Illness or Deviance: Drug Courts, Drug Treatment and the Ambiguity of Addiction

Illness or Deviance presents an in-depth, qualitative study of two North American criminal justice/drug treatment contexts. The first is a drug court. The second is a community drug service with two arms: intensive group treatment (Westview); and an opioid prescribing clinic with a less intensive group programme (Southside). Underpinning Murphy’s analysis is a substantive body of fieldwork: approximately a year of participant observation, spread over 2005–2007; and 8 staff and 24 client interviews. All of this is contextualised by a detailed review of the deeply interconnected histories of US criminal justice and drug treatment agencies, which Murphy uses to problematise the tensions between “disease” models of addiction and punitive or stigmatising responses within frontline practice. As she surmises, institutional responses are rarely straightforward: “our current view … is that drug addicts are both diseased and deviant” (p.7).

If anything, this headline framework does not do justice to the complexity and richness of Murphy’s qualitative accounts. Disease and deviance are sprinkled throughout, but far more prevalent are themes centred on power, marginalisation and complex needs – a particular issue for services that approach all problems through a lens of “addiction”. This is apparent in the drug court, where court officials and lawyers for both prosecution and defence colluded in a mission of perceived redemption (p.58) focussed on resocialising “any kind of marginalised population” (p.89). An unfortunate confluence of eligibility criteria (non-prolific, non-violent offenders only (p.59)) and incentives to apply (the expunging of a criminal record following treatment completion (p.67)) led to the courts working with a wide array of people who were not drug dependent. Officials thus reframed their work as targeting “addiction to the drug-selling lifestyle” (p.76) and the “irresponsibility that came from poor values” (p.79), and so determined the intensity of mandated treatment on the basis of moral judgments about the level of “structure’ in defendants” lives (p.60).

The tensions between disease and deviance are more visible in the next chapter, which focuses on Westview and Southside. Staff ambivalence about, and conflicting responses to, the “disease” model of addiction are manifest; none cleanly or clearly bought into it (pp.102–110). At the same time, staff presented shame and personal responsibility as therapeutic responses to drug problems (p.129) whilst methadone, the most “medicalised” of treatments (p.151), was acutely stigmatised (p.140). Once more, though, tensions between illness and deviance only represent a subset of the complex issues suffusing treatment. Separated by a chasm of social distance, staff distrusted and undermined clients (p.139), whilst clients distrusted staff (pp.142–143) and established hierarchies between themselves: non-heroin users looked down on heroin users (p.118); court-referred clients were seen as unmotivated and inauthentic (p.123). Varying client groups also aspired to different treatment goals. Those prescribed methadone were wary about twelve-step meetings (p.136), and about Southside’s expectation of total abstinence from drugs and alcohol (p.125).

Chapter 5 knits the preceding chapters together by emphasising the coercive undertones in each treatment setting. Within the drug court, a range of “therapeutic punishments” (such as being sent to a “recovery house”) were portrayed by staff as supportive interventions, but experienced by clients as highly punitive (p.153). Within Southport, leverage of a different kind was used: non-compliant behaviour could result in forced detoxification. As one professional surmised, “[t]he medication is the whip that we crack” (p.163). Murphy thus contends that a relationship between punishment and therapy was maintained, even if it varied between settings: courts punished with more treatment; community providers punished with less.

As a rich, detailed, qualitative study of a US drug court and community treatment setting, Illness or Deviance makes a strong contribution to the literature on a wide range of issues. It has considerable resonance with contemporaneous UK studies on the criminalisation of drug treatment (McSweeney, Stevens, Hunt, & Turnbull, 2007; Seddon, Williams, & Ralphs, 2012), and adds depth and nuance to the literature on stigma (Lloyd, 2010). It is also unusual to find such an extensive, qualitative account of drug treatment, and many of the fine details and interpersonal dynamics are likely to resonate with the findings of any qualitative study on drug treatment. For all these reasons, this is a book that is eminently worth reading.

Given this thematic depth, it seems striking that the book’s central thesis feels underdeveloped. Ultimately, Murphy concludes: “just because something is labelled a ‘disease’ and managed in a clinical setting does not mean that we do not continue to also incorporate punishment into its treatment” (p.171). This descriptive summary feels as if it fails to address some of the broader debates about coercive drug treatment. Not least, questions about balances of individual and social rights, morality, and the efficacy of compulsion (Stevens, McSweeney, van Ooyen, & Uchtenhagen, 2005; Wild, Roberts, & Cooper, 2002); and the extent to which “therapeutic punishment” embodies a broader shift in policy and practice towards “third generation” risk assessment, wherein interventions for “risk” and “need” are conflated (Andrews, 1989:4). Notably, many critiques of risk/need echo Murphy’s central concerns (Hannah-Moffat, 2005). In a contemporary study of criminal justice drug treatment, this feels like an important, absent context.

Moreover, information that treatment and punishment coexist is not a new finding. Murphy acknowledges similarities between responses to addiction and “diabetes, heart disease, lung cancer, and HIV/AIDS” (p.174), and mental health could readily be added to this list. Perhaps crystallised by working on the hard edge of medicalisation and deviance – serious mental illness and violence – a wealth of authors have delivered deep philosophical considerations on responses to and the reconciliation of punishment, treatment and social control; as signified by the title of Prins (2005) Offenders, Deviants or Patients? (2005; see also Scott, 1975; Stone, 1984; Stone, 2008; Maden, 2010). This complex theoretical tapestry, with firm roots in conflicted practice, has a great deal to offer this debate.

In sum, as a book of two parts, Murphy’s contextual literature review and qualitative analyses are excellent. However, the links between them could be firmed up; and the inclusion of some additional relevant literature could strengthen the book’s central thesis.

Geoff Page

Mental Health and Addiction Research Group,University of York, York, UK

E-mail: [email protected]