Academic journal article Journal of Marital and Family Therapy

An Examination of Mandated versus Voluntary Referral as a Determinant of Clinical Outcome

Academic journal article Journal of Marital and Family Therapy

An Examination of Mandated versus Voluntary Referral as a Determinant of Clinical Outcome

Article excerpt

A literature review was undertaken to examine evidence for the effectiveness of psychotherapy with mandated clients. The primary question addressed was whether or not clients mandated to therapy, whether by court order or by order of their employers, show poorer outcomes than clients who enter therapy voluntarily. To this end, research on client resistance and motivational readiness to change was reviewed. This was followed by an examination of research on the effectiveness of mandated treatment. The question of the potential influence of relationship factors such as the therapeutic alliance was also addressed. The literature review was followed by suggestions for future research on the effectiveness of treatment for clients with mandated or voluntary referral status.

Psychotherapy encompasses a vast array of psychotherapeutic and systemic schools of thought, each with their corresponding styles and techniques. Although models may differ, one widespread assumption is that clients enter therapy voluntarily and are at least somewhat motivated to be there (Cingolani, 1984; Haley, 1992; Harris & Watkins, 1987; Rooney, 1992). Unfortunately, this assumption fails to account for clients who enter therapy under duress. Some of these clients are legally required by the courts to attend therapy for a variety of offenses involving child abuse and neglect, domestic violence, incest, or substance abuse. Others are referred to therapy by their employers for a variety of mental health problems (often substance abuse) under threat of losing their jobs.

The question of whether traditional therapy techniques, which are generally based on working with voluntary clients, can be effective when applied to clients who do not attend treatment voluntarily has received limited attention in the field of psychotherapy and even less in the field of marriage and family therapy. Harris and Watkins (1987) noted, for instance, that "little has been written about the problems of adapting psychological theories to clients who are involuntary and reluctant to participate in a change process" (pp. 6-7). The involuntary client is likely to resist treatment in all the ways that the voluntary client might, but the coerced entry into counseling can compound the resistance and add new complications to the beginning of the therapy process. Most authors who have addressed this subject agree that mandated clients generally enter treatment with greater resistance to therapy and less motivation to change than those who begin treatment voluntarily (Begun et al., 2003; Chamberlain, Patterson, Reid, Kavanaugh, & Forgatch, 1984; Lehmer, 1986; Miller & Rollnick, 1991; Rooney, 1992; Taft, Murphy, Elliott, & Morrei, 2001). The greater the resistance, the less likely clients will change (Miller & Sovereign, 1989) or remain in therapy (Chamberlain et al., 1984).

It would seem that mandated versus voluntary referral status, and the accompanying issues of client resistance and motivation to change, constitute key determinants to psychotherapy outcome. The purpose of this article is to examine this issue by reviewing research on client resistance and motivational readiness to change. This is followed by an examination of research on the effectiveness of mandated treatment. The potential influence of relationship factors such as the therapeutic alliance is also discussed. The article concludes with suggestions for future research on the effectiveness of treatment for clients with mandated versus voluntary referral status.

CLIENT RESISTANCE

The literature is relatively uniform in suggesting that mandated clients are more resistant to treatment than voluntary clients (Chamberlain et al., 1984; Haley, 1992; Lehmer, 1986; Miller & Rollnick, 1991; Rooney, 1992; Taft et al., 2001). DiClemente (1991) suggested that this resistance is the result of "the four R's": client reluctance, rebellion, resignation, and rationalization. A broader view is that this phenomenon is a normal reaction to compulsory treatment, as people are likely to resist their loss of freedom and independence (Weakland & Jordan, 1990; Woody & Grinstead, 1992). …

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