Substance abuse treatment outcomes for coerced and noncoerced clients.

Research indicates that only a small proportion of individuals with alcohol and other drug (AOD) problems seek help voluntarily (Bannenberg, Raat, & Plomp, 1992; National Survey of Drug Use and Health (NSDUH), 2003; Price, Cotler, & Robins, 1990), and many who enter treatment drop out (Higgens & Budney, 1997; Stark, 1992). Moreover, without intervention AOD problems often lead to the development of chronic, progressively debilitating disorders with high costs to those afflicted, their families, and the community at large (NSDUH). Legal coercion compelling individuals with AOD problems to enter treatment as an adjunct or alternative to incarceration has become widespread (Leukefeld & Tims, 1988; Price & D'Aunno, 1992; Shottenfeld, 1989).

The use of legally coerced care remains controversial, however, and poses a variety of challenges for social workers and other behavioral health care workers. This controversy sometimes centers on ethical or due process issues associated with the use of forced entry into treatment, but also often focuses on debate about the effectiveness of coerced care (Fagan, 1999; Marshall & Hser, 2002; O'Hare, 1996). Concern about the efficacy of legally coerced treatment for AOD problems stems from beliefs that coercion interferes with the ability to establish and maintain a therapeutic relationship that enables participants to benefit from treatment (Behroozi, 1992; Garfield, 1994). O'Hare argued that "most treatment models in social work assume a reasonable degree of voluntariness by the client" (p. 2). A second, related concern, focuses on the notion that to fully benefit from treatment clients must be motivated to participate in treatment and that the use of coercion largely disregards the importance of motivation in recovery (Fagan).

It is not surprising that involuntary clients have often been perceived negatively by practitioners as resistant, hostile, and unmotivated (Goldstein, 1986; Miller & Rollnick, 1991 ; Rooney, 1992). Proponents of more confrontational approaches to people with substance abuse problems, such as the Johnson Intervention Model, assert that coercive measures can enhance the motivation to seek treatment (Johnson, 1980, 1986). In any case, court-ordered care is a growing element of current drug policy aimed at closing the "denial gap" by exposing people to treatment who might not otherwise seek it (National Drug Control Strategy, 2004).

Resolution of the debate about the impact of coerced care on treatment outcomes is, in large part, an empirical question. Studies of legally coerced treatment for substance abuse have not been conclusive in their findings, although several studies support the notion that coerced clients do as well or better than clients who enter treatment voluntarily (Anglin & Hser, 1990; Collins & Allison, 1983; Leukefeld, 1988; Miller & Flaherty, 2000). Earlier studies have often been limited in a number of ways (Marlowe et al., 2001; Marshall & Hser, 2002). Many earlier studies have focused on treatment retention rather than treatment outcomes such as the reduction or elimination of drug use or the severity of AOD-related problems. At least some of these studies found that coerced individuals remained in treatment longer than noncoerced individuals (Anglin, Brecht, & Maddahian, 1989; Collins & Allison; DeLeon, 1988a; Leukefeld; Loneck, Garrett, & Banks, 1996). In other studies there were no significant differences noted in treatment retention between coerced and voluntary clients (Allan, 1987; Brizer, Maslansky, & Galanter, 1990; DeLeon, 1988b; Rosenberg & Liftek, 1976; Simpson & Friend, 1988). In their study of outpatient drug-free treatment programs, Joe and colleagues (1999) found that legal coercion had a positive effect on session attendance, but a slightly negative effect on a client's therapeutic involvement. Among a sample of inpatient clients, legal pressure had no effect on either therapeutic involvement or treatment retention. To be sure, these are important findings given evidence for a significant relationship between treatment retention (that is, length of stay or time in treatment) and positive outcomes for recipients of substance abuse treatment (Grella, Hser, Joshi, & Anglin, 1999; Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997; Simpson, Joe, & Brown, 1997). They do not, however, directly address the issue of whether coerced and noncoerced clients experience similar benefits from participation in treatment.

Findings from studies that have compared treatment outcomes for coerced and noncoerced clients have also been mixed (Miller, 1985; Rotgers, 1992; Weisner, 1990; Wild, Cohen, Mann, & Ellis, 1995). Some studies have reported no difference in use for legally coerced and noncoerced clients (Anglin, 1988; Brecht, Anglin, & Wang, 1993; Collins & Allison, 1983; Inciardi, 1988; Simpson & Friend, 1988). Other studies suggested that coerced clients do better than noncoerced clients on some outcomes (Friedman, Horvat, & Levinson, 1982; Loneck et al., 1996; Watson, Brown, Tilleskjor, Jacobs, & Purcell, 1988).

Marshall and Hser (2002) argued that earlier studies have been limited by their failure to adequately consider important potential differences between coerced and noncoerced clients that might influence treatment outcomes. They added that the relatively small body of research that has begun to explore differences between coerced and noncoerced clients has focused too much on sociodemographic characteristics and neglected potentially more important psychosocial factors such as motivation, psychological and health status, and prior drug use history.

This study aimed to contribute to this debate by providing new evidence about the relation of legal coercion to treatment outcomes. Both substance use and addiction severity were examined as outcomes for clients six months after treatment. These outcomes were examined while focusing on a variety of psychosocial characteristics that might be expected to impinge on the outcome of treatment. More specifically, this study compared outcomes for coerced and noncoerced clients while taking into account important covariates of recovery, including readiness to change and severity of alcohol, drug, and psychiatric problems at admission.

METHOD

Study Design and Sample

Baseline data for this study were obtained from adult clients participating in a prospective study of substance abuse treatment outcomes. Potential study participants consisted of 320 consecutive admissions to outpatient treatment in five large, public substance abuse treatment programs located throughout Ohio. During the initial assessment session, agency staff asked clients to participate in a follow-up study consisting of data collection at admission, discharge, and six and 12 months after treatment. Participants received a $10 gift certificate to a local discount store for their participation at each data collection interval. A total of 297 people, 92.8 percent of those asked, agreed to participate in the study.

Eight cases were deleted from this analysis due to missing data (n = 289). For the initial sample, the mean age was 32.5 years (SD = 9.35 years) and more than three-fourths (77.6 percent) were men. Nearly the same proportion (71.9 percent) were white; 19.4 percent were African American, and 7.7 percent were Hispanic. Just fewer than 78 percent reported they had regular full--or part-time employment. This treatment episode represented the initial substance abuse treatment experience for about one-third (32.6 percent) of participants. The mean number of prior treatment episodes among those with a treatment history was 2.9 (SD = 3.04). With respect to legal coercion, 75.5 percent reported that the criminal justice system had precipitated this treatment admission. Alcohol was the sole drug of choice for 41 percent of the participants. An additional 18 percent regularly used alcohol along with some other substance. Marijuana use was the primary problem for 16 percent of participants; 11 percent endorsed cocaine as their drug of choice, and just fewer than 4 percent indicated either opiate use or regular use of multiple drugs.

Measures

The fifth edition of the Addiction Severity Index (ASI) (McLellan et al., 1992) was used to collect the demographic data and to assess both pretreatment alcohol and drug problem severity and posttreatment outcomes. Follow-up data were collected with the short form of the ASI. This form omits redundant demographic and lifetime data collection and takes about 20 minutes to administer. The ASI yields composite severity scores for seven problem domains: medical, legal, employment, alcohol, drug, family and social status, and psychiatric status. The reliability and validity of this instrument has been established for use with a wide range of populations (Alterman, Brown, Zabellero, & McKay, 1994; Argeriou, McCarty, Mulvey, & Daley, 1994; McLellan et al., 1985).

Readiness to change was measured by adapting the 12-item Readiness to Change Questionnaire (RTCQ) (Rollnick, Heather, Gold, & Hall, 1992). Data from this self-administered instrument were used to categorize individuals into one of three stages of change: precontemplation, contemplation, or action. Rollnick and colleagues reported test-retest reliabilities for the three scales as follows: precontemplation. 82, contemplation. 86, and action .78. In support for the validity of the questionnaire, the authors demonstrated a significant relationship between the stage of change and endorsement of the need to modify behavior measured in a health history screening instrument. Heather and colleagues (1993) found that stage of change was an accurate predictor of alcohol consumption among heavy drinkers at a six-month follow-up.

For this study, the RTCQ was modified to allow clients to describe their readiness to change with respect to their alcohol or other drug use behavior. Clients received scores in each of the three stages and were assigned to a particular stage on the basis of their highest score. Scoring instructions suggested assigning tied scores to the highest level of readiness. Because of the availability of other empirical data supporting client motivation, a different approach was used in this study. Shen and colleagues (2000) found that ASI client ratings of the importance of receiving treatment served as a proxy for motivation. When cases were tied the participant's ASI rating of treatment importance was used to assign the participant to a stage of change.

Follow-Up Interview Sample. Although agency staff recruited participants, obtained written informed consent, and collected intake and discharge data, university research staff members conducted follow-up telephone interviews. Participants were located using follow-up contact information obtained by agency staff at admission and updated at discharge. Callers made up to 10 attempts to contact participants. Contact attempts also included a postcard mailed to participants requesting them to contact the researchers at no cost using a 1-800 number. Neither the postcard nor any phone messages identified the purpose of the study, to protect client confidentiality. Research team members made an average of seven calls per completed interview. Nearly half (47.8 percent) of clients in the initial sample were located and agreed to complete a six-month follow-up interview (141 of 289). Although there was no significant difference in the characteristics of lost cases by treatment program, a substantial number of the lost cases came from two treatment sites. Despite regular monitoring by research staff, agency staff turnover resulted in the failure to obtain follow-up contact information for numerous clients. The lack of client contact information made it more difficult to locate and interview clients served in these two agencies. Hence, missing cases at follow-up were due much more to the inability to locate clients than to their refusal to participate. Problems locating clients for follow-up were more pronounced at 12 months after treatment, resulting in the decision to examine outcomes at six rather than 12 months after treatment.

We compared lost cases with those who were interviewed on a number of key characteristics (Table 1).The ability to obtain completed follow-up interviews did not appear to be a function of coercion, motivation, or pretreatment addiction severity. Fifty percent of the coerced clients and 45 percent of the noncoerced clients completed a six-month follow-up interview (Table 1).These data demonstrate no significant difference in follow-up interview participation rates for coerced and noncoerced clients [[chi square] (1, N = 289) = .521, p = .559].

Similar results are evident when comparing those included in the follow-up sample with those not included with respect to pretreatment readiness to change. Analysis of baseline data regarding readiness to change revealed that all but a few respondents entered treatment either in the contemplation or action stage. The few (n = 7) individuals who scored in the precontemplation stage were combined with those in the contemplation stage. Follow-up interviews were conducted with slightly more than 50 percent of clients included in the action group and 47 percent of those in the contemplation group, also representing a nonsignificant difference [[chi square] (1, N = 285) = .031, p = .860] (Table 1).With one exception, respondents who were reinterviewed did not differ significantly from those lost to follow-up on any pretreatment ASI composite scores. Although psychiatric severity scores were generally low among both groups, clients lost to follow-up had significantly higher pretreatment psychiatric severity scores [t(285) = 4.586,p < .001].

The ability to locate and reinterview clients was not a function of gender [[chi square] (1, N = 287) =.018, p = .892] (Table 1). Nearly half (49.6 percent) of the male participants and a similar proportion (47.5 percent) of the female clients in the initial sample completed a six-month follow-up interview. Drug of choice did not influence subsequent participation in follow-up [[chi square] (4, N = 267) = 1.34, p = .854]. Age emerged as a statistically significant difference when comparing those who completed the six-month follow-up interview with those who did not [t(280) = -2.21, p = .028]. The mean age of respondants completing follow-up interviews was 33.8 (SD = 8.8) compared with 31.3 (SD = 10.8) for those not included in the six-month follow-up.

Analysis

We used a binary logistic regression analysis to assess the relationship of coercion and pretreatment readiness to change in posttreatment substance use with abstinence (yes/no) as the dependent variable. Differences in pretreatment severity were controlled by including interviewer ratings of the severity of the client's psychiatric, alcohol, and drug problems recorded on the ASI during the intake interview. To further account for pretreatment severity, a measure of family substance abuse history was also included in this analysis. Significant differences in addiction severity have been attributed to family history (Coviello, Alterman, Cacciola, Rutherford, & Zanis, 2004). Family history was operationalized here as a client's count of the number of parents and siblings with an alcohol or other drug problem.

A multivariate analysis of variance (MANOVA) was used to assess differences in posttreatment addiction severity. The dependent variable measures were the ASI alcohol, drug, and psychiatric composite scores. Although ASI composite scores at intake are commonly used as measures of pretreatment severity, this study did not use this approach. Preliminary analysis found a significant interaction between the coercion variable and the pretreatment alcohol severity rating when introduced as a covariate. This violated the homogeneity of regression assumption. This assumption requires that covariates not exert a differential effect on the dependent variable as a function of the values of the independent variable (coercion in this case). A significant interaction is indicative of a violation of this assumption (Cohen, Cohen, West, & Aiken, 2003). Having determined that a covariance analysis was inappropriate, residualized gain scores were created by regressing posttreatment severity ratings on their pretreatment counterparts. These residualized scores, representing net severity, were then examined as dependent variables in the MANOVA.

RESULTS

Posttreatment AOD Use

Nearly three-fourths (72.3 percent) of those who completed a follow-up interview reported no use of alcohol or other drugs in the 30 days before the interview. After controlling for pretreatment severity, the addition of the coercion variable resulted in significant improvement in the log-likelihood ratio [[chi square] (1, N = 141) = 5.614, p = .018]. Participants in the coerced group were 2.8 times more likely to report abstaining from alcohol or other drugs in the 30 days before the six-month follow-up interview than were those in the noncoerced group (Table 2). However, readiness to change at admission was not associated with posttreatment substance use. The subsequent addition of the readiness to change variable did not significantly affect the log-likelihood ratio [[chi square] (1, N = 141) = 5.614, p = .018].

Addiction Severity

As indicated earlier, residualized scores represent posttreatment severity scores for clients net of their pretreatment scores. In general, clients who were coerced into treatment tended to have lower net severity scores at outcome (Table 3). There appeared to be no difference in follow-up severity scores based on readiness to change at admission, however.

Using Pillai's Trace as a test criterion, the MANOVA revealed no difference in addiction severity based on readiness to change [F(3,131) = 1.12,p = .345]. The multivariate test for coercion was determined to be significant, however [F(3, 131) = 4.36, p < .01] indicating that clients who were coerced into treatment had lower severity scores at follow-up. Based on evidence from the multivariate test for a significant effect of coercion on posttreatment severity, univariate tests were then examined. These analyses revealed significant differences in drug severity [F(3,131) = 10.92,p = .001] and psychiatric severity [F(3, 131) = 5.18,p = .024].The difference in alcohol severity approached but did not obtain significance [F(3, 131) = 3.399,p < .067].

DISCUSSION

This article presents new evidence intended to contribute to the ongoing debate about the effect of legally coerced care on substance abuse treatment outcomes. Data presented here indicate that legally coerced clients reported less drug use than did noncoerced clients when interviewed six months after treatment. These data also indicate lower addiction severity scores at follow-up for those who were legally coerced to enter treatment compared with those who entered treatment voluntarily, controlling for pretreatment severity. Moreover, coercion was related to posttreatment AOD use and addiction severity regardless of the client's stage of change at admission.

It could be argued that people legally coerced into treatment were more likely to report abstinence from substance use out of fear that to admit such use would put them at risk of legal sanctions. However, respondents were aware that the follow-up interviews were being conducted by people not affiliated with treatment agencies and were advised that their responses were being collected in confidence and reported only in the aggregate. Moreover, findings that coerced participants demonstrated better outcomes for both substance use and addiction severity lend credence to the validity of these findings.

These data do not provide evidence about why those coerced into care reported better outcomes. Two plausible explanations--that coerced and noncoerced clients were somehow different in addiction severity or in their readiness to change at admission--have been examined here. Clients coerced into treatment reported better outcomes at follow-up even when taking into account differences at admission in readiness to change and addiction severity. It should be noted that limited variability in the dichotomous (contemplation versus action) readiness to change variable used in these analyses may not have represented the full impact of motivation at admission on outcomes. Also, the readiness to change instrument did not distinguish the sources of motivation in determining readiness. Although coercion is clearly an external source of motivation, some participants may have had varying degrees of internal motivation to change or pressure from sources other than law enforcement. Although pressure from family members, employers, or personal commitment to change may wane, legal coercion tends to remain in force throughout the treatment experience. Legal pressure to attend treatment and comply with treatment expectations may have compelled even people initially unmotivated for treatment to engage in the prescribed change behavior. Subsequent studies that attempt to discern the influence of the source of a client's motivation on the stability of the stage of change may help answer this question.

Caution should be taken in generalizing these findings on the basis of this relatively small sample (n = 141) in a single state. Larger, comparative studies could allow for examination of more elaborate analytic models to account for other important factors that can impinge on posttreatment outcomes. For example, these data do not address the issue of post-treatment surveillance and supervision that might be provided to coerced clients after they have left treatment. Six months is not a long posttreatment period, and it may be that many of these clients were still being monitored by the court system and were required to remain abstinent to avoid incarceration. Some studies of probation and parole programs in which clients received enhanced access to a range of substance abuse treatment services demonstrated lower rates of use compared with clients in traditional probation programs; although clients were monitored, relapse rates increased substantially after termination of supervision (Bailey, 1975; Brecht et al., 1993).

Such monitoring may also require coerced clients to be more engaged in self-help groups that support and encourage continued sobriety. Evidence suggests that although aftercare is widely regarded as important to relapse prevention and positive posttreatment outcomes, few treatment providers have the resources to offer such services (Hubbard et al., 1989). Although too little research has been done on the efficacy of involvement in 12-step programs, some research has indicated a significant relationship between participation in Narcotics Anonymous and Alcoholics Anonymous meetings and posttreatment sobriety (Christo & Sutton, 1994; Johnsen & Herringer, 1993).

Future studies ought to more directly address issues related to the effect on outcomes of posttreatment surveillance and supervision as well as participation in self-help and other forms of aftercare. As indicated earlier, attrition problems at the 12-month follow-up interval did not permit examination of the effect of coercion on longer term posttreatment outcomes, which could be valuable in more fully understanding the effect of coercion on recovery from substance abuse problems.

Despite limitations, these findings ought to be somewhat reassuring to social workers and other treatment staff concerned about lack of client choice and right to self-determination among coerced clients. In this study legally coerced care does not appear to impede recovery and, in fact, was associated with better posttreatment outcomes. That is not to say that social workers will no longer face dilemmas associated with trying to balance concerns for the individual rights of their clients with broader community interests. It is unlikely that court- or employer-mandated care will diminish in the foreseeable future; therefore, social work professionals should enhance their ability to provide ethical and effective treatment for clients coerced into treatment.

Both research and practice with coerced clients may benefit from adopting a broader approach that addresses both objective and subjective elements of coercion. More specifically, Marlowe and his associates (2001) asserted that "substance abusers are commonly subjected to a broad array of coercive, treatment-entry pressures, not all of which emanate from legal sources" (p. 208) and argued for the importance of assessing the full range of these treatment-entry pressures. Explicitly examining the context and conditions that propel or compel individuals into treatment seems an important starting point for establishing a therapeutic relationship that can foster and support change. Such a focus may also be useful in treatment planning by helping clients to clarify goals and identify important sources of leverage for change. A more comprehensive approach to measurement of coercive pressures on clients may also aid in evaluating treatment outcomes in light of what is more likely a continuum of divergent circumstances than the simple dichotomy examined here and in most earlier studies.

Farabee and Leukefeld (2001) suggested that treatment providers focus on two principles from Thompson's Guide to Ethical Practice of Psychotherapy (1990)--autonomy and fidelity. According to Farabee and Leukefeld, "Autonomy requires that the therapist create an environment in which the client is free to actively collaborate in his or her own treatment. The clinician must also provide the least restrictive form of treatment necessary and limit any coercive elements of the program as quickly as possible. The principle of fidelity requires the therapist to work primarily for the good of the client and to avoid any dual responsibilities that may potentially compromise the therapeutic relationship" (p. 46). They asserted that the practitioner must clarify his or her obligations to the client and to the criminal justice system, including circumstances in which the counselor should report a client's behavior to authorities. Moreover, these decisions must be made and communicated in writing to the client at the onset of treatment.

Finally, Farabee and Leukefeld (2001) argued that external pressures such as legal coercion can get and even keep clients in treatment who might not otherwise seek treatment but that coerced care "must be matched by equally earnest efforts to enhance offenders' internal motivation during the early phases of treatment" (p. 53; see also, Marlowe et al., 2001). Such efforts require skillful as well as ethical behavior on the part of practitioners. Several strategies are available for engaging and motivating involuntary clients to be partners in their treatment and make behavioral changes, including motivational interviewing and a variety of solution-focused brief interventions intended to address the barriers to participation posed by coercion, legal or otherwise (De Jong & Berg, 2001; Meichenbaum & Turk, 1987; Miller & Rollnick, 1991; Rooney, 1992). Of course training is required to make these techniques more widely available to social workers and other professionals. Explicit training on managing ethical dilemmas and acquiring the skills required to address the needs of this population are integral to improving education for social work practitioners in the area of substance abuse treatment and improving treatment outcomes for clients coerced into receiving care.

Original manuscript received April 27, 2004

Final revision received December 6, 2004

Accepted May 3, 2005

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Anna C. Burke, PhD, is associate professor, and Thomas K. Gregoire, PhD, is associate professor, College of Social Work, Ohio State University. Address all correspondence concerning this article to Dr. Anna C. Burke, College of Social Work, Ohio State University, Stillman Hall, Room 340A, 1947 College Road, Columbus, OH 43210; e-mail: [e-mail].

Table 1: Substance Abuse
Treatment Client Characteristics,
by Follow-up Status (N = 289)

                               Lost to           Follow-Up
                               Follow-Up         Conducted

Characteristic             M       (SD)      M       (SD)

Age                        31.3   (10.8)     33.8   (8.80)
ASI composite scores
  Medical                 0.177   (0.76)    0.145   (0.77)
  Employment              0.582   (0.30)    0.517   (0.27)
  Alcohol                 0.232   (0.30)    0.213   (0.30)
  Drug                    0.079   (0.23)    0.086   (0.20)
  Legal                   0.237   (0.12)    0.246   (0.12)
  Family                  0.207   (0.22)    0.176   (0.23)
  Psychiatric             0.179   (0.22)    0.128   (0.20)

                           N        %        N        %
Legal coercion
  Coerced                   109     50.0      109     50.0
  Noncoerced               39.0     54.9     32.0     45.1
Readiness to change
  Contemplation             106     49.3      109     50.7
  Action                     32     52.5       29     47.5
Gender
  Male                      114     50.4      112     49.6
  Female                     32     52.5       29     47.5
Drug of choice
  Alcohol                    60     51.7       56     48.3
  Multiple substances        32     51.6       30     48.4
  Cocaine                    16     51.6       15     48.4
  Marijuana                  22     50.0       22     50.0
  Other drugs                 5     35.7        9     64.3

Note: ASI = Addiction Severity Index.

Table 2: Logistic Regression Predicting
Substance Use at Six-Month Follow-Up

                                            Odds
Variable                   B       SE B    Ratio

Coerced                   1.043     .469    2.839 *
Readiness to change       0.197     .505    1.217
Family history            0.059     .153    1.060
Severity ratings
  Psychiatric            -.012      .077    0.988
  Alcohol                -.004      .080    0.996
  Drug                   0.040      .064    1.041
Constant                 -.184      .724    0.832

* p [less than or equal to]. 05.

Table 3: Net Addiction Severity
Index Composite Severity Scores,
by Coercion and Readiness to Change

                               M (SD)
Variable          Alcohol       Drug      Psychiatric

Noncoerced     0.114 (0.19) 0.056 (0.09) 0.171 (0.21)
Coerced        0.051 (0.09) 0.008 (0.02) 0.067 (0.14)
Contemplation  0.068 (0.12) 0.016 (0.04) 0.086 (0.15)
Action         0.064 (0.13) 0.020 (0.05) 0.093 (0.17)