trauma? No. Are many drug abusers moved more by curiosity and pleasure seeking than by pain avoidance and self-medication? Yes. It is rarely an either/or scenario. This is all to say, the trauma-informed perspective, while well-intentioned, is oversimplified and overapplied. It is a perspective that empathetically replaces “What’s wrong with you?” with “What happened to you?” While this is ethically appropriate for many, it is not practically helpful for any. At least, not when misapplied to proportions which excuse, and even enable, self-destructive choices. That is when empathy becomes entropy.
So what do we do when empathy is not enough? From a psychological perspective, we treat the underlying personality disorder. Personality disorder is a very abstract concept that means different things to different people. However, for purposes of treating extreme drug abuse, it is best understood as a pattern of self-defeating behavior that resists treatment. Whether this pattern of behavior is genetically predetermined (for example, low EQ), environmentally predetermined (for example, trauma), or personally determined (in other words, free will), we do not know. It is probably a combination of all three. What we do know is that, absent external limit setting, people with extreme personality disorders will hurt themselves and others. The latter can range from disrupting public transit (for example, urinating or defecating in a subway train) to killing someone (for example, impaired driving).
Since such personality disorders, by definition, resist treatment, treatment plans won’t work. When something cannot be treated, it needs to be managed. The most responsible way to manage extreme drug abuse is to contain it. This means housing the addict, with or without their consent. The same way we house homeless children. People do not condemn child protection laws as an infringement of civil liberties. Why condemn “addict protection laws” in such a manner? The freedom of “live and let die” has honor, within limits, right up until it infringes on the life and freedom of others.
Does this mean having a serious conversation about the recriminalization of drugs? Yes. Does it mean having a serious conversation about the recriminalization of all drug-related behavior? No. This is not an either/or scenario. No one questions the fairness of criminalizing impaired driving. So why question the fairness of criminalizing other extreme drug-related behaviors?
We need a three-pronged approach to solving this problem: Plan A, prevention; Plan B, treatment; Plan C, containment.
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Tougher laws can go far in leveraging all three. The greatest lesson I learned when working with substance-abusing patients in New York was this exhortation: “We need to give these patients what they need — not what they want.” Let that be our guiding principle. It is the loving choice. From a Christian perspective, love is patient and forgiving, but it is also protective (1 Cor. 13: 4-8). Sometimes protection trumps patience and “forgiveness.” What is more humane? Letting adults roll around in their own excrement, after shooting up outside a safe injection site? Or feeding, housing, and loving them, within the safe confines of a secure setting?
Though suspension of freedom is a very sad scenario, the alternative is much sadder.
Dr. Glendon Rayworth is a registered psychologist, licensed under the College of Psychologists and Behavior Analysts of Ontario and the New York State Education Department Office of the Professions, having worked professionally with a diverse range of populations for 30 years.