Academic journal article Health and Social Work

Substance Abuse Treatment Outcomes for Coerced and Noncoerced Clients

Academic journal article Health and Social Work

Substance Abuse Treatment Outcomes for Coerced and Noncoerced Clients

Article excerpt

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. …

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