Ethics of Mandated Treatment

PSY699: Master of Arts in Psychology Capstone The Ethics of Mandated Treatment Scenarios

Scenario 1: A client with a well-established history of repeated dangerous behavior and inpatient commitment has been treated, stabilized, and discharged into the community. The treating psychiatrist believes that the client’s success in the community is far more likely if treatment is continued. However, the client wishes to terminate treatment. A request for mandated treatment is filed by the psychiatrist with the court. During the hearing, the psychiatrist testifies that while the client is not imminently dangerous, he potentially could become dangerous again without treatment.

Scenario 2: A long-term client appeared quite excited during a recent session with her therapist. Speaking rapidly, she told the therapist that she was planning a gambling trip that would win her millions of dollars. After some probing, the therapist learned the client had recently stopped taking the medication prescribed for her bipolar disorder because she had been feeling so happy. The client also indicated that she no longer saw a need for therapy and was planning to stop treatment.

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AN EXAMINATION OF MANDATED VERSUS VOLUNTARY REFERRAL AS A DETERMINANT OF CLINICAL OUTCOME Snyder, Christine M J;Anderson, Stephen A Journal of Marital and Family Therapy; Jul 2009; 35, 3; ProQuest Central pg. 278

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Care, Control, or Both? Characterizing Major Dimensions of the Mandated Treatment Relationship

Sarah M. Manchak University of Cincinnati School of Criminal Justice

Jennifer L. Skeem and Karen S. Rook University of California, Irvine

Current conceptualizations of the therapeutic alliance may not capture key features of therapeutic relationships in mandated treatment, which may extend beyond care (i.e., bond and affiliation) to include control (i.e., behavioral monitoring and influence). This study is designed to determine whether mandated treatment relationships involve greater control than traditional treatment relationships, and if so, whether this control covaries with reduced affiliation. In this study, 125 mental health court participants described the nature of their mandated treatment relationships using the INTREX (Benjamin, L., 2000, SASB/ INTREX: Instructions for administering questionnaires, interpreting reports, and giving raters feedback (Unpublished manual). Salt Lake City, UT: University of Utah, Department of Psychology), a measure based on the interpersonal circumplex theory and assesses eight interpersonal clusters organized by orthogonal axes of affiliation and control. INTREX cluster scores were statistically compared to existing data from three separate voluntary treatment samples, and structural summary analyses were applied to distill the predominant theme of mandated treatment relationships. Compared with voluntary treatment relationships, mandated treatment relationships demonstrate greater therapist control and corresponding client submission. Nonetheless, the predominant theme of these relationships is affiliative and autonomy- granting. Although mandated treatment relationships involve significantly greater therapist control than traditional relationships, they remain largely affiliative and consistent with the principles of healthy adult attachment.

Keywords: mandated treatment, therapeutic alliance, treatment alliance, interpersonal circumplex, SASB, INTREX

The quality of the therapist– client relationship is the strongest controllable predictor of outcome in psychotherapy (Horvath, Del Re, Flueckiger, & Symonds, 2011; Klinkenberg, Calsyn, & Morse, 1998; Krupnick et al., 1996; Luborsky, Chandler, Auerbach, Co- hen, & Bachrach, 1971; Martin, Garske, & Davis, 2000). This relationship reflects an accumulation of interpersonal interactions over time that vary in their degree of (a) affiliation or connected- ness (ranging from hostile to friendly) and (b) control or influence

(ranging from controlling to autonomy-granting on the part of the therapist or from submissive to autonomy-taking on the part of the client; see Benjamin, Rothweiler, & Critchfield, 2006; Henry, Schact, & Strupp, 1990; Kiesler, 1983).

Conceptualizations of high-quality therapeutic relationships tend to focus almost exclusively on strong affiliation between therapist and client (see Bordin, 1979; Horvath & Luborsky, 1993). For example, the most widely used measure of the thera- peutic alliance (Horvath & Symonds, 1991; Martin et al., 2000; Tryon, Blackwell, & Hammel, 2007), the Working Alliance In- ventory (WAI; Horvath & Greenberg, 1989), emphasizes an inter- personal bond between the therapist and client and collaboration in working toward shared goals. In contrast, the role of control in these relationships tends to be neglected or explicitly minimized (see Curtis & Hirsch, 2003; Rogers, 1957).

Therapist Control and Assertive or Involuntary Treatment

In contemporary service contexts for clients with serious mental illnesses (e.g., schizophrenia, bipolar disorder, major depression), control may play a prominent role in treatment relationships, because services are often assertively delivered, leveraged, or even mandated by the court. This may be because individuals with serious mental illness often have co-occurring substance abuse problems and difficulty following treatment recommendations (see American Psychiatric Association, 1994; Cramer & Rosenheck,

This article was published Online First July 8, 2013. Sarah M. Manchak, University of Cincinnati School of Criminal Justice;

Jennifer L. Skeem and Karen S. Rook, Department of Psychology and Social Behavior, University of California, Irvine.

This research was funded by the American Psychology-Law Society Grant-in-aid program and the University of California, Irvine Newkirk Center for Science and Society. The authors also thank Shaudi Adel and Felicia Keith for their assistance with interviewing participants; Ken Critchfield and Edward Shearin for providing the raw data from their studies and input on this paper; Aaron Pincus for his assistance with the Structural Summary analyses; and the Orange Country, California, and San Bernardino County, California, mental health courts and their affiliated probation departments and treatment agencies/providers for their approval and support of this research project.

Correspondence concerning this article should be addressed to Sarah M. Manchak, University of Cincinnati School of Criminal Justice, 665-BA Dyer Hall, Clifton Ave, P.O. Box 210389, Cincinnati, OH 45221-0389. E-mail: [email protected]

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Law and Human Behavior © 2013 American Psychological Association 2014, Vol. 38, No. 1, 47–57 0147-7307/14/$12.00 DOI: 10.1037/lhb0000039

47

1998; Fenton, Blyler, & Heinssen, 1997; Karberg & James, 2005; Kessler et al., 1996; Regier et al., 1990).

There are clear signs that therapist control plays a role in treatment services for this population. For example, Assertive Community Treatment (ACT; see Dixon, 2000; Drake et al., 1998; McCabe & Priebe, 2004) is one of the best-known evidence-based treatment programs for clients with serious mental illness. Studies of ACT teams have revealed that therapists often try to increase their clients’ medication adherence by applying pressure, with- holding assistance, and occasionally threatening to pursue invol- untary hospitalization (see Angell, 2006; Neale & Rosenheck, 2000).

There may be a similar “pull” toward therapist control when clients are informally or formally mandated to take part in treat- ment. Informally, services in the community can be “leveraged,” or made contingent upon treatment compliance. In a study of more than 1,000 patients, Monahan et al. (2005) found that patients were often required to participate in therapy and/or take medication to obtain discretionary money (7%–19%) or maintain housing (23%– 40%; see Monahan et al., 2005). Treatment may also be formally mandated by a court, in both civil (i.e., inpatient or outpatient commitment) and criminal contexts. In fact, Monahan et al. (2005) found that among patients who had ever been arrested, up to half were told that they would be incarcerated unless they complied with treatment. When patients are required to participate in treat- ment, control may become an important component of the rela- tionship.

Does Therapist Control Necessarily Reduce Affiliation?

Does increased control in a therapeutic relationship come at the expense of affiliation? Data relevant to this question are available from studies of voluntary psychotherapy (K. Critchfield, personal communication, June, 2011; Coady & Marziali, 1994; Critchfield, Henry, Castonguay, & Borkovec, 2007; Harrist, Quntana, Strupp, & Henry, 1994; Henry et al., 1990; Najavits & Strupp, 1994; Shearin & Linehan, 1992) that apply the interpersonal circumplex model of relationships (Freedman, Leary, Ossorio, & Coffey, 1951; Gurtman, 1992; Kiesler, 1983; Leary, 1957). We provide a brief introduction to the model here, using Benjamin’s (1996) operationalization.

As shown in Figure 1, the circumplex is defined by a horizontal axis of affiliation (“Attack” to “Love”) and a vertical axis of control (“Autonomy Granting” to “Control”). Each point in cir- cumplex space reflects a weighted combination of these two di- mensions and can be used to map the therapeutic relationship (see Freedman et al., 1951; Gurtman, 1992; Kiesler, 1983; Leary, 1957). For example, prototypic therapist behaviors that combine moderate affiliation with moderate control are mapped as “Pro- tect,” whereas those that combine moderate affiliation with mod- erate autonomy granting are mapped as “Affirm.” Beyond describ- ing relationships, the circumplex model also allows for prediction. Specifically, according to the principle of complementarity, one person’s behavior evokes a class of behavior from the other person that is similar on the affiliation axis (e.g., therapist hostility invites client hostility) and reciprocal on the control axis (e.g., therapist control invites either client submission or client autonomy taking; Benjamin, 2000).

According to both the structure of the interpersonal circumplex (see Figure 1) and the principle of complementarity, therapist control alone will not influence the degree of affiliation in the therapeutic relationship. Given that the control axis is orthogonal to the affiliation axis, therapist behavior can be purely controlling (and neutral in affiliation). Theoretically, control will come at the expense of affiliation only if control tends to be combined with hostility. Specifically, hostile control from a therapist (i.e., “Blame,” Figure 1) would elicit hostile submission (“Sulk”) or hostile autonomy taking (“Wall Off”) from a client.

Two relevant findings have emerged from studies of volun- tary psychotherapy that apply Benjamin’s circumplex mea- sures: the observer-rated Structural Analysis of Social Behavior (SASB: Benjamin, 1996), or the self-report INTREX (Benja- min, 2000). First, therapists rarely exercise pure control or hostile control and (perhaps for that reason) clients rarely respond in a manner that is disaffiliative or distancing. Instead, voluntary treatment relationships are predominantly character- ized by therapist “Affirm” and “Protect” (i.e., affiliative autonomy-granting and control) and corresponding client “Dis- close” and “Trust” (i.e., affiliative autonomy-taking and sub- mission; Critchfield et al., 2007). Even among patients with poor outcomes, therapist pure control (M � 5.3) and patient pure submission (M � 4.2) are quite low, relative to therapist “Affirm” (M � 35) and “Protect” (M � 20) and patient “Trust” (M � 17) and “Disclose” (M � 101; Henry et al., 1990; see also Harrist et al., 1994; Shearin & Linehan, 1992; K. Critchfield, personal communication, June, 2011; Tables 1 and 2).

Second, when therapists do exercise pure or hostile control, patients tend to behave in a manner that is disaffiliative and often experience poor clinical outcomes. INTREX ratings of high therapist control are associated with disaffiliative re- sponses from the client (e.g., “Sulk” and “Wall off”; see K. Critchfield, personal communication, June, 2011; Harrist et al., 1994; Table 2). Similarly, therapist “Watch/Control” early in therapy is associated with poorer overall therapist-rated alliance (Coady & Marziali, 1994). Moreover, having a therapist with low “Affirm” and high “Control” is predictive of longer hos-

Figure 1. Simplified One-Word Cluster Model (Benjamin, 1996) with Corresponding Angular Displacement Added. Therapist transitive scores in bold; client intransitive scores underlined.

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48 MANCHAK, SKEEM, AND ROOK

pital stays and less symptom improvement for clients (Najavits & Strupp, 1994).

In summary, research on voluntary treatment relationships sug- gests that therapists rarely express “pure” or hostile control, but when they do, it tends to promote disaffiliation, distancing, and poor outcomes. The extent to which these findings generalize from voluntary to involuntary treatment contexts is unknown. In invol- untary contexts, therapists may be pulled toward more controlling behavior, and clients may feel coerced to take part in treatment. Patients who feel coerced may respond with (a) anger and resis- tance to treatment goals or (b) a sense of helplessness and de- creased therapeutic engagement (see Monahan et al., 1995).

There is indirect evidence for such propositions. Specifically, patients in mandated civil psychiatric treatment perceive greater coercion to take part in treatment than voluntary patients (Shee- han & Burns, 2011; Swartz, Wager, Swanson, Hiday, & Burns, 2002). In turn, perceived coercion is inversely associated with patient ratings of the therapeutic alliance (Sheehan & Burns, 2011), which emphasize affiliation. Similarly, in correctional

treatment, rehabilitative probation officers’ use of hostile con- trol (i.e., “toughness”) is associated with decreased caring, fairness, and trust in the officer–probationer relationship (Skeem, Eno Louden, Polaschek, & Camp, 2007).

The extent to which mandated treatment relationships involve greater amounts of therapist control than voluntary treatment relationship is unknown. Even more, it is unclear whether pronounced control (which is rare in voluntary relationships, but may be common in mandated relationships) comes at the expense of affiliation. Because the quality of the client-provider relationship may play a crucial role in behavior change, it is necessary to properly operationalize the construct to study its effects on client outcomes. Ratings of the therapeutic alliance (i.e., affiliation) may not fully capture therapist– client relation- ship quality in mandated treatment, where control may play a prominent role. It is necessary to first empirically test whether it is the case that mandated treatment relationships are higher in control and explore how control and affiliation are related in mandated treatment.

Table 1 Therapist Transitive INTREX Cluster Score Predictions and Preexisting Voluntary Data Findings

Cluster Predictiona Critchfieldb Shearin & Linehan (1992) Harrist et al. (1994) Grand M (used as distilled data)

Affiliation clusters Affirm/Understand���1 Highest 95.4 (6.8) 85.0 (14.5) 74.4 (15.9) 78.4 (14.3) Love/Approachc���2,3 High 75.0 (33.4) 82.1 (12.0) 40.5 (18.0) 65.9 (21.1) Nurture/Protectc���4 Highest 83.0 (25.3) 89.1 (11.4) 57.3 (17.5) 76.5 (18.0)

Attack clusters Belittle/Blame Lowest 0.3 (1.3) 5.4 (6.6) 3.1 (6.9) 2.7 (5.9) Attack/Reject Lowest 0.0 (0.0) 5.8 (10.5) 2.5 (5.6) 2.2 (4.9) Ignore/Neglect Lowest 0.3 (1.3) 9.8 (14.5) 4.5 (9.3) 4.0 (8.2)

Control dimension Free/Forget Moderate 43.0 (40.1) 44.6 (28.4) 44.2 (17.3) 44.0 (21.6) Watch/Control Low 18.3 (21.2) 34.1 (32.1) 12.9 (12.8) 14.8 (15.1)

Note. Values are means with standard deviation in parentheses. A Bonferroni correction was applied to the Attachment and Attack Clusters and Control Dimension. Any flagged significant effects in these clusters are � � .02. a High � M � 75; moderate � M 26 –74; low � M � 25. b K. Critchfield, personal communication, June, 2011. c Unweighted grand M was used. ��� p � .001, F test for comparing sample means; 1 Critchfield vs. Harrist t(df � 83) � 5.0, p � .001; Cohen’s d � 1.1;

2 Critchfield vs. Harrist t(df � 83) � 5.7, p � .001; Cohen’s d � 1.3; 3 Shearin & Linehan vs. Harrist t(df � 72) � 4.6, p � .001; Cohen’s d � 1.1;

4 Critchfield vs. Harrist t(df � 83) � 4.7, p � .001; Cohen’s d � 1.0.

Table 2 Client Intransitive INTREX Cluster Score Predictions and Preexisting Voluntary Data Findings

Cluster Predictiona Critchfieldb Shearin & Linehan (1992) Harrist et al. (1994) Grand M (used as distilled data)

Affiliation clusters Disclose/Express Highest 75.0 (23.7) N/A 78.6 (13.9) 78.0 (15.6) Joyfully Connectc���1 High 65.7 (34.5) N/A 47.5 (15.4) 56.6 (25.0) Trust/Relyc���2 Highest 82.0 (19.7) N/A 65.2 (14.7) 73.6 (17.2)

Attack clusters Sulk/Scurry Lowest 16.0 (28.8) N/A 9.6 (11.3) 10.7 (14.4) Protest/Recoil Lowest 7.0 (16.2) N/A 4.9 (8.3) 5.3 (9.7) Wall-off/Distance���3 Lowest 24.3 (23.3) N/A 9.8 (12.3) 12.4 (14.2)

Control dimension Assert/Separate���4 Moderate 32.0 (34.2) N/A 62.3 (11.9) 57.0 (15.8) Defer/Submit Low 18.7 (29.6) N/A 12.4 (12.4) 13.5 (15.4)

Note. Values are means with standard deviation in parentheses. N/A � not available. A Bonferroni correction was applied to the Attachment and Attack Clusters and Control Dimension. Any flagged significant effects in these clusters are � � .02. a High � M � 75; moderate � M 26 –74; low � M � 25. b K. Critchfield, personal communication, June, 2011. c Unweighted grand M was used. ��� p � .001; t test for comparing sample means; 1 t(df � 83) � 3.6, p � .001; Cohen’s d � .79;

2 t(df � 83) � 3.8, p � .001; Cohen’s d � .83; 3 t(df � 83) � 3.5, p � .001; Cohen’s d � .77;

4 t(df � 83) � �6.0, p � .001; Cohen’s d � 1.3.

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49CHARACTERIZING MANDATED TREATMENT RELATIONSHIPS

Present Study

Based on a sample of individuals with serious mental illness mandated to mental health treatment through the criminal justice system, we addressed two aims in this study. First, we seek to determine how more frequent control is present in mandated treatment relationships than voluntary treatment relationships. Sec- ond, we determine whether increased therapist control in mandated treatment is associated with decreased client–therapist affiliation. We articulate our hypotheses and the procedures to test these hypotheses below.

To address our first aim, we provide not only a descriptive summary of our mandated sample, but we also seek to place our findings in context. To do so, we compare ratings of control and affiliation from our mandated sample to those found in prior studies of voluntary clients. We use this approach for two primary reasons. First, it is difficult—perhaps infeasible—to randomly assign offenders to voluntary versus mandated treatment. As noted by Parhar, Wormith, Derkzen, and Beauregard (2008, p. 1111), “[t]rue voluntary participation [in correctional treatment] does not exist in the criminal justice system because there is always some degree of external pressure.” A judge is unlikely to mandate treatment arbitrarily for some people with serious mental illness but not others. Second, absent any comparison or context, it is often difficult to interpret purely descriptive findings. Having a group against which to compare new data can place research findings in context.

Such practices are used both in the interpersonal circumplex (Excel Circumplex Calculator, A. Pincus, personal communica- tion, April 25, 2011; Wright, Pincus, Conroy, & Hilsenroth, 2009) and the psychological assessment literatures. For example Morgan, Fisher, Duan, Mandracchia, and Murray (2010) examined the criminal thinking styles of prison inmates with serious mental illness in light of scores obtained from nonoffender psychiatric patients and nonmentally ill offenders. More formally, Bornstein, Gottdiener, and Winarick (2009) used existing validation data on interpersonal dependency from nonclinical college samples as a benchmark against which to statistically compare their newly obtained data from a clinical substance-abusing sample.

Given the precedent to use existing data as a point of compar- ison when providing descriptive information about a sample for which there is not direct comparison group, we use published and nonpublished patient-rated, self-report INTREX data to which we compare our mandated sample data (K. Critchfield, personal com- munication, June, 2011; Harrist et al., 1994; Shearin & Linehan, 1992). Based on previous research (Angell, 2006; Monahan et al., 2005; Neale & Rosenheck, 2000) and consistent with the princi- ples of complementarity in interpersonal theory (i.e., behavior toward a person will elicit a complementary response; e.g., control and submission; see Benjamin, 2000), we hypothesize that man- dated treatment relationships involve greater therapist control and corresponding greater client submission than voluntary treatment relationships.

To address our second aim—to examine the relationship be- tween affiliation and control, we focus exclusively on the man- dated treatment sample and use several different indices com- monly used in interpersonal research in general (e.g., structural summary analyses to characterize the predominant interpersonal pattern in the client–therapist relationship) and with SASB/INTREX

technology, specifically (e.g., use of cluster score correlations and pattern coefficients, described below). Given that observer-rated and self-report studies of voluntary treatment relationships suggest that when control is present, it may adversely affect the relation- ship, we hypothesize that higher levels of control in mandated treatment will be associated with reduced client–therapist affilia- tion.

Method

We interviewed 125 mental health court participants about their relationship with their primary treatment provider and rated this relationship on the INTREX (Benjamin, 2000). We then compared data from this sample to published and unpublished data on pa- tients in voluntary treatment and used several interpersonal circumplex- specific statistical techniques and indices to examine the quality of mandated treatment relationships.

Procedure

Participants were recruited either at a courthouse or mandated treatment facility. Research assistants (RAs) made brief announce- ments to groups of prospective participants to describe the study (e.g., eligibility requirements, interview nature, confidentiality protections, and compensation of $30) and invited them to partic- ipate. RAs screened interested participants for eligibility and scheduled an interview for eligible persons at a time and location of their convenience. At the scheduled time, RAs completed the informed consent process and a 2-hr interview with participants, which included verbal administration of the INTREX and several other measures not central to the present study aims. The study protocol was approved by relevant Institutional Review Boards.

Participants

Participants were English-speaking adults who (1) were current participants in one of four mental health courts, (2) had completed at least one mandated treatment session with a therapist, case manager, or counselor, and (3) had a remaining mental health court term of approximately 4 months. Participants’ average age was 37 years (SD � 11.4); 54% were women, and 67.2% were White (16% Hispanic, 10.4% African American, 3.2% Native American, 3.2% Asian). Although 87% were currently unemployed, 70% of participants had received high school diploma/GED or greater education. Participants’ self-reported (and chart-verified) primary diagnosis was for a mood disorder (bipolar disorder � 54%; major depression � 19%; mood NOS � 2%); 23% had a diagnosis of schizophrenia, schizoaffective disorder, or other psychotic disor- der; and 2% had another Axis I mental disorder (e.g., anxiety, ADHD). Participants’ index offense was for drug (50%), property (32%), minor (11%), and person (6%) crimes (as defined by Monahan et al., 2001).

The average participation rate across the four courts, defined as the total number of people enrolled in the study divided by the total number of people enrolled in the mental health court during the year in which the study was conducted, was 32% (range � 25%– 40%). As shown in Table 3, enrolled participants did not differ from the court populations from which they were drawn in terms of gender, ethnicity, and age, which helps mitigate concern about selection bias.

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50 MANCHAK, SKEEM, AND ROOK

Data on participants were pooled across the four courts. There were no court-related differences between participants in gender or race/ethnicity. Although participants in Court 3 were younger than those in the other three courts (F(df � 3) � 3.3, p � .05; see Table 3), age generally does not predict client–therapist relationship quality (see Constantino, Arnow, Blasey, & Agras, 2005; cf. Schiff & Levit, 2010), and participants from this court did not differ from those in the other courts on INTREX ratings. For these reasons, participants were pooled for analyses.

Measure

Because many (56%) of the enrolled mandated clients were involved in day treatment programs where clients worked with several mental health providers at once (e.g., case worker, thera- pist, substance abuse counselor), participants were asked to rate the INTREX (Benjamin, 2000) on the provider who was consid- ered to be “the mental health professional you are most likely to turn to when you need advice or assurance, who helps you the most, and/or with whom you have the most significant discus- sions.” This professional could be a mental health therapist, a case worker, or a substance abuse counselor whom the participant saw individually on a regular basis.

The INTREX is a self-report version of the SASB (Benjamin, 1996).The 64-item medium form of the INTREX, which was used in the present study, provides for an “octant” model. The INTREX has three foci: (1) how an individual acts transitively toward another, (2) how an individual responds or reacts intransitively to another, and (3) how an individual relates to him/herself (not shown because this domain is not used in the present study). The horizontal axis is the “Love–Hate” (i.e., “affiliation”) axis, and the vertical axis is the “Differentiation–Enmeshment” (i.e., “control”) axis.

Participants rated how well each item described their relation- ship with their primary provider on a scale that ranged from 0 (never describes) to 100 (describes perfectly all of the time). Because the focus of the present study is largely on how the

therapist transitively acts toward the client and how the client intransitively reacts toward the therapist, our analyses focused on 32 of the original 64 items. Sixteen items assessed how the provider treated or acted toward the client (therapist focus, “tran- sitive surface”—two items � eight clusters, e.g., “My therapist helps, guides, and shows me how to do things”). The other 16 items described how the client reacted or responded to the therapist (“intransitive” surface, client focus—two items � eight clusters, e.g., “I defer to my therapist and conform to his or her wishes”). As shown in Figure 1, provider transitive cluster scores are shown in bold font, the client intransitive cluster scores are shown with an underline. Across both foci, the eight clusters can be simplified as (a) three “Affiliation Clusters” on the right side of the circumplex (provider “Affirm,” “Active love,” and “Protect”; client “Dis- close,” “Reactive love,” and “Trust”), (b) three “Attack Clusters” on the left side (provider “Ignore,” “Attack,” and “Blame”; client “Wall-off,” “Recoil,” and “Sulk”), and (c) two clusters at the poles of the vertical axis that reflect Pure Autonomy (provider “Auton- omy granting” and client “Autonomy-taking”) and Pure Control (provider neutral “Control” and client neural “Submission”).

The INTREX is written at a seventh grade reading level (Ben- jamin, 2000). For the purposes of this study, we made minimal changes to the wording of a few INTREX items to fit the thera- peutic relationship, but maintained emphasis on reading ease (e.g., “lovingly” was changed to “caringly”). The INTREX demonstrates good split half (� � .82) and test–retest (� � .84; Benjamin, Rothweiler, & Critchfield, 2006) reliability and good (Cronbach, 1951) internal consistency in the present sample (� � .85). With respect to validity, the INTREX has been shown to predict both patient satisfaction (Schedin, 2005) and clinical improvement (i.e., reduced parasuicidal behavior; Shearin & Linehan, 1992).

Distilling Voluntary Comparison Data

Three steps were taken to identify, analyze, and distill a com- parison data set from previous studies of voluntary treatment relationships. First, we conducted a two-pronged search strategy to

Table 3 Demographic Characteristics of Enrolled Samples vs. Court Populations

Demographics Total

enrolled

Court 1 Court 2 Court 3 Court 4

Enrolled (n � 61)

Court (n � 168)

Enrolled (n � 28)

Court (n � 70)

Enrolled (n � 9)

Court (n � 33)

Enrolled (n � 27)

Court (n � 110)

Age M (SD) 37 (11) 38 (11) 36 (12) 28 (8) 40 (12) Age grouping (%)

18–21 12.0 9.8 8.3 14.3 10.0 33.3 18.2 7.4 5.0 22–30 18.4 13.1 25.0 21.4 25.7 44.3 30.3 18.5 32.0 31–40 28.0 36.1 29.8 21.4 32.9 11.1 21.2 22.2 24.0 41–50 30.4 29.5 23.8 32.1 21.4 11.1 30.3 37.0 27.0 51� 11.2 11.5 13.1 10.7 10.0 0.0 0.0 14.8 12.0

Race (%) Caucasian 67.2 63.9 73.2 78.6 75.7 66.7 85.0 63.0 49.0 African American 10.4 9.8 5.3 3.6 4.3 11.1 3.0 18.5 22.0 Asian 3.2 3.3 1.8 7.1 4.3 0.0 0.0 0.0 1.0 Hispanic 16.0 19.7 15.5 7.1 12.9 22.2 9.0 14.8 22.0 Other 3.2 3.3 4.2 3.6 2.9 0.0 3.0 3.7 6.0

Gender (% women) 54 57 54 61 59 78 61 33 43

Note. For Court 4, the age distribution provided was 18 –20, 21–30; all other categories were the same; Group 3 vs. Group 1: t(df � 13) � 3.3, p � .05; Group 3 vs. Group 2: t(df � 21) � 2.3, p � .05; Group 3 vs. Group 4: t(df � 20) � 3.4, p � .05.

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51CHARACTERIZING MANDATED TREATMENT RELATIONSHIPS

identify relevant INTREX data sets. One prong involved using a variety of search terms in PsychInfo (i.e., combinations of “therap�,” “client,” “patient,” “relation�,” “alliance,” and “INTREX”) to identify research teams who had used the medium version client-rated INTREX to assess client–therapist relationships (to match the data and clusters examined in the present study). Three teams were identified and contacted to request descriptive data (i.e., means and standard deviations for eight therapist transitive clusters and eight client intransitive clusters). Data were obtained from two teams; the third declined our request. The second prong of the search strategy involved contacting researchers who were known to rou- tinely use the INTREX in clinical research and/or practice. This method yielded one additional set of data, for a total of three data sets: (1) Shearin and Linehan’s (1992) study of four borderline women in manualized Dialectical Behavioral Therapy across 31 weeks, (2) Harrist et al.’s (1994) “Vanderbilt II-based” study of 70 patients with primarily anxiety and depression in manualized time- limited dynamic psychotherapy (�25 sessions), and (3) Critch- field’s study (K. Critchfield, personal communication, June, 2011) of 15 patients with predominantly co-occurring Axis I (largely anxiety and depression) and II disorders in Interpersonal Recon- structive Therapy (Benjamin, 2003).

Although we were unable to directly compare our mandated sample with these voluntary samples on several sample demo- graphic characteristics, we were able to determine that our sample was not statistically different in age (M � 37, SD � 11) from the Harrist et al. (1994; M � 41, range � 24 – 64) and Critchfield’s (M � 36, SD � 11) samples (K. Critchfield, personal communi- cation, June, 2011). Our mandated sample (54% women) was also comparable to the Harrist et al. (1994) and Critchfield samples on gender composition (77% and 65% women, respectively). Addi- tionally, our mandated sample was comparable to the Critchfield sample on education level (70% vs. 64% had high school degree or higher, respectively), but the Harrist et al. (1994) sample was slightly more educated (79% had some college). The mandated sample has some overlap with the Harrist et al. (1994) and Critch- field samples, in terms of Axis I mood— but not psychotic— disorders, and the voluntary samples appear to have higher rates of Axis II personality disorders. Finally, our mandated sample ap- pears to be somewhat more racially diverse (67% Caucasian) than the Harrist et al. (1994) and Critchfield samples (95% Caucasian for both). We were unable to obtain this information on the Shearin and Linehan (1992) sample.

Next, we analyzed these three data sets to assess the degree of consistency in INTREX scores across studies. Specifically, we tested whether the studies yielded significantly different average client-rated INTREX cluster scores, using ANOVA and t tests, and calculated effect sizes for significant differences using Cohen’s d (1988), where effects of .2, .5, and .8 can be considered small, medium, and large, respectively. A Bonferroni correction (requir- ing � � .02) was applied to maintain a family-wise error rate of � � .05 for the “Affiliation” family (three clusters), “Attack” family (three clusters), and “Control” family (two clusters). The results are shown in Table 1 (for transitive or therapist clusters) and Table 2 (for intransitive or client clusters). In discerning patterns, we placed emphasis on transitive (therapist) ratings de- scribed in Table 1, because (a) the study aims emphasize therapist control (or lack thereof), and (b) only two data sets were available for intransitive (client) ratings, which limits pattern detection. As

shown in Table 1, despite differences in therapy types, there were few significant differences among the preexisting studies’ transi- tive INTREX scores; the consistencies across the studies far out- weigh the discrepancies.

Third, we distilled a comparison voluntary treatment data set by calculating the grand mean for each cluster. For most clusters (12 of 16), we weighted the grand mean by sample size, because (a) larger sample sizes tend to yield more stable estimates and (b) the study with the largest sample (Harrist et al., 1994) yielded transi- tive scores similar to one or both of the smaller samples. For a minority of clusters (4 of 16), we did not weight the grand mean, because the study with the largest sample (Harrist et al., 1994) strongly differed from both the smaller samples on the transitive surface (“Active Love,” sometimes also referred to as “Love/ Approach,” and “Watch/Protect” for therapists) and intransitive surface (“Reactive Love,” sometimes referred to as “Joyfully con- nect,” and “Trust/Rely” for clients) and from theory that suggests that high quality relationships are characterized by high affiliation (e.g., operationalized in this study as M � 75–100), low attack (M � 25), and moderate (M � 50 –75) autonomy (Florsheim, Henry, & Benjamin, 1996). The distilled data set is shown in the last column of Tables 1 and 2.

Results

Are Mandated Treatment Relationships Characterized by Greater Control Than Voluntary Treatment Relationships?

We used independent t tests of cluster means to examine whether mandated treatment relationships are characterized by greater therapist control and corresponding client submission than voluntary treatment relationships. We applied a Bonferroni cor- rection to maintain a family wise error rate of .05 for the affiliation family, attack family, and control dimension (for details, see Method above) and calculated Cohen’s d to reflect the magnitude of any group differences.

The results are shown in Tables 4 and 5. The six clusters relevant to the present aim involve therapist control and client submission. The results indicate that mandated treatment relation- ships involve much greater therapist neutral control (Watch/Con- trol) than voluntary treatment relationships, even though there are no significant differences between the two types of treatment in therapists’ affiliative control (Nurture/Protect, which is uniformly high) or hostile control (Belittle/Blame, which is uniformly low). In addition, mandated treatment relationships involve greater client neutral submission (Defer/Submit) and affiliative submission (Trust/Rely) than voluntary treatment relationships, but not greater client hostile submission (Sulk/Scurry, which is uniformly low). The effect size for therapists’ neutral control and clients’ neutral submission were large.

Is Greater Control Associated With Less Affiliation?

Given that mandated treatment is associated with particularly high therapist control, are mandated treatment relationships less affiliative (and/or more hostile) than voluntary treatment relation- ships? The results that address question are shown in Tables 4 and 5. The 12 relevant clusters are those in the therapist and client

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52 MANCHAK, SKEEM, AND ROOK

“affiliation” and “attack” families. The results indicate that, if anything, mandated treatment relationships are slightly more af- filiative than voluntary ones. Specifically, compared to voluntary treatment, mandated relationships were minimally greater in ther- apist pure affiliation (“Love/Approach”) and affiliative autonomy- granting (“Affirm/Understand”), and moderately greater in client pure affiliation (“Joyfully connect”) and affiliative submission (“Trust/Rely”).

Even if mandated relationships are no less affiliative, on aver- age, than voluntary ones, it is still possible that greater control is associated with less affiliation within mandated treatment. To directly test this possibility, we calculated bivariate correlations between “attack” and “control” pattern coefficients. These coeffi- cients are computed from the SASB/INTREX software and reflect the degree to which the eight clusters are oriented around the two axes—specifically how the patterning of the current data relates to an ideal patterning of scores within the circumplex framework (see Benjamin, 2000). These coefficients can be viewed as summary indices of the degree of hostility (or nonaffiliation) and control (for the transitive focus) or submission (for the intransitive focus) present in the relationship, respectively. Therapist control was inversely associated with therapist attack (r � �.39, p � .01) and was not significantly related to client attack (r � �.16). In keeping with the results above, these results suggest that control does not come at the expense of affiliation.

As a third method of analyzing the association between control and affiliation, we completed a “structural summary” analysis of INTREX cluster scores to describe the dominant process or “theme” of mandated relationships (see Gurtman, 1992; Gurtman & Pincus, 2003; Wright et al., 2009). Specifically, this analysis was completed to yield an “angular displacement” statistic, or angle on the circumplex (see Figure 1). Because voluntary treat- ment data were used as the metric against which the mandated data were compared, conceptually, the voluntary data may be viewed as the “predicted” cluster scores and the angular displacement is where the INTREX profile for the mandated sample “achieves its

highest predicted correlation” (Gurtman & Pincus, 2003, p. 421). The results indicate that mandated relationships are best charac- terized as affiliative and autonomous. Specifically, therapist tran- sitive angular displacement is 72°, which corresponds to the clus- ters of “Free/Forget” and “Affirm/Understand.” The client intransitive angular displacement is 61°, which corresponds to the clusters of “Assert/Separate” and “Disclose/Express.” Across this set of three analyses, results indicate that increased control does not come at the expense of decreased affiliation in mandated treatment relationships.

Discussion

This study is among the first to explore whether and how treatment mandates alter the form of the therapeutic relationship. The results indicate that mandated treatment relationships involve substantially more therapist control and client submission than observed in extant studies of voluntary treatment relationships. Nevertheless, mandated treatment relationships remain largely af- filiative, that is, control does not come at the expense of warmth. As a group, mandated therapists seem to treat—and mandated clients seem to respond—in a manner that is consistent with healthy affiliation and good relationship quality.

Finding 1: Therapist Control and Client Submission Are Much Stronger in Mandated Than Voluntary Treatment Relationships

This study is the first to demonstrate that therapist control and client submission are present to a significantly greater degree in mandated versus voluntary treatment relationships. This finding is particularly remarkable, because the voluntary comparison data were obtained from patients predominantly with co-occurring mood and personality disorders in manualized treatment. This treatment context may be associated with increased therapist di- rectiveness, and thus greater control, than in typical voluntary

Table 4 Therapist Transitive Cluster Scores for Voluntary and Mandated Samples

Cluster

Distilled voluntary

data (N � 89)a

Mandated sample

(n � 125)a Cohen’s

d [95% CI]

Affiliation clusters Affirm/Understand�� 78.4 (14.3) 85.8 (20.2) �0.41 [�2.8, 2.0] Love/Approach�� 65.9 (21.1) 75.7 (29.0) �0.38 [�3.9, 3.1] Nurture/Protect 76.5 (18.9) 82.5 (24.1) �0.27 [�3.2, 2.7]

Attack clusters Belittle/Blame 2.7 (5.9) 3.9 (12.6) �0.12 [�1.5, 1.3] Attack/Reject 2.2 (4.9) 1.7 (9.9) 0.06 [�1.0, 1.2] Ignore/Neglect 4.0 (8.2) 5.0 (14.4) �0.08 [�1.7, 1.6]

Control dimension Free/Forget��� 44.0 (21.6) 56.9 (30.3) �0.48 [�4.1, 3.1] Watch/Control��� 14.8 (15.1) 66.5 (29.7) �2.10 [�5.4, 1.2]

Note. A Bonferroni correction was applied to the Attachment and Attack Clusters and Control Dimension. Any flagged significant effects in these clusters are � � .02. a Values are means with standard deviation in parentheses. �� p � .01; ��� p � .001; t test for comparing sample means.

Table 5 Client Intransitive Cluster Scores for Voluntary and Mandated Samples

Cluster

Distilled voluntary

data (N � 85)a

Mandated sample

(n � 125)a Cohen’s

d [95% CI]

Affiliation clusters Disclose/Express 78.0 (15.6) 83.6 (23.4) �0.27 [�3.1, 2.5] Joyfully Connect��� 56.6 (25.0) 75.4 (30.1) �0.67 [�4.5, 3.1] Trust/Rely��� 73.6 (17.2) 83.6 (21.7) �0.50 [�3.2, 2.2]

Attack clusters Sulk/Scurry 10.7 (14.4) 12.4 (21.6) �0.09 [�2.7, 2.5] Protest/Recoil 5.3 (9.7) 4.8 (15.4) 0.04 [�1.7, 1.8] Wall-Off/Distance 12.4 (14.2) 18.6 (27.7) �0.27 [�3.4, 2.9]

Control dimension Assert/Separate 57.0 (15.8) 45.7 (33.4) 0.41 [�3.3, 4.1] Defer/Submit��� 13.5 (15.4) 33.1 (31.2) �0.76 [�4.3, 2.7]

Note. A Bonferroni correction was applied to the Attachment and Attack Clusters and Control Dimension. Any flagged significant effects in these clusters are � � .02. a Values are means with standard deviation in parentheses. ��� p � .001; t test for comparing sample means.

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53CHARACTERIZING MANDATED TREATMENT RELATIONSHIPS

outpatient treatment. The fact that the effects for control were large and much higher in mandated than manualized voluntary treatment strongly suggests that control is central to, and should be included in, operationalizations and measurement of mandated treatment relationships. The large effects observed for therapist control in the mandated sample may be attributable to the roles (e.g., behavior monitoring), goals (e.g., improving treatment adherence), and ac- countabilities (e.g., to the court) that treatment mandates add to traditional provider– client relationships (see Ross, Polaschek, & Ward, 2008; Trotter, 1999). The present findings are consistent with the literature on treatment for people with serious mental illness in that, as providers are called upon to manage multiple domains of clients’ lives and to target outcomes that extend be- yond symptoms and functioning, their use of control increases (Angell, 2006; Monahan et al., 2005; Neale & Rosenheck, 2000).

Finding 2: Despite Pronounced Control Dynamics, Mandated Relationships Are Predominantly Affiliative

Our hypothesis that increased therapist control would be offset by decreased affiliation was clearly rejected by findings that (a) mandated participants perceived their treatment relationships as slightly more affiliative than voluntary clients did, (b) within the mandated sample, therapist control was moderately inversely as- sociated with therapist attack (indicating a positive association between control and affiliation), and (c) the predominant theme of mandated relationships (i.e., the theme that best fit predictions from voluntary relationships) was affiliative and autonomy- granting.

Although it is possible that these findings reflect a positive response bias wherein either (a) mandated clients “bumped up” their affiliation ratings of their therapist to compensate for high control ratings or (b) the criteria for nominating a provider to rate (e.g., “the provider you are most likely to turn to for advice or assurance”) potentially affected clients’ ratings, there is evidence that this was not the case. For example, there is considerable variance in scores across clusters, suggesting that participants were willing to report negative aspects of the relationship, when present. Instead, we believe that relatively high affiliation ratings in man- dated relationships reflect the fact that (a) social networks of offenders in mandated criminal justice treatment are very small and (b) service providers (controlling or not) are often one of the only “positive” individuals in that network (see Skeem, Eno Louden, Manchak, Vidal, & Haddad, 2009). It is plausible, then, that mandated clients perceive their provider as more affiliative than voluntary clients in part because they feel closer to their provider and/or their provider is more important to them. Higher affiliation ratings in the mandated sample could also be attribut- able to attenuated expression of affiliation that may accompany manualized therapy (see Henry, Strupp, Butler, Schacht, & Binder, 1993). Future research should explore differences between man- dated and more common, “real world” voluntary treatment rela- tionships that are often not manualized and instead reflect an eclectic blend of techniques (see Norcross, Hedges, & Prochaska, 2002).

The high affiliation we found in mandated treatment relation- ships— despite high therapist control—is consistent not only with circumplex theory (which views dimensions of affiliation and control as orthogonal), but also with principles of procedural

justice. Procedural justice is present when an individual believes that an authority figure provides her with an opportunity to voice her opinions (including disagreements) and participate in decision making, treats her with respect (e.g., explaining the reasons for decisions and courses of action), and acts partially out of concern for her welfare (see Tyler, 1989). When procedural justice char- acterizes a decision process, individuals tend to perceive the au- thority figure as fair and legitimate and are relatively likely to abide by his or her decision (Lind & Tyler, 1988; Tyler, 1989, 1994; Watson & Angell, 2007).

More directly, our finding that high affiliation can coexist with high control in mandated treatment relationships is consistent with past research on “dual role relationship quality” between proba- tion/parole officers and their supervisees (see Kennealy, Skeem, Manchak, & Eno Louden, 2012; Klockars, 1972; Paparozzi & Gendreau, 2005; Skeem et al., 2007). For example, a relatively well-validated measure of dual role relationship quality assesses not only affiliation (i.e., “caring”), but also dimensions related to control (i.e., “fairness” and “trust”; Skeem et al., 2007). Strong dual role relationship quality has been shown to protect against recidivism, both for offenders with and without serious mental illness (Kennealy et al., 2012; Skeem et al., 2007). This charac- terization of strong dual role relationships as fundamentally au- thoritative (not authoritarian, not permissive) seems to mirror this study’s description of mandated treatment relationships as both affiliative and controlling.

Although control does not seem to harm relationship quality for the group as a whole, there may be a subgroup for whom control comes at the expense of affiliation. There is one suggestion that this may be the case—as shown in Table 2, mandated clients obtained modestly higher hostile withdrawal (“Wall off/Distance”) scores than voluntary clients (d � �.27). Although this hostile withdrawal lies downstream from therapist control and related contextual factors (e.g., providers’ responsibility to report to the court), it is impossible to test this possibility with the current, cross-sectional data. Future process-based research is needed to determine whether therapist neutral or affiliative control predicts hostile withdrawal for some clients, which would be inconsistent with the principles of complementarity in interpersonal circumplex theory (see Tyler, 1989; Benjamin, 2000), or whether clients respond only when therapist exhibit hostile control (“blame”) or under specific circumstances (e.g., differing of opinion, client receipt of criminal justice sanction for treatment noncompliance).

Limitations

The findings of the present study need to be interpreted with consideration for two primary limitations. First, the extent to which differences in ratings of affiliation and control can be attributed to factors that could not be directly assessed in the present design is unknown. Although the comparison data repre- sent INTREX consistencies across various types of voluntary clients, symptom severity, Axis I and II comorbidity, therapists, and treatment, we could not measure and statistically compare the current mandated sample with the voluntary comparison samples on these factors. The comparability of the voluntary samples to our mandated sample on age, education, and gender is perhaps under- mined by our inability to say with certainly that the observed differences in mandated and voluntary treatment relationships are

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54 MANCHAK, SKEEM, AND ROOK

not due to differences in clients’ clinical characteristics. In theory, client and therapist factors can influence relationship quality (for a review, see Horvath, 2000). It is also possible that therapeutic approach (e.g., psychotherapy vs. case management) and structure (e.g., manualized vs. not) may provide an alternative explanation for the differences seen between mandated and voluntary treatment relationships (see Critchfield et al., 2007; Henry et al., 1993). Even so, there is a clear signal here that mandated treatment is higher in control, and such findings are likely to be upheld in a more rigorous test of the differences between voluntary and involuntary treatment.

Second, the way in which participants were asked to choose a provider to rate, when they had more than one provider (i.e., “the mental health professional you are most likely to turn to when you need advice or assurance, who helps you the most, and/or with whom you have the most significant discussions”) could have biased the findings for Aim 2 in favor of a more affiliative relationship. The Aim 2 finding that mandated relationships are largely affiliative and autonomy-granting, despite high levels of therapist control, may be considered a “best-case scenario.” As such, it is quite feasible that the relationship between control and affiliation may differ in a more rigorous test of mandated relation- ship quality (e.g., spontaneously assessing relationship quality of particular mandated providers), rather than having the participant rate his or her favorite.

Despite these limitations, parallels between our findings and relevant past research lend confidence that our results are not merely a function of methodology. For example, given that past studies of nonoffenders enrolled in ACT reveal a substantial amount of control (Angell, 2006; Monahan et al., 2005; Neale & Rosenheck, 2000), our finding of greater control in mandated than voluntary treatment does not appear solely attributable to our use of a comparison group derived from the literature. Nevertheless, to build confidence in the present findings, they must be replicated in a future controlled trial of mandated versus voluntary treatment and in more ethnically diverse samples.

Implications

Given that mandated treatment relationships involve much greater therapist control and client submission than voluntary treatment relationships, it seems important to assess this dimension as part of relationship quality in mandated treatment. This could be accomplished by adapting existing measures of the therapeutic alliance (to emphasize control), adapting existing measures of dual role relationship quality (to fit mandated treatment relationships), or developing a new measure. Pursuing one of these paths may allow researchers to tease apart the differential effects of care and control on various outcomes. It may be that control not only does no harm to relationship quality, but also improves the therapists’ ability to change behavior. In keeping with this possibility, dual role relationship quality— but not “working alliance”— has been shown to predict improved criminal justice outcomes (Skeem et al., 2007). Thus, the dimension of control in mandated treatment may be integral to both process and outcome.

Providers of mandated treatment may find our findings rela- tively reassuring, given that they directly challenge clinical im- pressions that control is necessarily antitherapeutic (e.g., see Curtis & Hirsch, 2003). Combined with past research, these findings

suggest that when providers express control in a caring, respectful, nonauthoritarian manner, relationship quality can remain positive. The potential utility in combining care with control for affecting outcomes beyond symptoms and functioning is yet to be explored but holds much promise. The first step toward examining this is to accurately assess and measure what treatment relationships look like across a variety of voluntary, asserted, leveraged, and man- dated (civil vs. criminal) contexts.

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Received January 4, 2013 Revision received March 26, 2013

Accepted March 28, 2013 �

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57CHARACTERIZING MANDATED TREATMENT RELATIONSHIPS

Denying autonomy in order to create it: the paradox of forcing treatment upon addicts

THE PRIMACY OF AUTONOMY IN PROVIDER–PATIENT RELATIONSHIPS

American bioethics affords extraordinary respect to the values of personal autonomy and patient self- determination [1]. Many would argue that the most sig- nificant achievement deriving from bioethics in the past 40 years has been to replace a paternalistic model of health provider–patient relationships with one that sees patient self-determination as the normative foundation for practice. This shift away from paternalism towards respect for self-determination has been ongoing in behav- ioral and mental health as well, especially as it is reflected in the ‘recovery movement’ [2–4].

As a result of the emphasis placed on patient autonomy, arguments in favor of mandatory treatment are rare and often half-hearted. Restrictions on autonomy are usually grounded in the benefits that will accrue to others from reining in dangerous behavior [5]. However, anyone who wishes to argue for forced or man- dated treatment on the grounds that society will greatly benefit is working up a very steep ethical hill.

A person has the fundamental right, well established in medical ethics and in Anglo-American law, to refuse care even if such a refusal shortens their own life or has detrimental consequences for others. Therefore, while the few proponents of mandatory treatment for those afflicted with mental disorders or addictions are inclined to point to the benefit such treatment could have for society, it is exceedingly unlikely that any form of treat- ment that is forced or mandated is going to find any traction in American public policy on the basis of a con- sequentialist argument, great as those benefits might be.

However, is benefit for the greater good the only basis for arguing for mandatory treatment? Can a case be made which acknowledges the centrality and importance of autonomy but which would still deem ethical mandatory treatment for addicts? I think it can.

INFRINGING AUTONOMY TO CREATE AUTONOMY

People who are truly addicted to alcohol or drugs really do not have the full capacity to be self-determining or autonomous. Standard definitions of addiction cite loss of control, powerlessness and unmanageability [6]. An addiction literally coerces behavior. An addict cannot be a fully free, autonomous agent precisely because they are

caught up in the behavioral compulsion that is addiction. If this is so, at least for some addicts, then it may be possible to justify compulsory treatment involving medi- cation or other forms of therapy, if only for finite periods of time, on the grounds that treatment may remove the coercion causing the powerlessness and loss of control.

Addicts, just as many others with mental illnesses and disabilities, are not incompetent. Indeed, to function as an alcoholic or cocaine addict one must be able to reason, remember complex information, set goals and be orien- tated to time, place and personal identity; but compe- tency by itself is not sufficient for autonomy. Being competent is a part of autonomy, but autonomy also requires freedom from coercion [7]. Those who criticize mandatory treatment on the grounds that an addict is not incompetent and thus ought not be forced to endure treatment are ignoring this crucial fact. Addiction, bring- ing in its wake as it does loss of will and control, does not permit the freedom requisite for autonomy or self- determination.

If a drug can break the power of addiction sufficiently to restore or re-establish personal autonomy then man- dating its use might be ethically justifiable. Government, families or health providers might force treatment in the name of autonomy. If a drug such as naltrexone is capable of blocking the ability to become high from alcohol, heroin or cocaine [8,9], then it may release the addict from the compulsive and coercive dimensions of addiction, thereby enhancing the individual’s ability to be autonomous. If a drug or therapy can remove powerless- ness and loss of control from the addict’s life, then that fact can serve as an ethical argument allowing the man- dating of treatment. If naltrexone or any other drug can permit people to make choices freed from the compulsions or cravings that would otherwise control their behavior completely, then it would seem morally sound to permit someone who is in the throes of addiction to regain the ability to choose, to be self-governing, even if the only way to accomplish this restoration is through a course of mandated treatment.

Of course, it would not be ethical to force treatment upon anyone if there were significant risks involved with the treatment but new drugs, such as naltrexone, appear safe and effective for those addicted to heroin and perhaps cocaine, and should also prove so for alcoholics. The mechanisms behind the drug are well understood [8,9], and in some populations this drug has been used for a long time to reduce the cravings of addiction safely and

EDITORIAL doi:10.1111/j.1360-0443.2008.02369.x

© 2008 The Author. Journal compilation © 2008 Society for the Study of Addiction Addiction, 103, 1919–1921

effectively. Mandating treatment requires that the inter- vention carry minimal risk as the patient cannot consent, but some interventions may be able to meet this admit- tedly difficult standard.

Nor would it make moral sense to force treatment upon someone, restore their autonomy successfully and then continue to force treatment upon them in their fully autonomous state. The restoration of autonomy is the end of any moral argument for mandatory treatment.

Similarly, efforts to restore autonomy would not justify continuous, open-ended use of drugs or therapy in addicts. There must be some agreed-upon interval, after which treatment must be acknowledged to have failed and other avenues of coping with addiction to alcohol or drugs pursued.

PRECEDENTS FOR MANDATING TREATMENT IN THE NAME OF AUTONOMY

Interestingly enough, despite the emphasis on autonomy in law and ethics in American health care there are situ- ations where the ethical acceptability of the rationale of autonomy restoration in permitting mandatory treat- ment is already accepted. Consider what occurs in reha- bilitation medicine. The short-term infringement of autonomy is tolerated in the name of long-term creation or restoration of autonomy.

Patients, after devastating injuries or severely disfigur- ing burns, often demand that they be allowed to die. They say: ‘Don’t treat me’, or they may insist that: ‘I can’t live like this’. In evaluating their requests, no one would be able to question seriously their competency. They know where they are. They know what is going on. However, staff in rehabilitation and burn units almost always ignore these initial demands. Patient autonomy is not respected. Why?

What rehabilitation experts say is that they want to allow an adaptation to the new state of affairs: to the loss of speech, amputation, facial disfigurement or paralysis. They know from experience that if they do certain things with people—train them, counsel them, teach them adaptive skills—they can encourage them to start to ‘adjust’ [10].

There are, admittedly, still people who say at the end of a run of rehabilitation: ‘I don’t want to live like this’. The suicide rate is higher in these populations. Nevertheless, at least initially, rehabilitation specialists will say that they have to force treatment on patients because they know from experience that they can often encourage them to accept their new state of affairs. The normal practice of rehabilitation immediately after a severe injury is to mandate treatment, ignore what patients have to say, and then see what happens. If they still do not

want treatment after a course of rehabilitation then their wishes will be respected [10].

The rehabilitation model is precisely the model to follow in thinking about the mandatory use of a drug such as naltrexone for the treatment of addiction. The moral basis for mandating treatment is for the good of the patient by rebirthing their autonomy. How long and whether someone ought to be able at some point say: ‘I’ve done this for 6 months, I’m finished, I want to get high again’ is a challenging problem, but it is not the key one. The key moral challenge is to open the door to temporary mandatory treatment. That can be achieved, ironically, on the grounds of autonomy. It may press current ethical thinking to the limit, but mandating treatment in the name of autonomy is not as immoral as many might otherwise deem forced treatment to be [7]. Once compe- tency and coercion are distinguished, it is clear that both are requisite for autonomy. Mandatory treatment which relieves the coercive effects of addiction and permits the recreation or re-emergence of true autonomy in the patient can be the right thing to do.

Acknowledgement

The author is grateful for the support of the Scattergood Foundation in writing this essay.

Declaration of interest

None.

Keywords Addiction, autonomy, mandatory treat- ment, naltrexone, paternalism, right-to-refuse treatment.

A RT H U R CA P L A N

Emanuel and Robert Hart Professor of Bioethics, Chair, Department of Medical Ethics, and Director for Center for

Bioethics, University of Pennsylvania, PA, USA. E-mail: [email protected]

References

1. Beauchamp T. L., Childress J. Principles of Biomedical Ethics, 5th edn. Oxford: Oxford University Press; 2008.

2. Sheldon K., Williams G., Joiner T. Self-Determination Theory in the Clinic. New Haven, CT: Yale University Press; 2003.

3. Cook J. A., Jonikas J. A. Self-determination among mental health consumers/survivors: using lessons from the past to guide the future. J Disabil Policy Stud 2002; 13: 87– 96.

4. The White House. The President’s New Freedom Initiative; The 2007 Progress Report. Available at: http://www.whitehouse. gov/infocus/newfreedom/newfreedom-report-2007.html (accessed 14 September 2008).

5. Silber T.J. Justified paternalism in adolescent health care. Cases of anorexia nervosa and substance abuse. J Adolesc Health Care 1989; 10: 449–53.

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6. Goodman A. Addiction: definition and implications. Br J Addict 1990; 85: 1403–8.

7. Caplan A. L. Ethical issues surrounding forced, mandated or coerced treatment. J Subst Abuse Treat 2006; 31: 117–20.

8. Comer S., Sullivan M. A., Yu E., Rothenberg J. L., Kleber H. D., Kampman K. et al. Injectable, sustained release naltrex- one for the treatment of opioid dependence. Arch Gen Psy- chiatry 2006; 63: 210–18.

9. Krystal J. H., Cramer J. A., Krol W. E., Kirk G. F., Rosenheck R. A. Naltrexone in the treatment of alcohol dependence. New Engl J Med 2001; 345: 1734–9.

10. Caplan A. L., Haas J., Callahan D. Ethical and policy issues in rehabilitation medicine. In: Duncan B., Woods D., editors. Ethical Issues in Disability and Rehabilitation. New York: World Institute on Disability; 1990, 135–54.

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Substance Use & Misuse, 43:1785–1801 Copyright © 2008 Informa Healthcare USA, Inc. ISSN: 1082-6084 (print); 1532-2491 (online) DOI: 10.1080/10826080802297484

Identifying Client-Level Indicators of Recovery Among DUI, Criminal Justice, and Non–Criminal

Justice Treatment Referrals

ROBERT WALKER, JENNIFER COLE, AND T. K. LOGAN

Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA

This study is part of a mandated treatment outcome study on all government-funded programs in a rural state. This naturalistic study included a sample of 888 clients who served between July 2003 and June 2004 in a state-funded treatment for substance misuse and were included in a follow-up interview 12 months after treatment. To examine differences in treatment outcome, clients were examined in three referral conditions: (1) driving under the influence (DUI) referral; (2) criminal justice referral; and (3) non–criminal justice referral. While more DUI referrals reported alcohol use at 12- month follow-up, there were no other differences between referral conditions. Instead, controlling for factors like age, gender, and race, recovery intent at intake, and 12- step program participation at follow-up predicted positive treatment outcomes, while persistent depression predicted negative outcomes. This study of clients in state-funded treatment for substance misuse provides additional evidence that referral condition does not predispose clients toward positive or negative outcomes. Secondly, client-level factors related to recovery practices and intent to reduce or stop using substances may need closer attention in the clinical process. Study limitations included data being collected by clinicians during intake, which may have resulted in reliability questions about how data are entered.

Keywords recovery indicators; recovery intent; outcome indicators; treatment out- comes; naturalistic environment

Introduction

There is increasing interest in the outcomes associated with treatment for substance use– related disorders, along with an emphasis on the use of evidence-based practices with substance use–related disorders. In 2007, the Substance Abuse and Mental Health Ser- vices Administration (SAMHSA) issued a requirement for states to collect the National Outcomes Measures, which SAMHSA describes as “the lifeblood of quality assurance at each level of administration—Federal, State, and local” (SAMHSA, 2007). For substance user treatment,1 the most critical outcome objective is to attain and sustain “abstinence

This study was funded by the Kentucky Division of Mental Health and Substance Abuse under a contract with the University of Kentucky Center on Drug and Alcohol Research.

Address correspondence to Robert Walker, Center on Drug and Alcohol Research, University of Kentucky, 915B South Limestone Street, Lexington, KY 40536. E-mail: [email protected]

1Treatment can be briefly and usefully defined as a planned, goal-directed change process, of necessary quality, appropriateness, and conditions (endogenous and exogenous), which is bound (by culture, place, time, etc.) and can be categorized into professional-based, tradition-based, mutual

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from drug use and alcohol abuse,” along with improved functioning (SAMHSA, 2007). In response to these policies, providers have an increasing need to identify what works, for whom, and under what conditions. The focus on attaining positive treatment out- comes is intensified by the fact that only a small percent of persons needing treatment ever receive it (SAMHSA, 2006). For example, in 2005 there were an estimated 22.2 mil- lion people over the age of 12 in the United States with substance abuse or dependence problem, but only 3.9 million had received any substance abuse services in the past 12 months, and 2.2 million had received services from a self-help group, and 1 million (4.5%) had received services at a mental health center in the past 12 months (SAMHSA, 2006).

For several decades there has been interest in the outcomes of treatment for substance use–related disorders, with a preponderance of evidence suggesting that positive outcomes result from a variety of different clinical approaches and modalities, including residential and outpatient counseling (Floyd, Monahan, Finney, and Morley, 1996; Morley, Finney, Monahan, and Floyd, 1996; Moyer, Finney, and Swearingen, 2002; Swearingen, Moyer, and Finney, 2003). Further, length of treatment has been demonstrated to be associated with better treatment outcomes in several studies (Hser, Evans, Huang, and Anglin, 2004; Moos and Moos, 2003; Moos, Moos, and Andrassy, 1999). Studies have also demonstrated that client characteristics as well as motivation and creation and maintenance of therapeutic alliance contribute to outcomes (Cacciola, Dugosh, Foltz, Leahy, and Stevens, 2005; Ilgen, McKellar, Moos, and Finney, 2006; Joe, Simpson, Dansereau, and Rowan-Szal, 2001). Thus, providers who have an increased investment in achieving positive outcomes may need to not only use evidence-based practices and skilled clinicians but also pay close attention to client-level variables that may foster posttreatment recovery. Clinicians may benefit from being able to screen for indicators of client recovery intent as a way of identifying clients most likely to benefit from treatment services. Clients who are identified as having lower potential for positive outcomes may require additional motivational approaches or pretreatment services.

Community treatment for substance misuse receives many, if not most, of its clients from the criminal justice system (Farabee and Leukefeld, 2001). Criminal justice–referred clients may underreport substance use and related problems and may lack internal motiva- tion to engage in treatment processes (Farabee and Leukefeld, 2001). However, research has largely dispelled mistaken beliefs about criminal justice system– and DUI-referred clients not benefiting from treatment or recovery (Cavaiola, Strohmetz, and Abreo, 2007; DeYoung, 1997; Gregoire and Burke, 2004; Hiller, Knight, Rao, and Simpson, 2002; Lo- gan, Hoyt, McCollister, French, Leukefeld, and Minton 2004; Kelly, Finney, and Moos, 2005; Miller and Flaherty, 1999; Ninonuevo and Hoffmann, 1993). However, how clients are referred to treatment (due to DUI charges, criminal justice, or other, non–criminal jus- tice referral) may still interact with other important factors that affect outcomes or may have an independent impact on treatment outcomes in a naturalistic treatment setting. The literature has identified other client characteristics that have influenced negative treatment outcomes such as a history of unemployment, depression, and other mental health problems

help–based (AA, NA, and the like), and self-help (“natural recovery”) models. There are no unique models or techniques used with substance users—of whatever type—which aren’t also used with nonsubstance users. In the West, with the relatively new ideology of “harm reduction” and the even newer quality of life (QOL) treatment–driven model there are now a new set of goals in addi- tion to those derived from/associated with the older tradition of abstinence-driven models. Editor’s note.

Indicators of Recovery at Intake 1787

(Rounsaville, Dolinsky, Babor, and Meyer, 1987; Sinha and Schottenfeld, 2001). For ex- ample, pretreatment employment has been identified as an important indicator of positive substance user treatment outcome (Cebulla, Smith and Sutton, 2004; Galaif, Newcomb, and Carmona, 2001; McCaul, Svikis, and Moore, 2001; McLellan, 1983; Slaymaker and Owen, 2006; Sterling, Gottheil, Glassman, Weinstein, Serota, and Lundy, 2001; Vaillant, 1988). Also, low social functioning and overall severity of mental health symptoms have been demonstrated to predict negative treatment outcomes (McLellan, Alterman, et al., 1994), and depression, in particular, may predict decreased likelihood of abstinence following treatment (Dodge, Sindelar, and Sinha, 2005). However, it is unclear whether clinicians in publicly funded treatment programs, who may have biases about “unmotivated” court- referred clients, trust the findings from controlled research studies of criminal justice– and DUI-referred clients and their treatment outcomes. In addition, it is unclear whether the findings from controlled studies about the treatment outcomes of criminal justice and DUI clients are actually replicated in naturalistic studies of publicly funded treatment. While the drug abuse treatment outcome study (DATOS) suggested positive treatment outcomes across a wide range of treatment sites, the study was carried out among carefully recruited treatment sites and for a specified 2-year period (Fletcher, Tims, and Brown, 1997; Flynn, Craddock, Hubbard, Anderson, and Etheridge, 1997). There is a need for ongoing studies that are embedded in everyday practice settings on a routine basis to help identify predictors of better outcomes in terms of abstinence. Naturalistic studies of substance user treatment outcomes possess realism and external validity because they examine outcomes in real-world situations (Timko, Moos, Finney, and Connell, 2002). One other important component of naturalistic research on substance user treatment outcomes is that self-reported client re- covery activities and intentions can be examined along with their clinical characteristics and referral conditions and in the wide mix of treatment types and approaches that occur under the “treatment-as-usual” condition.

Recovery activity or intent toward recovery, while subject to influence through motiva- tional approaches (Miller and Rollnick, 2002), is distinct from actions taken by treatment providers, since these two factors are within clients’ sphere of experience and control. The two are independent of treatment per se (McLellan, Chalk, and Bartlett, 2007). Recovery is a term with many different denotations that has overlap with treatment outcomes but has clear connotations associated with using mutual help (McLellan, et al., 2007; Tims, Leukefeld, and Platt, 2001). Recovery activity is also a client-level factor rather than a treatment ac- tivity or program-related factor. For the purposes of this study recovery is understood as abstinence from alcohol or drugs.

Study Objectives

To better understand the relative role of client-level recovery activity and intent to end or reduce substance use under different referral conditions, we examined outcomes in the nat- uralistic environment of publicly funded treatment in one state, by focusing on follow-up data to identify intake client characteristics that predict factors related to positive outcomes 12 months after treatment. The study examined client-level clinical characteristics associ- ated with substance use, referral condition, and clients’ self-reported intent to be substance free and their participation in mutual help 1 year after intake. The study hypothesis was that neither clinical characteristics nor referral condition would predict treatment outcomes but that clients’ report of positive recovery intent and use of mutual help at intake and/or follow-up would predict positive outcomes.

1788 Walker et al.

Method

Procedures

In Kentucky, all state-funded programs treating substance misuse participate in a statuto- rily mandated treatment outcome study. After informing clients about the purpose of the follow-up study and the study’s confidentiality protections, clinicians in outpatient, intensive outpatient, and residential settings collect data on clients during the intake and assessment phase of services. The Kentucky Substance Abuse Treatment Outcome Study (KTOS) is conducted annually, using intake data collected by clinicians in the course of substance use assessment. The data were collected using a personal digital assistant (PDA)–based instru- ment that is administered by the clinician. The intake data were synchronized via modem on a regular basis to the University of Kentucky Center on Drug and Alcohol Research (CDAR) for analysis.

Clients who voluntarily agreed to participate in the follow-up study gave informed consent to participate before giving personal locator information that was used to locate them for follow-up telephone interviews 12 months after treatment. Research staff from CDAR then sampled clients for follow-up interviews. In state fiscal year 2004, there were 9,876 intake records, and 3,136 clients consented to follow-up interviews and had face valid contact information. The initial sample was 50% of these (1,568) with 249 being ineligible (in controlled living conditions or deceased), and 431 could not be located, with a final follow-up sample of 888 clients. The follow-up rate was 67.3%. All data are client self-reports. No incentive was given for participation in the study at intake. Participants received $20 for completing the follow-up interview. All study procedures were approved by the University of Kentucky institutional review board.

Participants

Overall there were 9,876 intake records of client entering state-funded treatment in the Commonwealth of Kentucky during a 12-month period (from July 1, 2003 to June 30, 2004). The sample for this analysis was 888 adults who participated in a follow-up inter- view approximately 12 months later. The treatment programs included outpatient, intensive outpatient, case management, and short-term (30-day) residential settings statewide, rang- ing from urban to very rural sites. Clients providing intake information included even those who came only for assessment visits. Just over one fifth of clients (20.4%) received 4 or fewer services, 28.3% received 5–15 services, 21.5% received 16–30 services, 17.2% re- ceived 31–50 services, and only 12.6% received 51 or more services. Clients often received a combination of residential and outpatient services.

Measures

Substance Use. Substance use measures were taken from the SAMHSA Center on Sub- stance Abuse Treatment (CSAT) Government Performance and Results Act (GPRA) data collection tool, which has been used to examine treatment outcomes in treatment capacity expansion and other CSAT-funded programs (Mulvey, Atkinson, Avula, and Luckey, 2005). The CSAT GPRA is based on the Addiction Severity Index (ASI) (Kosten, Rounsaville, and Kleber, 1983; McLellan, Kushner, et al., 1992), and it measures substance use, criminal activity, employment, and other related behaviors during the past 30 days. For the this study, the GPRA was modified to include past 12-month and lifetime use as well as past 30-day

Indicators of Recovery at Intake 1789

use of all substances. Clients were asked if they had ever used each class of substance (e.g., alcohol, and illicit drugs like marijuana, opiates, tranquilizers, cocaine, stimulants, nonprescription methadone, inhalants, and hallucinogens), and if so, how many months out of the past 12 months they had used each class of substance. A composite measure of any illicit drug use was computed from clients’ reports of individual classes of illicit drugs, by computing the maximum number of months that illicit drugs were reported.

Recovery Intent. Questions were added to the core instrument to examine self-reported 12-step program participation at intake and follow-up as well as clients’ own rating of the odds of being able to get off and stay off drugs or alcohol. These questions do not examine motivation, but were developed to characterize recovery intent and use of recovery activities independent of treatment. First, attendance at Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings during the 30 days prior to intake and follow-up were included in the analyses as two separate variables. Second, clients were asked at intake, “Based on what you know about yourself and your situation, how good are the chances that you can get off and stay off of drugs/alcohol?” The values ranged from 1 (very good) to 5 (very poor). They were also asked at intake and follow-up, “How many days in the past 30 days have you attended AA, NA or other mutual-help group meetings?”

Mental Health Problems. The mental health measures were taken from the ASI and included self-reported depression, anxiety, trouble in concentration, difficulty in controlling violence, hallucinations, as well as suicidal thoughts and attempts in the past 12 months (McLellan et al., 1992). Since depression at intake can be directly a function of substance use (due either to intoxication or withdrawal effects), clients who reported experiencing serious depression at both intake and follow-up were categorized as experiencing persistent depression to exclude substance-affected depressed mood of a more transient nature.

Criminal Justice System Involvement. Criminal justice referral conditions were derived from ASI-adapted measures of referral source. Clients were asked if the admission was prompted or suggested by the criminal justice system and whether the admission resulted from a DUI charge. Questions about number of arrests in the past 12 months and the past 30 days were modified from the ASI.

Data Analysis

Two logistic regression models were run to examine the relationship between clients’ in- volvement with the criminal justice system, indicators of intent to achieve and maintain abstinence, mental health problems, and recovery from alcohol use and illicit drug use ap- proximately 12 months after intake into substance abuse treatment. In one model alcohol use in the 12-month follow-up period was the outcome variable, and in the second model any illicit drug use in the 12-month follow-up period was the outcome variable. Involvement with the criminal justice system was operationalized as the three groups: (1) clients who were referred to treatment by the criminal justice system for any charge other than a DUI were categorized into the CJ group (n = 296); (2) clients who were referred to treatment by the criminal justice system based on a DUI charge were categorized into the DUI group (n = 273); and (3) clients who had a referral condition not related to the criminal justice system were categorized as belonging to the Non CJ group (n = 317). Two clients were dropped from the group analysis because no data were available on their referral condition at intake. In the logistic regression models the Non CJ group was used as the reference

1790 Walker et al.

group. Number of arrests in the 12 months before intake was also included as predictor variable in the logistic regression models. Indicators of intent to reduce or end substance use were taken from two items. The first one was the clients’ rating at intake of their chances of staying off alcohol/drugs. Second, attendance at AA/NA meetings in the 30 days before intake and the 30 days before follow-up were included in the analyses as two separate vari- ables. Attendance at AA/NA meetings in the 30 days before follow-up was used to indicate recovery activity independent of treatment. The correlation between attendance in mutual help groups in the 30 days before intake and the 30 days before follow-up was small (Pear- son r = 0.294). Also, clients who reported experiencing serious depression at both intake and follow-up were categorized as experiencing persistent depression. Control variables included gender, race, age, employment status at treatment intake, and the highest level of education attained. Control variables were selected because each has been associated with independent contributions to outcomes, and there were significant differences in these variables across the three referral conditions.

In order to assess recovery from use of alcohol and illicit drugs, only individuals who reported use of each class of substance in the 12 months before intake were included in each of the logistic regression models. Because interpretation of adjusted odds ratios is difficult to interpret, relative risk was used when possible (Holcomb, Chaiworapongsa, Luke, and Burgdorf 2001; Osborne, 2006; Zhang, 1998).

Results

Sample Descriptives by Referral Condition

Table 1 presents the results of bivariate analyses of the criminal justice groups on demo- graphic variables. The vast majority of individuals in the DUI group were male, and a significantly greater proportion of the DUI group was male compared to individuals in the CJ group and the Non CJ group. Individuals in the CJ group were significantly younger than individuals in the Non CJ group and individuals in the DUI group. The DUI group was composed of a larger proportion of White individuals compared to the other two groups. The greatest proportion of individuals reported that they had either never been married (38.6% of the sample) or recently been divorced (27.8% of the sample). The only difference in marital status was that significantly fewer individuals in the DUI group were separated at the intake interview compared to the individuals in the Non CJ group. The average highest level of education attained by the sample was a little less than 12 years of education. Individuals in the CJ group reported significantly more years of education compared to individuals in the other two groups. More individuals in the DUI group were employed full-time at the time of the intake interview compared to individuals in the Non CJ group and the CJ group, and significantly fewer individuals in the DUI group were unemployed compared to the individuals in the other two groups. About 16% of the sample reported disability at intake.

Table 2 presents the results of bivariate analyses of the criminal justice groups on mental health, treatment, perceptions of treatment success, mutual help group participation, and arrests. Significantly more clients in the Non CJ group reported depression at intake, follow- up, and both time periods compared to clients in the CJ group and DUI group. Compared to clients in the DUI group, significantly more clients in the Non CJ group reported that they had ever been in substance abuse treatment before the current treatment; however, there was no difference by CJ group in the number of times individuals had been in treatment among those who had had past treatment. The majority of clients in all the groups rated

Indicators of Recovery at Intake 1791

Table 1 Demographic characteristics of follow-up sample at intake by criminal justice

referral group

No CJ DUI CJ, referral charge non-DUI Statistical

Demographics Response (n = 317) (n = 273) (n = 296) test Gender Masculine 49.8%a 85.7%a,b 54.4%b χ 2(2) = 92.658∗∗ Mean age 34.4a 35.2b 31.7a,b F (2, 883) = 9.724∗∗ Race White 82.6%a 95.2%a,b 83.4%b χ 2(4) = 33.488∗∗

Black 13.6%a 4.0%a,b 15.9%b

Other 3.8% 0.7% 0.7% Marital status Never married 38.9% 33.5% 42.9% χ 2(8) = 22.007∗

Married 20.3% 23.9% 18.9% Divorced 25.3% 33.8% 25.0% Separated 14.6%a 6.3%a 10.8% Widowed 0.9% 2.6% 2.4%

Education Mean education 11.8a,b 11.2a 11.2b F (2, 878) = 10.140∗∗

(years) Employment Current Full time 22.5%a 41.0%a,b 26.1%b χ 2(8) = 35.604∗∗

employment Part time 12.1% 10.3% 10.2% status Unemployed 45.1%a 28.6%a,b 47.5%b

Disabled 17.1% 17.2% 13.9% Other 3.2% 2.9% 2.4%

a,b,c: groups differ significantly at p < .01; ∗ p < .01; ∗∗ p < .001.

their chances of success in treatment as being moderately to very good, with significant differences between the Non CJ group and the DUI group. Clients in the DUI group had the lowest rates of mutual help group participation at both intake and follow-up when compared to the other two groups. Finally, there was no significant difference in number of arrests between the three groups.

A total of 513 clients (58%) reported using alcohol in the 12 months before follow- up, and 275 clients (31.1%) reported using illicit drugs in the 12 months before follow-up. Further, among the clients who reported using alcohol in the 12 months before intake, 69.6% reported using alcohol at follow-up. Among the clients who reported using illicit drugs in the 12 months before intake, 40.7% reported using illicit drugs at follow-up. In addition, at follow-up, 196 clients (38.4%) reported using both alcohol and illicit drugs in the past 12 months.

Multivariate Analysis

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Indicators of Recovery at Intake 1793

Table 3 Logistic regression predicting alcohol use at follow-up

β Wald Odds ratio (C.I.)

Gender (0 = Masculine) −0.432 4.516 0.649 (0.384, 1.096) Age −0.021 4.844 0.979 (0.955, 1.004) Race (0 = White) −0.130 0.220 0.878 (0.431, 1.789) Employed (0 = Employed) 0.126 0.423 1.135 (0.688, 1.871) Highest level of education completed 0.088 3.600 1.092 (0.969, 1.231) Persistent depression (0 = No) 0.869 13.215∗∗ 2.385 (1.288, 4.414) No. of arrests in the past 12 months −0.057 0.758 0.944 (0.797, 1.119) No. of times in substance abuse treatment

in lifetime 0.011 0.093 1.011 (0.924, 1.106])

Chances of staying off alcohol or drugs 0.144 1.796 1.155 (0.876, 1.522) Self-help in the 30 days before intake −0.107 0.241 0.899 (0.513, 1.574) Self-help in the 30 days before follow-up −0.587 7.963∗ 0.556 (0.326, 0.950) DUI-referred 0.907 12.753∗∗ 2.476 (1.288, 4.763) CJ-referred 0.076 0.109 1.079 (0.596, 1.952)

∗ p < .01; ∗∗ p < .001.

individuals who were not referred to treatment by the criminal justice system (RR = 1.28). Second, clients who reported persistent depression were 1.23 times more likely to report using alcohol in the 12 months after intake compared to clients who did not report persistent depression (BRR = 1.23). Third, clients who reported attending AA/NA meetings in the 30 days before follow-up were less likely to report alcohol use in the 12 months before follow-up (RR = 0.834). None of the other variables were significantly associated with alcohol use during the follow up period (Nagelkerke R2 = 0.130).

Table 4 Logistic regression predicting illicit drug use at follow-up

β Wald Odds ratio (C.I.)

Gender (0 = Male) −0.341 2.899 0.711 (0.424, 1.191) Age −0.026 5.918 0.975 (0.949, 1.002) Race (0 = White) −0.346 1.518 0.707 (0.343, 1.459) Employed (0 = Employed) .263 1.762 1.300 (.781, 2.164) Highest level of education completed 0.127 6.447 1.136 (0.998, 1.292) Persistent depression (0 = No) 1.086 24.644∗∗ 2.963 (1.686, 5.206) No. of arrests in the past 12 months −.040 .501 .961 (.830, 1.112) No. of times in substance abuse treatment

in lifetime 0.092 5.683 1.096 (0.993, 1.211)

Chances of staying off alcohol or drugs 0.423 15.983∗∗ 1.526 (1.162, 2.003) Self-help in the 30 days before intake −0.324 2.398 0.723 (0.421, 1.240) Self-help in the 30 days before follow-up −0.042 0.041 0.959 (0.565, 1.628) DUI-referred −0.433 2.389 0.649 (0.315, 1.334) CJ-referred −0.116 0.284 0.891 (0.509, 1.559)

∗ p < .01; ∗∗ p < .001.

1794 Walker et al.

Among clients who reported that they had used illicit drugs in the 12 months preceding the intake interview (n = 568), several predictors were significantly associated with illicit drug use at follow-up. First, persistent depression (RR = 1.78) was positively associated with illicit drug use at follow-up. In other words, clients who reported experiencing persistent depression were 1.78 as likely to report using illicit drugs during the follow-up period compared to clients who did not experience persistent depression. Second, clients’ ratings at intake of their chances of staying off alcohol/drugs were significantly associated with using illicit drugs during the follow-up period. Clients who rated their chances of staying off alcohol/drugs as better, thus expressing intent toward recovery, were less likely to report using illicit drugs at follow-up. Level of involvement with the criminal justice system was not associated with the likelihood of using illicit drugs during the follow up-period. No other variables were significantly associated with reporting illicit drug use during the follow-up period (Nagelkerke R2 = 0.166).

Discussion

We found that the hypothesis was in part substantiated. One referral condition (DUI) did predict negative treatment outcomes with DUI offenders more likely reporting alcohol use at follow-up. However for all other referral conditions, there was no alcohol or drug use outcome effect. We also found that self-reported intent toward recovery and use of mutual help predicted substance use outcomes with those who reported using mutual help at follow- up being less likely to report alcohol use at follow-up. Also, clients who reported good or very good chances of stopping illicit drug use at intake were less likely to report any illicit drug use at follow-up. Persistent depression was not included in the hypothesis, but it too predicted more likely negative outcomes.

This naturalistic study examined 886 substance-using clients who entered community- based treatment with one of three referral conditions—criminal justice, DUI, or non– criminal justice. The clients received substance abuse treatment from a variety of community-based, publicly funded programs and in varying intensity of services.

To better identify indicators of positive treatment and recovery outcomes in state- funded community treatment this study considered referral conditions, client-level clinical characteristics, as well as self-reported recovery intent and use of mutual help. Given the many factors that can contribute to outcomes we used a multivariate analysis to control for alternative explanations for recovery-related outcomes. By examining the outcomes of clients in three referral conditions it was clear that there were very few differences between them after controlling for other variables. There were four key findings that have importance to clinical providers in publicly funded treatment: (1) referral conditions such as court or probation referrals or DUI-initiated treatment did not predict treatment outcomes positively or negatively with the exception of DUI-referred clients being more likely to report alcohol use at follow-up; (2) persistent depression (that is, depression that was present at intake and still at follow-up) predicted a greater likelihood of alcohol and illicit drug use at follow- up; (3) client reports at intent to achieve abstinence of intake were significantly associated with lower likelihood of reporting illicit drug use 12 months after treatment; and (4) while reporting use of mutual help at intake was not associated with outcomes, clients who reported use of mutual help in the period before follow-up were significantly less likely to report alcohol use at follow-up. Findings on the role of depression on substance use outcomes are consistent with research studies that have demonstrated that clients with co-occurring mental health problems have poorer substance use outcomes than those without mental

Indicators of Recovery at Intake 1795

health problems (Dodge, Sindelar, and Sinha, 2005; Ritscher, Moos, and Finney, 2002). In fact, depression is being increasingly identified as a risk factor for overall mortality among all disease-related causes of death (Mykletun et al., 2007). Its prominence as a contributor to mortality as well as disease expression suggests that clinical attention to it in substance misuse treatment and recovery support should be of paramount importance. In addition, depression may interfere with help-seeking and recovery behaviors (Mykletun et al., 2007). Thus, even providers of recovery supports, including members of the recovery community, might be alerted to the importance of facilitating treatment for depression to aid recovery from substance use. This education of the mutual-help community might include clarification of the actions of antidepressant medication compared to other psychoactive substances to dispel concern about the use of antidepressants being simply another form of drug dependence.

In addition, this study adds two important findings for clinical practice in regard to recovery in relation to treatment outcomes. Both of the key findings suggest the importance of focus by clinicians on clients’ own contributions to recovery instead of merely adding more treatment. First, clients’ own rating of their chances of getting off and staying off drugs or alcohol at intake and assessment was significantly associated with lower rates of reported illicit drug (but not alcohol) use at follow-up. Whether this measure was related to treatment motivation was not examined in this study. However, it is a simple measure to use in clinical practice, and client responses may be important cues to treatment and recovery intent. Second, client reports of taking mutual help at intake did not significantly predict abstinence outcomes, but use of mutual help after intake did predict greater likelihood of reporting abstinence from alcohol. While clinicians may not be able to directly monitor clients’ use of mutual help, these findings suggest that encouraging and guiding clients to use mutual help may be a significant contribution to treatment outcomes. This study’s findings on mutual help may have differentiated between clients who report mutual help at intake as a way to manage an impression of seriousness and clients who stick with mutual help 12 months later. The latter group clearly reports recovery activity, whereas the intake reports may be associated with managing how probation officers and treatment providers view the client. Other research has suggested that mutual help may be an important determinant of sustained abstinence (Moos and Moos, 2006; Moos, Schaefer, Andrassy, and Moos, 2001). A long-term follow-up study of alcohol dependent persons who were initially untreated reported that 12-step program participation in the first year of the study predicted better outcomes 16 years later (Moos and Moos, 2006). Furthermore, encouraging the use of mutual help means promoting recovery activity, which places more emphasis on what clients can do above mere participation in treatment. These simple ways to ask the client about intent and use of recovery activities may in part address complex questions about internal versus external motivations for treatment that arise with criminal justice and other court-related referrals (Leukefeld, Tims, and Platt, 2001).

Study’s Limitations

There were limitations to this study. First, the follow-up sample was taken from clients who consented at intake to participate in the follow-up study; therefore, it is possible that the clients in the follow-up sample do not represent all clients who enter treatment in state-funded substance user treatment. There were only three significant differences ( p < .01) between the follow-up and non–follow-up samples: the follow-up sample contained more females than the non–follow-up sample (37.6% vs. 32.4%); the follow-up sample had completed more education (11.4 years vs. 11.2 years); and the follow-up sample reported a

1796 Walker et al.

lower average number of arrests in the 30 days before intake compared to those who were not followed up (0.1 vs. 0.2).

All the data are client self-reports, and there were over 150 clinicians collecting data in a wide variety of clinical settings. While the intake data were collected by clinicians who may be under obligations to report to the court or probation/parole, the follow-up interviews were conducted by research staff under the direction of a study coinvestigator. Furthermore, participants were informed that interview data were covered by a federal Certificate of Confidentiality. The validity and reliability of self-reports of substance use has been supported by a number of studies (Del Boca and Noll, 2000; Rutherford, et al., 2000). Earlier studies have found that the context of the interview influences reliability (Babor, Stephens, and Marlatt, 1987), and generally self-reports at the beginning of treatment as well as during treatment have been demonstrated to be reliable (Rutherford et al., 2000). In addition, it is important to understand the reliance on self-reports in health research as well as in substance use and misuse studies. For example, research on other chronic health problems that have behavioral and recovery components such as diabetes, chronic headache, obesity, hypertension, and heart disease often depend on self-reported diet, exercise, medication compliance, and weight reduction efforts (Holroyd et al., 2001; Mokdad et al., 2001; Pereira et al., 2002). In addition, the depression measure did not include specific depression-related symptoms or criteria that are included in the DSM-IV-TR diagnosis.

This naturalistic study of treatment outcomes among clients in state-funded treatment for substance misuse has several implications for the practice community. First, findings provide additional evidence that referral condition does not predispose clients toward posi- tive or negative outcomes, with the exception of DUI referral being associated with alcohol use at follow-up. Second, client-level factors related to recovery practices and intent to reduce or stop using substances may need closer attention in the clinical process. There are two uses of this information: (1) client self-reports of intent to end or reduce substance use may provide important indicators of level of intensity of services that should be used; and (2) clinicians may need to more intently encourage engagement with self-help activities such as AA and NA.

The recognition of the importance of client-level factors in the recovery and treatment outcome process suggests that an exclusive focus on evidence-based or best practices may miss important factors related to recovery. This study suggests that clinicians may take into greater consideration clients’ intent level to end or reduce substance use and client recovery. The identification of clients who report little recovery intent may need either increased motivational approaches or pretreatment services. Alternatively, with low levels of funding for an ever-increasing demand in treatment services, clinicians may need to focus treatment efforts on those who convey the greatest intent toward recovery. These findings also suggest the possibilities for empowering clients to take more charge of their own recovery processes as a way to better treatment outcomes.

RÉSUMÉ

Identification d’indicateurs de guérison au niveau du client parmi les personnes en traitement de toxicomanie pour conduite sous influence, pour des raisons de justice

criminelle, et des raisons non-criminelles

La présente étude fait partie d’un projet d’évaluation des résultats du traitement concer- nant tous les programmes subventionnés par le gouvernement dans un état rural aux Etats

Indicators of Recovery at Intake 1797

Unis. Un des buts de l’étude est de générer des connaissances concernant les caractéristiques et les résultats des clients qui peuvent être utilisés pour améliorer les services. Cette étude utilise un échantillon de 888 clients recrutes entre juillet 2003 et juin 2004 en traitement d’abus de substances subventionné par l’État et qui ont participe a un entretien de suivi 12 mois après le traitement. Trois catégories de clients étaient examinées selon la raison pour leur entrée dans le programme pour examiner les différences de résultats: (1) Conduite sous influence (DUI – ‘driving under the influence’); (2) justice criminelle ; et (3) autres raisons. Tandis qu’un plus grand nombre de personnes dans le groupe DUI affirmaient consommer de l’alcool lors du suivi 12 mois plus tard, aucune autre différence n’a été constatée entre les groupes. Apres avoir contrôler pour l’âge, le sexe, la race et d’autres facteurs, l’intention de guérison à l’entrée et la participation aux 12 étapes au suivi prédisaient un résultat positif du traitement, tandis que la dépression persistante prédisait des résultats négatifs. Cette étude de clients dans le traitement pour abus de substances subventionné par l’État fournit des preuves supplémentaires que la raison pour entrer en traitement ne prédispose pas le client pour un résultat positif ou négatif. Deuxièmement, les facteurs au niveau du client qui sont liés aux pratiques de récupération et l’intention de réduire ou d’arrêter l’utilisation de substances pourraient nécessiter une plus grande attention dans le processus clinique.

RESUMEN

Definición de indicadores de curación en el cliente entre las personas en tratamiento de toxicomanı́a para conducta bajo influencia, por razones de justicia criminal,

y razones no criminales

El presente estudio forma parte de un proyecto de evaluación de los resultados del tratamiento relativo todos los programas subvencionados por el Gobierno en un estado rural en los Estados Unidos. Uno de los objetivos del estudio es generar conocimientos relativas a las caracterı́sticas y los resultados de los clientes que pueden utilizarse para mejorar los servicios. Este estudio utiliza una muestra de 888 clientes reclutados entre julio de 2003 y junio de 2004 en tratamiento de abusos de sustancias subvencionado por el Estado y que tienen participa tiene un mantenimiento de seguimiento 12 meses después del tratamiento. Se examinaban tres categorı́as de clientes según la razón para su entrada en el programa para examinar las diferencias de resultados: (1) Conducta bajo influencia (DUI—‘driving under the influence’); (2) justicia criminal; y (3) otras razones. Mientras que un mayor número de personas en el grupo DUI afirmaban consumir alcohol en el seguimiento 12 meses más tarde, ninguna otra diferencia se constató entre los grupos. Después de controlar para la edad, el sexo, la raza y de otros factores, la intención de curación a la entrada y la participación en las 12 etapas al seguimiento predecı́an un resultado positivo del tratamiento, mientras que la depresión persistente predecı́a resultados negativos. Este estudio de clientes en el tratamiento para abuso de sustancias subvencionado por el Estado proporciona pruebas suplementarias que la razón para entrar en tratamiento no predispone al cliente para un resultado positivo o negativo. En segundo lugar, los factores en el cliente que están vinculados a las prácticas de recuperación y la intención de reducir o decidir la utilización de sustancias podrı́an requerir una mayor atención en el proceso clı́nico.

1798 Walker et al.

THE AUTHORS

Robert Walker, MSW, LCSW, is an assistant professor of psychiatry at the University of Kentucky Center on Drug and Alcohol Research with conjoint appointments in behavioral science and social work. His over fifty publi- cations span a wide range of health and behavioral health topics including substance abuse, professional ethics in clinical practice, partner violence perpetration and vic- timization, and traumatic brain injury. He is the principal investigator for a state-mandated substance abuse treat- ment outcome study, a statewide outcome study of case management services for special education courses (SED) children and youth, and he is the evaluator for two feder- ally funded (CSAT) and four other state-funded projects.

Before coming to the university, he had over 25 years’ experience in the community mental health system as a clinician and Community Mental Health Center (CMHC) director, and he maintains close relationships with the mental and other health providers throughout the state. He has taught psychopathology as well as research in the master’s program in the College of Social Work. He has been a coinvestigator on partner violence studies in rural and urban areas and has been an evaluator of substance abuse treatment programs in rural and inner-city programs.

Jennifer Cole, MSW, is a PhD candidate in the College of Social Work at the University of Kentucky. She cur- rently works on the Kentucky Treatment Outcome Study Follow-Up as a research coordinator. She has worked as a project coordinator for a National Institute on Alcohol Abuse and Alcoholism (NIAAA) study, which examined alcohol, violence, mental health, health status, and service utilization among rural and urban women with protective orders against male partners, and a project coordinator on a National Institute on Drug Abuse (NIDA) study, which examined the nature, extent, and co-occurrence of HIV- risk behavior, violence, and crack use. Her primary inter- ests are in the areas of HIV sexual risk, intimate partner

violence, sexual violence, revictimization, and mental health issues of women.

Logan, PhD, is currently a professor in the department of behavioral science at the University of Kentucky and the Center on Drug and Alcohol Research, with joint ap- pointments in psychiatry, psychology, and social work. Dr. Logan has been funded by the NIDA, the NIAAA, and the National Institute of Justice (NIJ) to examine victimiza- tion, mental health, and substance use among women. She has a particular interest in understanding the intersection of intimate partner and sexual assault victimization, the health and mental health manifestations of victimization, help-seeking, and the justice system response to intimate partner and sexual assault victimization. She also has a

Indicators of Recovery at Intake 1799

particular interest in intimate partner stalking. Dr. Logan has coauthored several books including Women and Victimization: Contributing Factors, Interventions, and Implications and Partner Stalking: How Women Respond, Cope, and Survive.

Glossary

Recovery: Recovery as used in this study refers to abstinence. It is in contrast to another group of clients in this study who are defined as being in harm reduction with reduced substance use at follow-up.

Recovery intent: This is a new concept that is not synonymous with motivation, which is a more complex construct. Recovery intent, as used in this study, refers to clients’ vision of intended outcome as expressed as chances of becoming and remaining substance free.

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The American Journal on Addictions, 17: 36–47, 2008 ISSN: 1055-0496 print / 1521-0391 online DOI: 10.1080/10550490701756369

Uses of Coercion in Addiction Treatment: Clinical Aspects

Maria A. Sullivan, MD, PhD,1 Florian Birkmayer, MD,2 Beth K. Boyarsky, MD,3 Richard J. Frances, MD,4 John A. Fromson, MD,5 Marc Galanter, MD,4 Frances R. Levin, MD,1

Collins Lewis, MD,6 Edgar P. Nace, MD,7,8 Richard T. Suchinsky, MD,9

John S. Tamerin, MD,10,11 Bryan Tolliver, MD, PhD,12 Joseph Westermeyer, MD, PhD13,14 1Columbia College of Physicians & Surgeons/New York State Psychiatric Institute, New York, New York 2Department of Psychiatry, University of New Mexico, Albuquerque, New Mexico 3Committee for Physician Health, Albany, New York 4Department of Psychiatry, New York University School of Medicine, New York, New York 5Department of Psychiatry, Harvard Medical School, Boston, Massachusetts 6Washington University School of Medicine, St. Louis, Missouri 7University of Texas, Southwestern Medical School, Dallas, Texas 8Private practice, Dallas, Texas 9Private practice, Washington, District of Columbia 10Department of Psychiatry, Cornell/Weil School of Medicine, New York, New York 11Private practice, Greenwich, Connecticut 12Medical University of South Carolina, Charleston, South Carolina 13Department of Psychiatry and Medical Director, Mental Health Service, Minnesota VAMC, Minneapolis, Minnesota 14Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota

Coerced or involuntary treatment comprises an integral, often positive component of treatment for addictive disorders. By the same token, coercion in health care raises numerous ethical, clinical, legal, political, cultural, and philosophical issues. In order to apply coerced care effectively, health care professionals should appreciate the indications, methods, ad- vantages, and liabilities associated with this important clinical modality. An expert panel, consisting of the Addiction Commit- tee of the Group for the Advancement of Psychiatry, listed the issues to be considered by clinicians in considering coerced treatment. In undertaking this task, they searched the literature using Pubmed from 1985 to 2005 using the following search terms: addiction, alcohol, coercion, compulsory, involuntary, substance, and treatment. In addition, they utilized relevant lit- erature from published reports. In the treatment of addictions, coercive techniques can be effective and may be warranted in some circumstances. Various dimensions of coercive treatment are reviewed, including interventions to initiate treatment; contingency contracting and urine testing in the context of psy- chotherapy; and pharmacological methods of coercion such as disulfiram, naltrexone, and the use of a cocaine vaccine. The philosophical, historical, and societal aspects of coerced treatment are considered. (Am J Addict 2008;17:36–47)

Received April 13, 2006; revised June 22, 2006; accepted April 12, 2007.

This article is not subject to United States copyright laws. Address correspondence to Dr. Sullivan, Department of Psychia-

try, NYSPI, Substance Use Research Center, Unit 120, 1051 Riverside Dr, New York, NY 10032. E-mail: [email protected].

INTRODUCTION

Practitioners in the field of addiction treatment routinely encounter ambivalence in their patients’ motivation to seek treatment and follow clinical recommendations. Indeed, such ambivalence is understood to be integral to the process of effecting change.1 It is hoped that patients will work through their conflicts about alcohol or drug use in order to reach a state of decisive readiness to embrace sobriety. Yet even patients who remain ambivalent about their substance use can benefit, so long as they remain engaged in treatment. However, psychiatrists and other clinicians treating individuals with addictions must at times confront another dilemma: under what circumstances should treatment be imposed over a patient’s objections? In the United States, clinicians can, and indeed are, expected to undertake coerced treatment under certain circumstances, so the operative question is not so much “can” as “when” or “under what circumstances should” treatment be coerced. What are the legitimate uses of coercion in engaging a patient who refuses treat- ment because the substance use disorder is impairing his or her perception of the gravity of the disorder and its consequences?

In this review, we will consider a range of indications for coercion and practices that may serve as therapeutic tools in addiction treatment. Our discussion will focus on several broad areas where coercion may play a role:

36

� indications for compelling an individual to seek treatment,

� the application of coercive techniques in behavioral therapy and psychotherapy,

� pharmacological methods of coercion, and � societal, cultural and legal dimensions of coercion.

We will also address the limitations and possible abuses of such practices and suggest clinical guidelines for the application of coercion.

The crux of coercion is to motivate the patient to comply with addiction treatment by enforcing alternative consequences.2 In practice, the individual is rarely forced to comply with addiction treatment. However, an element of coercion in treatment often exists, such as when treatment is offered as an option to alternative consequences of addiction (eg, legal sentencing, loss of employment, loss of parental custody). Within the family setting, the consequences of refusing treatment may be the loss of marriage or the withdrawal of financial or emotional support by other family members. Within the occupational or professional context, consequences of refusing treatment might include termination or the loss of licensure. Therapeutic interventions are more likely to succeed if avoiding such alternative consequences is contingent not only on entering treatment, but on continued compliance with addiction treatment.3

Despite research literature confirming the efficacy of coerced addiction treatment,2,4 many clinicians are reluctant to invoke such techniques with patients. For some, concern about patient autonomy—even when such autonomy is clearly compromised by the cognitive and neurobiological effects of alcohol or substance abuse—is the primary deterrent to the use of coercive techniques. For other clinicians, a lack of experience with such interventions makes them reluctant to implement coercive strategies even when the therapeutic benefit seems clear.

In this paper we will consider the possible roles for coercion as a clinical tool. Case vignettes illustrating several mecha- nisms of coercion will be discussed, and their implications for clinical practice explored. We believe that the topic of coercive treatment is especially relevant to the treatment of the addictions, yet to date this technique has not received sufficient serious consideration as a therapeutic modality. We are also aware that any coercive practice carries the possibility of misuse, and we will seek to suggest a number of appropriate uses of coercion in addiction treatment, while highlighting limits on their application. In this report, we seek to present indications and methods that are currently supported by law, court decisions, ethics, and clinical guidelines in the United States.

HISTORY OF COERCED TREATMENT

Until the nineteenth century, addictive disorders were viewed as matters of moral weakness. Thus, people unable to control use of alcohol, opium, or other addictive disor-

ders were seen as morally weak, sinful, or otherwise evil people. Consequences of addiction thus involved alternatives such as social extrusion, incarceration, or other forms of punishment.

Historically, beginning in the 1700s, many psychiatrists have recognized significant self-harm as a sufficient criterion for involuntary treatment. While we physicians have a long tradition of engaging in involuntary treatment for mental illness, in recent decades there has been both professional and cultural resistance against extending such mandatory treatment to substance abusers who have not entered the legal system. By contrast, for drug addicts who get arrested, the choice is more clearly presented: drug courts offer forced substance abuse treatment as an alternative to a prison sentence. The current public ambivalence over whether non-criminal substance abusers should be seen as having an illness or a weakness of will has resulted in lagging support for substance abuse commitment policies. By contrast, in the 19th century, public opinion on this subject was more clear and had consequences for mental health policy. At that time, the prevailing view of addiction shifted away from its being a moral failing, toward a view of substance use as akin to insanity. In keeping with these attitudes, by the middle of the 19th century, states began developing substance abuse commitment codes and funding institutions to which addicts could be committed.

Shortly after the Harrison Act of 1914, the narcotics unit of the U.S. Treasury Department persuaded Congress to establish a chain of federal “narcotics farms,” where heroin addicts convicted of federal law violations could be incarcerated and treated for addiction.5 The first of these farms was the U.S. Public Health Service Hospital, established in Lexington, Kentucky, in 1935. A second hospital was established three years later in Fort Worth, Texas. Such farms housed both prisoners and voluntary heroin addicts. The goal of these facilities was to use psychiatric and vocational therapies to create a serene respite that would permit the rehabilitation of the individual. These narcotic farms had limited success because of certain design flaws, including a lack of mechanisms for holding voluntary patients until they had achieved some measure of recovery and a lack of aftercare services.6

About thirty years later, in the context of growing numbers of heroin addicts in the early 1960s, California implemented the first formal civil commitment program for addicted individuals in the United States in 1962. New York and the federal government followed suit within the next five years. The civil commitment process allowed willing addicts to “volunteer” for treatment (without involvement of the criminal justice system) and for addicts to be involuntarily admitted for treatment (by family or officials who believed there was imminent danger of self-harm or danger to the community). These civil commitment practices fell under suspicion in the 1970s because of concerns about due process issues related to lengthy stays in commitment facilities in which the environment was more correctional than therapeutic.6

Sullivan et al. January–February 2008 37

Public ambivalence in recent decades eroded support for these laws, and contemporary policymakers continue to struggle with the extent to which substance abusers should be subjected to involuntary treatment.7 Within the state of New York, it is rare for chronically substance-dependent individuals to be involuntarily admitted for a psychiatric admission unless the presence of a co-morbid psychotic or severe mood disorder can be documented. Emergency room psychiatrists may invoke “soft” evidence to support such a mentally ill chemically abusing (MICA) admission (eg, substance-induced mood symptoms or psychotic symptoms that clear after stopping the drug), and psychotropic agents are frequently prescribed to justify the MICA diagnoses. This philosophical stance—that substance abuse treatment must be entered into voluntarily— reflects a belief that drug dependence is fundamentally a free choice, an act of the will that cannot be countermanded by treatment interventions over the objection of the patient. Yet numerous clinical studies attest to the effectiveness of both psychotherapeutic and pharmacological means of coercing patients to enter treatment and to remain abstinent. In a study evaluating recovery following involuntary hospitalization of violent substance abuse patients, 60% of patients (12/20) maintained total abstinence at follow-up ranging from 3 to 24 months.8

COERCION AS A MEANS OF INITIATING TREATMENT

Perhaps the most widely recognized example of coercing a patient to enter treatment is the Johnson Intervention, a therapeutic technique in which members of the patient’s family or social group confront him or her about the consequences of drinking or drug use.9 This approach is considered coercive because the family members and friends set forth the consequences of continued drug use, namely certain losses that the individual will suffer, and contrast these with the outcome of addiction treatment. One group of researchers, in comparing methods of referral to outpatient addiction treatment, found that the coerced referral groups were more likely to complete treatment than those in the non-coercive referral groups.10

Whether this procedure takes place in the familial, social, or occupational context, we may identify several components of a successful intervention. First, a trained and experienced intervention leader is essential. This interventionist will select and train the other intervenors, set goals for the intervention, rehearse the intervention so that team members understand their roles and can practice what they will say, and promptly expedite the referral for recommended treatment.11 Second, the location and timing of the intervention is important. An early morning intervention, prior to the intake of drugs or alcohol, is recommended either in the addict’s home or in some neutral site. In addition, an intervention carried out immediately after an addiction-precipitated crisis is likely to succeed. Third, the intervention team members must document factual data and agree upon shared goals. The addict should be presented in writing with the team members’ experiences of

behaviors related to his or her addiction. He or she should be clearly told why the intervention is necessary. The personal, social, health-related, legal, and professional implications of the illness should be set forth.11 The successful carrying out of an intervention requires careful planning as well as a post-intervention regrouping to process the intervention team’s thoughts and feelings about the event, regardless of its outcome.

The intervention team should include the most significant people in the addicted person’s life: family members, close friends, supervisors, peers, or hospital administrators. The intervention must be planned to allow adequate time for discussion and relief from regular work duties. The following vignette (de-identified to protect confidentiality) illustrate such an intervention.

Case example 1. A 38-year-old married airline pilot had been drinking heavily on the days when he was not on flying duty, increasing his consumption to 8 to 12 drinks per day. Several fellow pilots became aware of his heavy drinking through observations at social events in their homes and the local community. They spoke to his wife about their concerns and their intent to confront him regarding his drinking. She endorsed their observations, shared their concerns, and agreed to attend the intervention, but did not want to speak about her concerns at the meeting. The pilots planned to report their concerns to the airline and Federal Aviation Agency if he did not voluntarily seek treatment, thereby triggering a mandatory evaluation. He could retain his position with the airline if he sought evaluation and treatment voluntarily, but could lose his position and his license if he was found to have a substance use disorder for which he was not voluntarily seeking care. The man agreed to enter treatment immediately. He responded well to treatment and returned to flight status six months later under close monitoring.

Case example 2. At the end of a work day, a 40-year-old neurologist was found scavenging through left-over ampules of hydromorphone hydrochloride in a cardiac catheterization lab. When confronted by the hospital administration and his chief of service, he initially denied using this drug, saying that he was concerned that medication with high addiction potential could be abused. He also said that he was acting as “a good Samaritan” and actually collecting the partially filled ampoules so that they could be discarded. He had no answer when asked why he would ever need to be in that particular area of the hospital, except to say that he often “roamed around” the building in his spare time. The chief asked the physician to voluntarily stop practicing and scheduled an intervention with the state physician health program. During this highly emotionally charged experience, the physician admitted to using IV hydromorphone hydrochloride for the past two months and was able to identify significant psycho-social stressors. These included the birth of his first child and extreme financial pressures associated with buying new office space. The physician was told that involvement with the state licensing board was inevitable, but that for his safety and the safety of his patients he should stop practicing, enter into a treatment program, and begin a monitoring contract after treatment to document that he was indeed substance- free and in recovery. He was also asked that he personally notify the state licensing board about these events. After much ambivalence, primarily centered around his fear of losing his license, he did notify the licensing board and was admitted into a treatment program, which he completed successfully. He subsequently began a monitoring contract with the physician health program and entered into a publicly disclosed probationary agreement with

38 Coercion in Addiction Treatment: Clinical Aspects January–February 2008

the licensing board. One year later, the physician was actually grateful that he was alive, in recovery, able to maintain his family relationships, and resumed the practice of medicine.

Often in special populations, such as physicians who practice in institutional or group settings, systemic issues act as barriers to their getting treatment for substance use disorders. For example, reluctance on the part of physicians to confront a colleague who is suspected of having a problem may be due to the fact that the concerned colleague may be the physician’s friend, business associate, or coverage partner. If a physician with a problem is a significant revenue producer, the hospital may be reluctant to take action for fear that business will be taken to a rival institution. At community hospitals, the chief of service may be appointed on a voluntary, rotating basis, often with no formal training on how to be a supervisor and deal with a problem physician. On a personal level, physicians may be reluctant to confront a colleague due to their over identification with the physician, thinking that, “It could just as easily be me with the problem.” Ironically, that is precisely the reason why colleagues need to reach out and let the physician with a suspected problem know that one is indeed concerned about them. They need to know that there is help, it works, and that while support may not always feel supportive, others do care deeply about them.12 Addicted persons who voluntarily enter the recommended treatment after assessment, successfully complete their treatment, and enter into a monitoring program sponsored by their state medical society will frequently avoid punitive sanctions and may receive advocacy instead.11

COERCION IN THE CONTEXT OF THERAPY

The use of “leverage” or coercion in psychotherapy or behavioral therapy for substance abusers represents a departure from the psychodynamic tradition, in which patients are guided to identify and confront internal psychological conflicts through unstructured, exploratory free association. In addition, it is a principle of the psychodynamic tradition that the therapist not take any responsibility for the patient’s behavior, as to do so would be infantilizing for the patient.

Psychodynamic psychotherapy is ill suited to dealing with substance-abusing patients because there are no behavioral controls to prevent the recurrence of drug use, nor are there any resources to conduct a behavioral intervention if and when a relapse occurs. Because of its inherent lack of limit-setting, psychodynamic psychotherapy fails to provide guidelines for dealing with intoxication during sessions, absences related to drug use, and dropouts because the primary problem is not brought under control. In addition, the anxiety-arousing nature of exploratory psychotherapy may give rise to intolerable affective or anxiety states that then drive a reinstatement of substance use.

Psychiatrists and other therapists working with addicted individuals recognize that drug-taking is a powerfully con- ditioned behavior marked by neurobiological changes in the reward pathways of the addict’s brain. Individuals seeking treatment for addictions require more active limit-setting

by the therapist. The presenting symptom, compulsive drug use, is initially intensely gratifying, although the long-term consequences are painful and destructive. Therapists who offer psychodynamic psychotherapy, with therapeutic neutrality and absence of structure, often find that their patients’ substance abuse continues unabated and undermines the treatment.

One critical tool in the psychotherapeutic armamentarium is that of contingency contracting. This practice involves drawing up a “contract” in which the patient agrees to perform certain behaviors or else face aversive consequences (eg, sending money to one’s most disliked charity, losing a license to practice a profession). Some behavioral contracts also include positive consequences (eg, receiving money) if the patient fulfills the conditions of the contract.13 The psychotherapist may also require that a patient initiating outpatient psychotherapy sign a behavioral contract agreeing to certain conditions of treatment, such as attending therapy sessions completely sober, refraining from seeking controlled prescriptions (ie, benzodiazepines, opioids) from any other physician, admitting to any lapse or relapse, submitting a urine sample at any time upon request, and granting permission for the therapist to contact the patient’s spouse or significant other if relapse occurs. In some instances, the patient may hold a job in which continued drug or alcohol use endangers the welfare of others. In this case, the patient may be required to prepare a letter informing his employer or state medical board of his addiction problem. If the patient relapses or drops out of treatment, his or her signed treatment contract grants permission for the therapist to mail this letter to the intended party. Such contracts can function as powerful external incentives to motivate continued participation in treatment and to secure sustained abstinence. Contingency contracting is often coupled with urine monitoring as a means of verifying the patient’s self-report of drug use or abstinence.14

Although it is a form of intrusive surveillance, urine testing is often considered an essential component of outpatient individual or group therapy with substance abusers. Addicts usually appreciate mandatory urine testing because it helps them counteract their urges to use and to conceal their use.15 Urine testing also keeps the patient from duping the therapist and thereby devaluing his or her treatment. Urine testing also allows family members and employers to be more supportive of the recovering addict because they need not constantly scrutinize him or her for signs of possible relapse. To ensure accuracy of urine testing, all samples should be “supervised” or witnessed by a same-sex staff person to prevent attempts at falsification. If sufficient staff are not available, a “buddy” system may be employed in which patients give urine samples under the supervision of a same- sex group member, according to a rotating schedule. When on-site testing is not available, a chain-of-custody procedure should be implemented to ensure that the sample taken at a remote location is transported safely to an analysis site. The specimen is labeled and sealed such that it is tamper- proof and can be accurately identified upon arrival. Given the sensitivity limits of standard laboratory testing methods, urine

Sullivan et al. January–February 2008 39

samples should be collected at least every 3–4 days.15 Urine samples should be routinely tested for all commonly abused drugs including opiates, marijuana, cocaine, amphetamines, benzodiazepines, and barbiturates. Urine testing should be continued throughout the entire duration of the treatment program. Even when patients have achieved several months of abstinence, it is useful to continue occasional random urine testing. In addition to urine drug testing, which remains the standard for drug use monitoring, sweat testing for drugs of abuse is increasing, especially in criminal justice programs.16

Sweat patches provide an advantage over urine drug testing by extending drug detection times to one week or longer.

Urine testing in the workplace enjoys regulatory approval under guidelines set forth by the National Institute on Drug Abuse (NIDA), the Department of Transportation (DOT), and the Nuclear Regulatory Commission (NRC). While these regulations were designed to address specific employment settings, they have been adopted by many employers as carrying regulatory approval for urine drug testing in a wide variety of work settings.17 According to guidelines published by the U.S. Department of Health and Human Services,18 a positive screening test obtained in most settings including the workplace should be followed by more specific testing (ie, gas chromatography/mass spectrometry) before sanctions are imposed. The standard of drug testing in the workplace includes secure collection, chain of custody, investigation by a medical review officer, and retention of positive samples for possible re-testing.18 Similarly, when urine testing results are used for legal purposes (eg, parolee monitoring), a chain- of-custody protocol is also used to ensure that a sample has not been compromised and that legal standards for protection of evidence are maintained. The collection site (laboratory, physician’s office or place of employment) must have trained personnel and adequate facilities to provide secure storage for samples awaiting analysis.

There has been growing evidence in the last decade that individuals who receive long-term aftercare and urine monitoring have better treatment outcomes than substance abusers who are less closely monitored. Frequent urine testing for illicit opioid and cocaine use in methadone programs has been found to produce more accurate use rates and help indicate the direction of needed interventions.19And in the treatment of therapy-resistant chronic alcoholics, an intensive outpatient approach developed in Germany has shown that monitored ingestion of disulfiram, as well as regular urine analysis for alcohol, yielded an abstinence rate of 60% at 6–26 months. The introduction of “control factors” thus appears to represent a promising advance for this population of treatment- resistant alcoholics.20

The advent of on-site urine drug testing has increased the use of drug testing in the workplace. Employees testing positive for illicit substances are often coerced into substance abuse treatments under threat of job loss. Lawental et al.21

compared pre-treatment problems, treatment performance, and post-treatment outcomes in a large sample of self- referred treatment program participants vs. those coerced into

treatment following detection of drug use at work. They found that the coerced group was significantly more likely to remain in treatment and had post-treatment improvements in alcohol and drug use as well as several other domains of functioning that were comparable to those shown by the self- referred patients. Further, workplace urine surveillance was successful in detecting employees with significant substance abuse problems. Among professionals with substance abuse problems, participation in a controlled aftercare program has been shown to be extremely effective. Reading found that New Jersey physicians who had completed a formal treatment and two years of program involvement had an overall success rate of 97.5%, and he attributed this to the frequent and structured outpatient counseling these physicians received.22 In another study of impaired physicians participating in urine monitoring, 12-step participation, and family therapy, Gallegos et al. reported that 77/100 physicians in the Georgia Impaired Physicians Program maintained documented abstinence from all mood-altering substances for 5–10 years after initiating a continuing care contract.23 Shore found that among 63 impaired physicians on probation with the Oregon Board of Medical Examiners, over an eight-year period there was a significant difference in the improvement rate for monitored individuals (96%) versus treated but unmonitored addicted physicians (64%).24 Such findings support the fact that random urine monitoring, despite its coercive nature, is associated with improved treatment outcome. An increasing body of literature on the treatment of addicted physicians underscore the value of strict aftercare monitoring. These studies also highlight the fact that the majority of physicians who complete treatment and undergo aftercare monitoring can successfully return to the practice of medicine.

One specific coercive use of urine testing is in relation to treatment-termination contracting. This intervention employs the contingent availability of further methadone treatment as a strategy for compelling abstinence from other drugs. McCarthy and Borders showed that the threat of methadone withdrawal for failure to meet specified standards of drug- free urine samples significantly reduced illicit opioid use and improved retention in treatment.25 Liebson and colleagues found that such negative contingency contracting increased compliance with disulfiram treatment among methadone- maintained alcoholic individuals.26 However, this strategy is not without its risks. While several studies have showed that 40–60% of patients will reduce or stop substance use under the threat of dose reduction or treatment termination,25,27,28 this approach is often counterproductive. Individuals with more severe polysubstance abuse tend to be unable to reduce their use under these conditions, and are thus forced to withdraw from treatment.27,29 Negative contingency contracting may therefore have the undesired outcome that the most severely impaired patients, who need treatment most, are forced to terminate treatment.30

Although not coercive in the strict sense, contingency man- agement exists on a continuum with contingency contracting. Contingency management relies upon the behavioral principle

40 Coercion in Addiction Treatment: Clinical Aspects January–February 2008

that behaviors that are rewarded or reinforced are more likely to be repeated in future. In many contingency management- based treatment programs, patients receive specific rewards for each urine specimen that tests negative for drugs. These rewards typically consist of vouchers that can be exchanged for retail goods and services, such as movie theater tickets or gift certificates for clothing, sports equipment, or electronics. In contingency management, voucher-based reinforcement of abstinence has been found to reduce cocaine abuse among methadone-maintained patients31 and marijuana-dependent adult outpatients.32 Higgins et al. have demonstrated that the treatment effects of voucher incentives endure after cessation of the contingencies.33

We find a clear example of the potential benefits of coercive treatment in the practice of establishing prison-based therapeutic communities. While these programs foster self- help in addressing life difficulties, and the individual may decline TC participation, the context in which participation takes place is perforce one of diminished autonomy. The alternative to participation is to serve a standard prison sentence. Wexler reviews outcome studies demonstrating that such therapeutic communities, while modified for a correctional setting, result in reduced recidivism by fostering personal responsibility for behavior and social integration.34

Melnick et al. found that the effect of TC participation on subsequent recidivism was mediated through entry into aftercare programs, as aftercare participation had a direct effect on diminishing relapse and recidivism. The authors further observed that program compliance based on external pressures without internal motivation was not associated with better outcomes. Rather, the interaction of motivation and participation early in the treatment process predicted entry into aftercare several months later.35

PHARMACOLOGICAL METHODS OF COERCION

The treatment of alcohol dependence enjoys the longest history of an effective pharmacological agent that mandates abstinence. Disulfiram (antabuse) inhibits aldehyde dehydro- genase, thereby leading to an accumulation of acetaldehyde if alcohol is consumed. Acetaldehyde is highly toxic; it produces nausea, diaphoresis, and hypotension, which in turn may lead to shock and prove fatal. In recent years, a lower dose of disulfiram 250 mg has been used, and no deaths have been reported from its use for a number of years.36 Because disulfiram takes up to five days to be fully excreted, a single dose will deter drinking for a 3–5-day period. Thus, although daily dosing is recommended, patients may benefit from observed ingestion of antabuse twice per week at the clinic or in the therapist’s office. The vast majority of patients—76% in one study37—will not risk drinking on disulfiram.

As only the most highly motivated patients would willingly and regularly take disulfiram, its appropriate use involves supervision by a family member or professional. It should be taken in the morning, when the urge to drink is generally lowest. Typically, the patient’s spouse observes the patient

ingest the antabuse and performs a visual inspection of the mouth to confirm compliance. Such monitored ingestion may be incorporated as a technique in Network Therapy.38 In this format, each day the observer records the time the pill is taken on a list prepared by the therapist. The observer brings the list to the therapist’s office at each network session. If ingestion is not clearly observed on a given day, the observer leaves a message on the therapist’s answering machine to this effect. Problems in compliance with the medication regimen are not policed by network members; rather, these issues are discussed in individual and network sessions.

Although monitored ingestion of disulfiram is a coercive practice and suggests that patients cannot be expected to continue such a program based on internal motivation alone, its therapeutic benefits are nevertheless well documented. By rendering alcohol physiologically unavailable, disulfiram reduces craving and enhances motivation for taking the medication the following day. In addition, because alcohol consumption is not an option, patients learn more adaptive strategies for coping with cues or triggers that previously resulted in abuse of alcohol.

PHILOSOPHICAL, HISTORICAL, SOCIETAL, CULTURAL, AND LEGAL DIMENSIONS OF COERCION

Philosophy of Coerced Treatment The prospect of compulsory treatment for drug addiction

has raised both philosophical and clinical objections.39,40

Some researchers have argued that involuntary treatment represents a substantial violation of personal liberty or deprives individuals of their right to participate fully and freely in society. Others oppose coerced treatment on clinical grounds, maintaining that treatment can only be effective if the person is motivated to change (ie, the addict must “hit bottom” before he can benefit from treatment). From this viewpoint, it is a poor investment to devote resources to individuals unlikely to change because they have little motivation to do so. Still others have argued that in a society where treatment slots are limited, providing treatment to addicts who do not really want it—even if they would benefit from it—ahead of those who desire treatment violates notions of distributive justice.41

While some view addiction as a product of individual choice, we have suggested that control is vital to the concept of personal responsibility. Factors that affect personal responsibility in addictive diseases include awareness of the problem, knowledge of a genetic predisposition, understanding of addictive processes, comorbid psychiatric or medical conditions, adequacy of the support network, nature of the early environment, degree of tolerance of substance abuse in the sociocultural context, and the availability of competent psychiatric, medical, and chemical dependency treatment.4

In addition, extended or excessive use of alcohol or other drugs may result in permanent cognitive deficits that interfere with treatment planning, insight, and impulse control. These cognitive deficits are often mislabeled as denial. Whereas the

Sullivan et al. January–February 2008 41

initiation of substance use may be an act of free will, continued abuse—after certain neurochemical changes have taken place in the brain—may fall more toward the deterministic end of the behavioral spectrum.42

Advocates of coerced treatment point out that few chronic addicts will enter and remain in treatment without some external motivation, and legal coercion is as justifiable as any other motivation for entry into treatment.43,44 Moreover, many “coerced” clients do not experience their referral as involuntary. A NIDA-funded Drug Abuse Treatment Outcome Study (DATOS) found that 40% of clients referred to treatment by the criminal justice system felt they “would have entered treatment without pressure from the criminal justice system.”

The involuntary treatment of substance use disorders remains highly controversial in some sectors, despite legal mandates and thousands of court cases. The civil libertarian position, as expressed by John Stuart Mill (1859) argues that

the sole end for which mankind are warranted, individually or collectively, in interfering with the liberty of action of any of their number, is self-protection. That the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant.45

According to this standard of ethics, coercive treatment of substance abuse can only be justified if it is not actually against the individual’s will, or the addict is causing harm to another person. Adhering to this standard, Ker et al. assert that because the majority of substance abuse clients surveyed while in treatment say they want to quit smoking,46,47 it is not a violation of their will to require it in chemical dependency programs.48 This argument does not fully address the issue of imposing smoking cessation on the minority of clients who may not wish to quit. Yet it has also been argued that because society as a whole benefits from controlling drug addiction, the criminal justice system should bring drug-abusing offenders into treatment in order to safeguard and promote the well- being and interests of the community.49,50 Criminal justice referrals constitute a substantial proportion (ie, 40–50%) of the publicly funded drug treatment population in the United States.41 Indeed, for many addicts, the only way they will receive treatment “in spite of themselves” is to end up in the criminal justice system, which is gradually evolving into an involuntary treatment system.4

Objections to coercive treatment options are often inspired by ethical concerns regarding the principle of autonomy in patient care. However, another central principle in medical ethics that is very pertinent to coercive treatments is benefi- cience. Definitions of beneficience center on the concept that it is the duty of health care providers to be of benefit to the patient, as well as to take positive steps to prevent and to remove harm from the patient.51 Autonomy and beneficience sometimes conflict in medicine; some coercive measures should be interpreted as a way to provide good care.52 Under the principle of beneficience, failure to increase the good of others when one is knowingly in a position to do so (ie, to offer effective treatments) is morally wrong.53−55 As the

evidence reviewed in this article suggests, coercive treatments are effective. Therefore, it would be unethical to withhold effective treatments, such as the coercive treatments described here, to the patients who could benefit from them.

While the philosophical discussion of free will and determinism has an ancient tradition, recent advances in neuroscience have added a biological dimension to this debate. For instance, advances in functional brain imaging have linked perceptual processing in the extrastriate visual cortices in the fusiform and superior temporal gyri to the formation of social judgments.56 However, even if the mental is reducible to the physical, it does not follow that free will is merely an illusion. In translating neuroscientific discoveries to the practice of addiction psychiatry, we must confront the question of impaired consent. Do the neurobiological sequelae of drug addiction constitute a state of compromised autonomy? And from a social and ethical standpoint, who would give permission for treatment on behalf of those who cannot give it by themselves?57 Such questions lie within the domain of the emerging field of neuroethics.

Science, Society, and Coerced Treatment Assisted outpatient treatment is a legal intervention in-

tended to improve treatment adherence among persons with serious mental illness. While opponents of coerced treatment argue that such mandates represent coordinated efforts to tighten social controls on people with mental illness, advocates of these policies believe that mandated care can be patient- centered in that it promotes patients’ engagement in their care to the maximun extent consistent with their abilities. Similarly, using incentives and disincentives to promote adherence is patient-centered care to the extent that these interventions are experienced by patients as being clinically grounded in a caring therapeutic relationship.58

Guidelines to help clinicians identify which patients are appropriate for involuntary outpatient treatment have been set forth by Geller.59 These guidelines begin with the premise that the patient has a chronic mental illness and a related history of dangerousness to self or others. The treatment guidelines follow a sequential order; the patient must meet the criteria for each guideline before being evaluated on the next guideline. The guidelines are as follows:

1. the patient must express an interest in living in the community;

2. he must have previously failed in the community; 3. he must comprehend the outpatient treatment require-

ments; 4. he must have capacity to comply with the involuntary

treatment plan; 5. the ordered treatment must have demonstrated efficacy; 6. the ordered treatment must be able to be delivered by the

outpatient system, be sufficient for the patient’s needs, and be necessary to sustain community tenure;

7. the treatment can be monitored by outpatient treatment agencies;

42 Coercion in Addiction Treatment: Clinical Aspects January–February 2008

8. the outpatient treatment system must be willing to de- liver the ordered treatments and be willing to participate in enforcing compliance;

9. the public sector inpatient system must support the outpatient system of involuntary community treatment; and

10. the outpatient must not be dangerous when complying with the ordered treatment.

Geller notes that community care that provides “an atmo- sphere that respects individual autonomy, enhances individual dignity, and encourages independence60” may be achievable only through coercion, for some persons.

Case example 3. A 26-year-old unmarried woman, unemployed with a history of heroin dependence, bipolar disorder, and borderline personality disorder, was hospitalized in a manic state, in the context of non-compliance with mood stabilizers and a relapse to heroin use. She had had two near-fatal heroin overdoses in the six months prior to admission. Her history was also notable for 24 prior psychiatric hospitalizations, episodes of self- mutilation, and non-compliance with both psychiatric medications and buprenorphine. During her hospitalization, the inpatient team applied for AOT and attended a court-ordered hearing for this patient. Based on the patient’s desire to live in the community but dangerousness to self and repeated failures in outpatient treatment, an AOT order was granted. She was mandated to daily attendance at a methadone program, attendance at recovery group therapy four times per week, and compliance with pharmacotherapy visits. She was also assigned a case manager who monitors her attendance at the methadone program to which she was referred. Urine toxicologies are collected weekly, and the results made available to her case manager, who is in regular contact with her treatment team. Failure of compliance with any element of her mandated outpatient treatment program may result in immediate involuntary hospitalization. Her primary psychiatrist reports that the patient has thus far remained abstinent from opiates and compliant with medications for the past three months, her longest period of mood stability and sobriety in the past seven years.

Forty-two states permit the use of assisted outpatient treatment (AOT), also called outpatient commitment. AOT is court-ordered treatment (including medication) for individuals who have a history of medication noncompliance, as a condition of remaining in the community. AOT has been proven to be effective in reducing the incidence and duration of hospitalization, homelessness, incarcerations, and violent episodes. AOT also increases treatment compliance and promotes long-term voluntary compliance. Data from the New York Office of Mental Health on the first five years of implementation of Kendra’s Law indicate that of those participating, 77 percent fewer were hospitalized (97 percent vs. 22 percent).61 Several studies have clearly established its effectiveness in decreasing hospital admissions.

A randomized controlled study in North Carolina demon- strated that intensive routine outpatient services alone, without a court order, did not reduce hospital admission. When the same level of services (at least three outpatient visits per month with a median of 7.5 visits per month) were combined with long-term AOT (six months or more), hospital admissions were reduced 57 percent and length of hospital stay by 20 days

compared with individuals without court-ordered treatment. The results were even more dramatic for individuals with schizophrenia and other psychotic disorders; long-term AOT reduced hospital admissions by 72 percent and length of hospital stay by 28 days compared to individuals without court-ordered treatment. The participants in the North Carolina study were from both urban and rural communities and “generally did not view themselves as mentally ill or in need of treatment.”62

AOT also improves substance abuse treatment. Individuals who received a court order under New York’s Kendra’s Law were 58 percent more likely to have a co-occurring substance abuse problem compared with a similar population of mental health service recipients. The incidence of substance abuse at six months in AOT as compared to a similar period of time prior to the court order decreased substantially: 49 percent fewer abused alcohol (from 45 percent to 23 percent) and 48 percent fewer abused drugs (from 44 percent to 23 percent).

In a review of the empirical literature on the effectiveness of this procedure, Swartz and Swanson conclude that AOT is most effective if it is sustained for six months or more. While AOT remains a controversial treatment strategy, clear practice guidelines for the treatment of specific conditions (eg, substance abuse comorbid with serious mental illness) could improve the understanding and utilization of AOT.63 Another arena in which important services have been withheld from substance abusers in that of money management assistance. Rosen et al. have documented a significant unmet need for money management assistance among psychiatric inpatients, particularly those with substance use disorders.64 Yet, in spite of this clear need, patients with comorbid substance use are typically not assigned a payee. Involuntary assignment of a payee based on substance abuse has been deemed controversial because, as substance abuse is often episodic, it is assumed that patients may be able to handle their funds independently when abstinent.65

Anglin and Hser recommended four important considera- tions for designing and implementing programs to serve legally coerced clients:

1. The period of intervention should be lengthy, at least three to nine months.

2. Programs should provide a high level of structure involving either residential stay or close urine monitor- ing in an outpatient program. Other ancillary services should be offered on an individual basis, including psychological/psychiatric care, vocational training, and GED courses.

3. Programs must be flexible: occasional drug use that does not threaten to disrupt the overall recovery process should be distinguished from relapse requiring detoxifi- cation or more intensive treatment.

4. Programs must undergo regular evaluation, preferably by an external evaluator, to determine their level of effectiveness and to detect changes in the client population they serve.50

Sullivan et al. January–February 2008 43

Drug courts comprise an example of a society-wide effort to employ coercion in the service of recovery from substance abuse.66 The initiative originates with courts of law, rather than from families or individuals. Indeed, many clients in drug courts have been alienated from their families. Thus, drug courts probably comprise a later intervention than might be feasible through commitment. Begun in the 1980s, drug courts use a coercive approach to encourage participation in treatment. Compliance is assessed monthly by a judge; positive behavior and abstinence are rewarded by reduced restrictions, while negative behavior or relapse is addressed by graduated sanctions including incarceration. Neither insight nor internal motivation need be present in order for participants to benefit from court-mandated drug treatment.67,68 The high program retention rates (more than 70%) and low re-arrest record of drug court graduates represent compelling evidence that such coercive practices can facilitate improved treatment outcomes.67,69 Further, Farabee et al.70 found that the use of coercive measures not only increased treatment retention, but also raised the likelihood of the legal offender entering treatment early in his substance-abusing career. Early entry into treatment has been consistently found to be associated with positive treatment outcomes.71

Culture, Ethnicity, and Coerced Treatment “Culture” refers to the social organization, norms, values,

and lifestyles of a people who share an over-arching identity and society; United States culture is an example. “Ethnicity” refers to subgroups within a culture that may share specific religion, national origin, language, or dress. Examples include African Americans, Irish Americans, Japanese Americans, Jewish Americans, and Navaho Americans.

Autonomous cultures hold the ideal of the individual as a “rugged individualist” who is a law unto him or herself.72 In such groups, family members and community peers respect and accept the self-destructive behaviors chosen freely by the group member, so long as the individual does not pose a risk to others. Cultures influenced by earlier Celtic societies and Plains Indians groups exemplify these values.

Such cultures have the advantage of holding individuals responsible for their alcohol and drug consumptions and associated behaviors. However, advanced cases of addiction can stymie families and even the societal institutions of such groups. The following case of a woodlands American Indian highlights the predicament that this value poses for family members.

Case example 4. In therapy, a recovering 28-year-old Chippewa man recalled his father’s suicide, which occurred when he was 15 years old. His mother had recently deserted his father and their five children. On a wintry Saturday morning, as the children were playing around the small three-room household, the father—hung over from the previous night’s drinking—uncharacteristically took out his shot gun and one shell. He watched spellbound as his father cocked the empty gun and held to his chin, manipulated the barrel around so he could discharge the weapon with his toe, clicked the firing pin against the empty chamber. Then he took the gun down and carefully loaded it with a shell, released the safety, repeated

the maneuver with his toe against the trigger. The round blew the top of his father’s head off, strewing blood around the room, filled a moment before with children playing and catching up on homework.

The patient even as an adolescent knew exactly what his father was doing, and why. Further, he knew that he could overpower his still drunken father, grab the shotgun, and throw the weapon off into the snowy woods where his father could not find it. Yet the respect for his father’s decision restrained any action, even if it meant his father’s life.

Parenthetically, this patient—later trained as a counselor— changed his mind about his decision as a 15-year-old. He now wishes that he had grabbed the gun and flung it out into the forest.

Leaving the addicted people to their own destiny is not a “no-fault” exercise for peers and for society at large. The self- destruction, incarceration, or disability of a family member does affect others. In the short term, there is a rip in the social fabric, financial losses, and crisis. Over the long term, the family is exposed to psychopathological role models, negative identities, and social shame. Ultimately, loss and grief ensue.

The “autonomy value” may cause one fail to appreci- ate that the addicted individual may have a compromised ability to make free, unencumbered choices. The autonomy perspective ignores the coercive forces of acute intoxication and withdrawal, subacute anxiety and depression, and chronic neurophysiological consequences of psychoactive substance use. Family members and society, choosing to support the addicted person’s “autonomy,” ally themselves with the coercive forces of the psychoactive substance. Family and societal education can help to inform and perhaps modify these cultural values, such as occurred in the life to the Chippewa counselor in the case above.

Collectivistic families and societies can also impede recov- ery if the group perceives the drinking or drugging behavior as being “normal,” even if it is “immoral” or an indication of “weak character.73” Examples of collectivistic societies include para-Mediterranean cultures, oriental societies, and many African and Hispanic societies.

Case example 5. A 56-year-old Hispanic married employed patriarch was brought to the hospital with bleeding esophageal varices. Laboratory evaluation revealed elevated liver enzymes and bilirubin with decreased albumin; antibody studies for hepatitis were negative. He had drunk about six beers per evening over the last forty years, with greater intake over the weekends and on vacation (12 beers or more).

Informed on his alcohol abuse diagnosis, he refused treatment, despite the potential seriousness of his resuming alcohol use. His family (wife, two daughters, and one son) would not consider initiating commitment and indeed actively supported the patient in resisting motivational interviewing. They stated that he could not be an alcoholic in view of his stable employment, his care and concern for his family, and the absence of fighting or trouble- making in the local community. This scenario repeated itself on two subsequent admissions for esophageal bleeding over the ensuing six months. He exsanguinated during his third esophageal hemorrhage before he could reach the hospital.

One might argue the family support for the patient’s perspective fostered his continued drinking and his early

44 Coercion in Addiction Treatment: Clinical Aspects January–February 2008

demise. In this instance, collectivism impaired his chances of recovery rather than enhancing it.

Of course, cultures often involve some elements of both autonomy and collectivism. Even if a society cathects to one of these world views and eschews the other, typically elements of both co-exist. Nonetheless, as exemplified by the two cases described above, these values can have powerful effects in driving addiction-related behaviors.

The uses of psychoactive substances are especially apt to change over time, sometimes over relatively brief periods of years or decades. Adoption of new psychoactive substances can derail cultural stability, especially when the use is integrated into other fundamental aspects of the culture.74 In Asia, the elimination of widespread opiate addiction in some areas led to increased alcohol abuse.75 Changes in the social or economic environment of a community can drastically alter substance use.76

Most case examples of culture change indicate a deterio- ration toward pathological substance use or other behaviors. However, numerous examples also document the abandonment of problematic cultural beliefs or customs. Gradual elimination of the Gin Epidemic in England occurred through voluntary and coercive means, including changes in the law (ie, a tax on beverage alcohol), establishment of new abstinence-oriented religions, and distribution of pamphlets that described the depredations of chronic alcohol use.77 In the United States, anti-smoking laws enacted over the past decade reflect and reinforce stronger negative cultural sanctions against nicotine dependence.

CONCLUSION

To date, coercive treatment has not received sufficient se- rious consideration as a therapeutic modality within addiction psychiatry. Current public ambivalence over whether non- criminal substance abuse should be seen as an illness or a weak- ness of will has resulted in a lack of support for involuntary treatment, despite the proven efficacy of such techniques and their special relevance to the treatment of addictions.66 In light of the compromised autonomy that individuals in the throes of addiction exhibit, coercion may be necessary to initiate treatment, through an organized intervention or other direct confrontation. Cognitive impairment related to addiction may impact on the addicted person’s ability to provide informed consent. Recent research in the neurobiological correlates of drug addiction has demonstrated, through functional imaging studies, that addicts have impaired response inhibition and abnormal salience attribution. Their motivation to obtain drugs overpowers the drive to attain most other non-drug-related goals.78 Motivational impairments and deficits in relative reward processing are consistent with uncontrolled drug- taking behavior and suggest that such individuals may not be capable of giving fully informed consent.

Recent pharmacological advances in the treatment of opiates and cocaine have highlighted how effective some coercive strategies can be. A depot formulation of naltrexone

(vivitrol, manufactured by Alkermes) was recently approved for the treatment of alcohol abuse but also holds promise for the treatment of opioid dependence. Given as a monthly injection, depot naltrexone virtually guarantees that heroin-taking will be extinguished. Further, a naltrexone implant currently being tested may block any opioid effects for six months or more. It is possible that depot naltrexone or naltrexone implants may become a legally mandated treatment in the future for patients who enter the criminal justice system. Under such conditions, these formulations would constitute coercive pharmacologic treatment. Similarly, the cocaine vaccine holds the promise of a similar “immunity” to cocaine dependence. This vaccine, which reduces drug craving, is still in efficacy trials but may eventually find application in legally mandated coercive treatment strategies. But the existence of such a vaccine raises important ethical and legal issues. Two fundamental questions that arise are the following:

� Is drug use ever a rational strategy for an addict? � Does he or she have a right to engage in such behavior

as an adaptive mechanism?

Another important question for future informed community debate is what role the cocaine vaccine should play in preventing cocaine addiction in children and adolescents. The efficacy of available treatments for substance abuse highlights the need for informed ethical and clinical discussion of the appropriate uses and limits of coercion in the practice of addiction psychiatry.

While such techniques are coercive to a greater or lesser degree, even mandated therapeutic techniques may be patient- centered in that they promote the individual’s engagement in treatment to the fullest extent consistent with his or her abilities. The clinical literature confirms that coercion can be a highly effective therapeutic strategy, and one that patients often retrospectively endorse. Yet clinicians should recall that coercion may have unintended as well as therapeutic consequences. As in all clinical interventions, it is necessary to exercise compassion and wisdom in the use of coercive techniques for the treatment of addictions.

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