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The Effectiveness of Coerced Treatment

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The Effectiveness of Coerced Treatment for Drug-

Abusing Offenders

M. Douglas Anglin

Michael Prendergast

David Farabee

UCLA Drug Abuse Research Center

1100 Glendon Avenue, Suite 763

Los Angeles, California 90024

Paper presented at the Office of National Drug Control Policy’s Conference of Scholars

and Policy Makers, Washington, D.C., March 23-25, 1998

The Effectiveness of Coerced Treatment

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Abstract

This paper presents an abbreviated survey of the substance abuse treatment literature

regarding the effectiveness of various levels of coercion. The review provides overall support for

the dictum that legally referred clients do as well or better than voluntary clients in and after

treatment. However, our review also reveals some divergence in findings which we consider

equally illuminating. We propose that the majority of the variation in coerced treatment outcomes

is due to (1) inconsistent terminologies for referral status, (2) neglected emphasis on internal

motivation, and (3) infidelity in program implementation. The paper concludes with specific

recommendations to improve upon the relative success of current coerced treatment strategies.

The Effectiveness of Coerced Treatment

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The Effectiveness of Coerced Treatment for Drug-Abusing Offenders

Background

Criminal justice referrals constitute a substantial proportion of the publicly funded drug

treatment population in the United States. According to recent data, the criminal justice system is

responsible for 40 to 50 percent of referrals to community-based treatment programs (Maxwell,

1996; Price & D’Aunno, 1992; Spiegelman, 1984; Weisner, 1987). Given our nation’s high

proportion of criminal justice treatment clients, a major policy and program issue in drug

treatment is the effectiveness and appropriateness of coercing offenders to enter and remain in

treatment. This paper provides an overview of studies regarding the effectiveness of various levels

of coerced treatment and concludes with a number of treatment and policy implications.

Some researchers (Hartjen, Mitchell, & Washburne, 1982; Platt, Buhringer, Kaplan,

Brown, & Taube, 1988; Rosenthal, 1988) have argued that little benefit can be derived when a

drug user is forced into treatment by the criminal justice system. Some oppose coerced treatment

on philosophical or constitutional grounds. Others argue against coerced treatment on clinical

grounds, maintaining that treatment can be effective only if the person is truly motivated to

change; a variation of this position is that addicts must “hit bottom” before they are able to benefit

from treatment, a circumstance that is not true of most coerced clients. According to this view, it

is a poor investment to devote resources to individuals who are unlikely to change because they

have little or no motivation to change. Furthermore, in situations where treatment slots are

limited, it may also violate notions of distributive justice to provide treatment to addicts who

don’t really want it--even if they might benefit from it--ahead of (or instead of) those who do

desire treatment.

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Other researchers (Anglin & Maugh, 1992; Salmon & Salmon, 1983) have argued that

few chronic addicts will enter and remain in treatment without some external motivation and that

legal coercion is as justifiable as any other motivation for treatment entry. It has also been argued

that because controlling drug abuse and addiction benefits society as a whole, the criminal justice

system should bring drug-abusing offenders into treatment to safeguard and promote the interests

and well-being of the community (Anglin, 1988; Anglin & Hser, 1991). But consideration of legal

and ethical questions surrounding coerced treatment do not arise unless it can be demonstrated

that coerced treatment is effective and that resources spent on coerced clients do produce

desirable results.

Answering the question regarding the effectiveness of coerced treatment is by no means

straightforward. A number of conceptual issues need to be addressed in order to design

meaningful empirical studies or to interpret existing studies appropriately. Two issues of particular

importance are the definition of coerced treatment and the interaction of coercion (external

pressure) and motivation (internal pressure).

The terminology used to discuss “coerced treatment” is far from consistent: “coerced,”

“compulsory,” “mandated,” “involuntary,” “legal pressure,” and “criminal justice referral” are all

used in the literature, sometimes the terms are used interchangeably within the same article. This

would not be a problem if these terms were synonyms. But “coercion” is not a single well-defined

entity; it in fact represents a range of options of varying degrees of severity across the various

stages of criminal justice processing. “Coercion” can be used to refer to such actions as a

probation officer’s recommendation to enter treatment, a drug court judge’s offer of a choice

between treatment or jail, a judge’s requirement that the offender enter treatment as a condition of

probation, or a correctional policy of sending inmates involuntarily to a prison treatment program

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in order to fill the beds. In other cases, a treatment client’s merely being “involved with the

criminal justice system” is sufficient for him to be brought under the umbrella of “coercion.”

Coercive treatment approaches for drug addiction have been applied consistently

throughout the twentieth century, beginning with the morphine maintenance clinics in some

communities during the 1920s. The 1930s marked the establishment of the federal narcotics

treatment facilities in Fort Worth, Texas and Lexington, Kentucky. During the 1960s broad-based

civil commitment procedures were implemented in the federal system, as well as in New York and

California. The present system, beginning in the 1970s, relies less on formal civil commitment

procedures and emphasizes community-based treatment as an alternative to incarceration, or as a

condition of probation or parole. More comprehensive historical reviews of coerced treatment in

the United States can be found elsewhere (Anglin & Hser, 1991; Inciardi, 1988).

Despite some variation in findings, empirical studies have largely supported the use of

coercive measures to increase the likelihood of an offender’s entering and remaining in treatment.

The following section describes the results of 11 such studies, which are briefly summarized in

Table 1.

Review of Coercion-Based Treatment Studies

For purposes of this paper, we reviewed 11 published studies involving the relationship

between various levels of legal pressure and substance abuse treatment (see Table 1). Of these,

five found a positive relationship between criminal justice referral and treatment outcomes, four

reported no difference, and two studies reported a negative relationship. How do we account for

these different findings? Closer inspection of these studies shows considerable variation in the

legal pressure applied, different outcome measures, and a range of types of programs and

substances treated.

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Table 1: Overview of Coerced Treatment Articles

Assessed

Authors Year Modality(s) Comparison Motivation Findings

Anglin et al. 1989 Methadone High, moderate, and No Main effect for treatment across

low legal coercion all three coercion groups, with

regard to drug use and criminality

during and after treatment.

Brecht & Anglin 1993 Methadone No CJ pressure vs. No All groups showed improvement.

moderate CJ pressure vs. Retention and drug use outcomes

strong CJ pressure were similar regardless of coercion

level.

Collins & Allison 1983 OP and Residential No CJ pressure vs. No Retention rates were lowest among

TASC vs. other CJ voluntary clients, slightly higher

referral among CJ referrals, and highest

among TASC referrals--presumably

due to the closer supervision of the

latter.

Harford et al. 1976 Residential-- Probation, parole, or No Depending on the program,

adolescent, residential pre-trial vs. voluntary retention rates were the same or

young adult, OP-- worse for CJ-referrals.

adolescent, OP young

adult, Methadone

Howard & McCaughrin 1996 Non-methadone Programs 75% + No CJ-dominated programs reported

court-mandated lower compliance. Providing CJ

clients vs. those w/ clients w/ information and choices

25% or fewer was associated w/ better outcomes.

McLellan & Druley 1977 90-day VA Court-referred vs. No Overall, no sig. differences. Trends

Residential voluntary indicate that court-referrals are

more withdrawn early in treatment

but become as engaged as

voluntary admissions during latter

stages of treatment.

Rosenberg & Liftik 1976 Outpatient-- Probation referrals vs. No Probation referrals had higher

alcohol voluntary patients attendance rates than voluntary

admissions. However, only 16%

of probationers continued in

treatment beyond probation period.

Salmon & Salmon 1983 Outpatient Drug-Free TASC referrals No Mixed. Coercion associated with

and Methadone vs. voluntary better outcomes for subgroups (e.g.

older, chronic opiate users), but not

others. Effective for OP, but

not MM.

Schnoll et al. 1980 Residential Legal status vs. no No Clients entering treatment directly

legal status at admission from prison had higher completion

rates than those with no legal

status.

Siddall & Conway 1988 Residential Voluntary vs. No Involuntary admission associated

involuntary with successful discharge.

(Undefined)

Simpson & Friend 1988 Methadone, TC, Legal status vs. no No Retention and drug use outcomes

OP, and Detox legal status at admission were similar for legal status and

non-legal status clients.

Of the five studies which found a positive relationship between legal coercion and

substance misuse treatment, two involved Treatment Alternatives to Street Crime (TASC

referrals). TASC attempts to identify drug abusers who come into contact with the criminal

justice system, refer eligible offenders to appropriate treatment, monitor clients' progress while in

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treatment, and return violators to the criminal justice system. The first study involving TASC

clients, by Collins and Allison (1983), assessed the impact of legal pressure on a drug abuser's

length of stay in treatment. The investigators focused on individuals who entered outpatient drug-

free and residential treatment programs through referrals by TASC, through other referrals from

the criminal justice system, and through non-legal sources. The investigators found that the effects

of being referred to drug abuse treatment by TASC and of being involved with the criminal justice

system at the time of treatment intake were statistically significant for both modalities. In addition,

the study found that legally referred clients entered treatment earlier in their addiction career than

would otherwise have been the case and that they stayed in treatment longer—both circumstances

that are conducive to better outcome.

The other TASC-related study, by Salmon and Salmon (1983), explored the impact of

TASC referrals on the rehabilitation of drug abusers in a methadone maintenance clinic and a

drug-free treatment setting (clients abusing only alcohol or marijuana were excluded). Unlike

other studies, which relied primarily on treatment retention and successful discharge as outcome

criteria, this study employed frequency of drug use, times arrested, abstinence, and time worked

on the job. They found that coercion facilitated success under certain circumstances: for certain

population groups (older, long-term heroin addicts), for certain criteria (arrest and abstinence),

and for certain treatment settings (drug-free versus methadone maintenance programs).

In another study finding a positive relationship between legal status and treatment

outcomes, Schnoll et al. (1980) examined a modified therapeutic community treating both

alcoholics and drug dependent clients in inpatient and residential programs. They grouped clients

into one of four mutually exclusive categories involving degree of legal involvement: (1) a

“directly from prison” group, (2) an “open cases” group, regardless of probation or parole status,

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(3) a “parole and/or probation” group, and (4) a “no legal involvement” group. Schnoll and

colleagues found that residents admitted directly from prison were more likely to complete

inpatient treatment than any other group since they faced the possibility of incarceration if they

did not do so. Siddall and Conway (1988) reported similar results in their study of 100 substance

abuse clients in a residential treatment center, 42 of whom were involuntary admissions. They

found that clients who successfully completed treatment were more likely to have been admitted

on an involuntary basis. Unfortunately, definitions of “voluntary” and “involuntary” were not

given. The last study reporting a positive relationship between legal coercion and treatment

outcomes focused on outpatient treatment of alcoholism (Rosenberg & Liftik, 1976). The

investigators found that the weekly attendance patterns of drivers who were convicted of driving

under the influence and who were mandated to treatment were significantly better than those of

voluntary admissions.

Four of the studies reviewed found that legal coercion made no difference in substance

misuse treatment outcomes (Anglin et al., 1989; Brecht & Anglin, 1993; McLellan & Druley,

1977; Simpson & Friend, 1988). The samples used in these studies were more homogeneous than

the studies described above. The majority of the subjects were male opiate addicts and the

programs evaluated were primarily methadone maintenance programs, though inpatient

rehabilitation and outpatient programs were also included. Outcome measures differed among

these studies, however. Two of the studies relied on measures that did not involve treatment

retention or successful treatment completion, but rather involved criteria such as criminal

involvement, drug involvement, and social functioning (Anglin et al., 1989; Brecht & Anglin,

1993), while another study examined disruptiveness by measuring number of contacts with staff

(McLellan & Druley, 1977). Despite these differences in outcome measures, these four studies

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concluded that clients who enter treatment under some degree of coercion did as well as clients

entering treatment voluntarily or under minimal levels of coercion.

Two studies reported a negative relationship between legal coercion and substance misuse

treatment outcomes. In the first, Harford and colleagues (1976) found that four measures of legal

pressure were either unrelated or negatively related to treatment retention and outcome in five

drug abuse treatment modalities: (1) a residential program for adolescents, (2) a residential

therapeutic community for young adults, (3) a day program for adolescents, (4) an outpatient

abstinence and narcotic antagonist program serving primarily young adults, (5) and a methadone

treatment program. Legal pressure was defined to exist if the applicant reported being on

probation, on parole, or awaiting trial at the time of admission. The fourth measure of legal

pressure was a logical composite of these three legal coercion status groups. The investigators

found that older methadone clients and adolescent clients who were admitted for treatment while

on probation were retained in treatment for shorter periods of time than were clients who were

not on probation. No other differences in retention or graduation rates involving any of the four

measures of legal pressure were statistically significant. The authors suggested the possibility that

legal pressure inhibits rather than facilitates treatment for addiction among some clients.

The final study differed from the others discussed here in that it surveyed organizations,

not individuals. This study asked whether outpatient substance abuse treatment organizations

have different outcomes for court-mandated and voluntary clients depending on the mix of clients

(Howard & McCaughrin, 1996). A nationally representative sample of 330 nonmethadone

outpatient substance misuse treatment organizations was surveyed in 1990 using two outcome

variables: meeting the goals of treatment and failing to comply with the treatment plan. The

investigators found that organizations with 75 percent or greater of court-mandated clients had a

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greater rate of clients failing to comply with their treatment plan than organizations with 25

percent or less court-mandated clients, but there were no differences in clients meeting their goals

of their treatment.

This discussion highlights the fact that, despite their addressing an apparently similar

issue—coerced treatment, these studies have concerned themselves with treatment of different

kinds of substances (drugs, alcohol, or both), different program types, different outcome

measures, and various measures of legal involvement or coercion. While the relative robustness of

this finding provides overall support for coercing substance-abusing offenders into treatment,

there are several equally important lessons to be learned from the variation among these studies.

Reasons for Cross-Study Variations

Based on our review, we propose that the majority of the variation in coerced treatment

outcomes is due to (1) inconsistent terminologies, (2) neglected emphasis on internal motivation,

and (3) infidelity in program implementation. These are summarized below:

Inconsistent Terminology

“Criminal justice referral” does not necessarily mean that a client is entering treatment

involuntarily. The importance of this distinction is clearly evident in studies of psychiatric

populations, which show that the majority of patients whose official records indicated that they

entered treatment voluntarily actually were under some form of official custody and were under

the threat of involuntary commitment if they failed to enter treatment “voluntarily” (Gilboy &

Schmidt, 1971). Conversely, other studies have indicated that clients entering mental health

treatment under involuntary status are not necessarily involuntary. For example, one study of

committed psychiatric patients revealed that approximately one-half did not know their

commitment status, and among those who said that they were denied the opportunity to enter

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voluntarily, approximately one-half said that they would have chosen to enter voluntarily if they

had been given the choice (Toews, el-Guebaly, Leckie, & Harper, 1984).

Likewise, the assumption that all criminal justice clients are entering treatment

involuntarily has little empirical support. In a study of 1,030 male prison inmates in Texas, 50

percent of the general population inmates said that they would be interested in participating in a

drug or alcohol treatment program at that time. Among those indicating an interest in treatment,

approximately 50 percent reported that they would be willing to participate in an in-prison drug or

alcohol program even if it meant extending their stay in prison for three months (Farabee, 1995).

Clearly, in spite of their criminal justice status, these potential clients would probably be entering

treatment voluntarily.

Recent data from the NIDA-funded Drug Abuse Treatment Outcome Study (DATOS)

provide further evidence that clients entering community-based treatment under a legal referral are

not necessarily involuntary. In fact, 39.8% of clients referred to treatment by the criminal justice

system report that “think [they] would have entered drug treatment without pressure from the

criminal justice system.” Among clients for whom treatment was required (rather than suggested),

42.6% reported that they would have been willing to enter treatment even without the use of

criminal justice pressure. When the sample is limited to criminal justice referrals, a second level of

diversity becomes apparent related to the level of criminal justice pressure. Among this subgroup,

23.3% were merely referred to treatment without a formal mandate and without drug testing (low

DATOS is a comprehensive multisite prospective study of drug treatment effectiveness. Among several other objectives, one of the

main purposes of this study is to examine the effectiveness of the drug abuse treatment programs through a study of treatment clients in

11 cities in the United States followed longitudinally over a period of 36 months. A population of 10,010 DATOS clients have been

interviewed at entry to treatment in a sample of 99 programs within the United Stated from 1991 to 1993. Cities and programs were

purposively (not randomly) chosen for participation; they were representative at the time of their selection of typical, stable drug

treatment programs in large and medium sized U.S. cities. Clients were selected from four drug treatment modalities, which were

presumed to reflect the current treatment system: 3,122 clients from 14 short-term inpatient programs, 2,774 clients from 21 long-term

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pressure). Twenty-two percent of the criminal justice referrals were mandated to treatment, but

without drug testing (moderate pressure), and 54.6% were mandated to enter treatment and to

undergo periodic drug tests (high pressure). However, Hiller et al.’s (1998) recent study of

retention in long-term residential programs suggests that the level of criminal justice pressure may

be less important than its mere presence.

The Role of Internal Motivation

According to Miller (1991), a client entering treatment prior to recognizing his or her

substance use as being problematic is unlikely to be open to therapeutic intervention. In this early

stage, a client is most likely to benefit from non-directive feedback and information to help raise

awareness of the problem. Direct challenges to the client will be perceived as aversive and will

typically disrupt therapeutic progress. Over time, these clients tend to shift between

acknowledging and denying that they have a substance use problem. Again, direct challenges by a

counselor may only serve to shift the client’s perception back to denial. However, more direct

recommendations toward taking action can be made during the client’s ephemeral phases of

problem recognition. Thus, both external and internal motivation play important roles in the

treatment process and relapse. Failure to address both types of motivation results in inferior

treatment participation and less favorable outcomes than if these motivational sources are treated

as complementary. Leukefeld and Tims (1988, p.243) have suggested that:

Recovery from drug abuse is an interactional phenomenon involving...client factors with

nontreatment factors, such as social climate, as well as treatment itself...Client factors

include...external pressure and internal pressure. Legal referrals belong in the external

pressure category. A stable recovery cannot be maintained by external (legal) pressures

residential programs, 1,540 clients from 29 outpatient methadone maintenance programs, and 2,574 clients from 35 outpatient drug-free

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only; motivation and commitment must come from internal pressure. The role of external

pressure from this point of view is to influence a person to enter treatment.

One study comparing voluntary and criminal justice-referred substance abuse clients

entering treatment showed both groups to be almost identical on a battery of psychosocial

measures, with the primary difference being significantly lower self-assessments of drug problems,

desire for help, and readiness for treatment reported by those who had been legally referred

(Farabee, Nelson, & Spence, 1993). Involuntary clients are also more likely to claim that their

substance use is purely recreational and does not pose a problem for their lives (Schottenfeld,

1989). Consequently, a large proportion of clients currently entering community-based treatment

under criminal justice referral have treatment needs similar to those of their voluntary

counterparts, but lack the internal motivation to readily engage themselves in the treatment

process. This lack of internal motivation for change is associated with lower treatment retention

rates (De Leon & Jainchill, 1986) and inferior outcomes (Simpson et al., 1997).

Fidelity of Program Implementation

Even among similar types of programs there is exceedingly high within-group variation in

actual implementation (Britt et al., 1992; Jones & Goldkamp, 1991; Visher, 1992). The level of

coordination between treatment providers and the criminal justice system is often inconsistent

between programs--a difference that has been associated with treatment retention (Hiller et al.,

1998). This lack of inter-organizational coordination and communication negatively impacts two

critical aspects of the legal coercion process. First, many offenders deemed eligible for treatment

by the criminal justice referral source may not necessarily be appropriate candidates for a given

modality, or for treatment in general. According to a large-scale evaluation of the Treatment

programs.

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Alternatives to Street Crime (TASC) programs, TASC referrals with the lowest problem severity

demonstrated the least improvement overall. In contrast, substance abuse treatment appeared to

have more favorable effects on “hard core” TASC referrals, as defined by baseline drug use prior

to TASC involvement (Anglin et al., 1996). As a result, inter-program variations in screening and

referral criteria can have a profound impact on the measurable success of these programs.

The second crucial impact of implementation relates to inter-agency communication. Poor

communication between treatment and criminal justice organizations inevitably diminishes the

provider’s ability to enact immediate sanctions for non-attendance or non-compliance. A notable

example of this problem was observed in the administration of the federally funded Narcotic

Addiction Rehabilitation Act of 1966, which included, among other treatment-related sections, six

months of narcotics addiction treatment through the U.S. Public Health System hospitals in

Lexington, Kentucky and Fort Worth, Texas. A commonly cited problem with these programs

was the providers’ lack of autonomy and their inability to communicate efficiently with the court

system. In fact, any movement or status change of an addict in these programs required court

approval, which, in turn, required that the addict be transported to and from the federal court for

the case to be presented (Anglin & Hser, 1991). Despite some positive findings for these

programs, the cumbersome administrative structure and poor linkages between the treatment

providers and the court system led to their eventual closure in 1972.

Conclusions and Recommendations

In general, our review of 11 empirical studies of compulsory substance abuse treatment

supports the use of the criminal justice system as an effective source of treatment referral, as well

as a means for enhancing retention and compliance. However, the divergence among these

results--with five of the studies reporting a positive relationship between legal coercion and

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treatment outcomes, four reporting no difference, and two studies reporting a negative

relationship--leads to a number of additional conclusions.

First, from a methodological standpoint, we reiterate De Leon’s (1988) contention that

research in this area has been confounded by the misuse of terms such as “legal referral,” “legal

status,” and “legal pressure.” De Leon suggests that legal referral should be used to express an

explicit procedure in which an offender is referred to treatment via probation, parole, diversion, or

specific sentencing stipulations. Legal status should be used to describe clients with any form of

legal involvement, ranging from warrants to incarceration. Finally, De Leon suggests that the term

legal pressure be used to describe the extent to which the offender experiences discomfort over

the potential consequences of noncompliance. Future studies should avoid using subjective terms

such as “involuntary” or “coerced” without directly assessing the client’s perception of the referral

process.

Second, the research emphasis on external pressure to enter treatment, and its relative

success, has largely eclipsed the potential role of internal motivation. There is strong support for

the role of internal motivation as a predictor of program retention and positive treatment

outcomes. Examining the role of coercion for clients in an alcohol treatment program, Freedberg

and Johnston (1978) found that, while external sources of coercion played an important role in

bringing the client into treatment, the decline in perceived external coercion over the following

year was a significant predictor of abstinence one year later. Likewise, Simpson et al. (1997)

report that a client’s internal motivation for change at the time of program admission significantly

predicted long-term post-treatment outcomes. Clearly, the relative success of external motivators

for treatment (i.e., legal coercion) should not preclude our efforts to enhance the internal

motivation of coerced clients.

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The variation in outcomes by the type of offender referred to treatment suggests another

conclusion regarding the type of offender most likely to benefit from legal coercion. According to

a panel of experts commissioned by the Center for Substance Abuse Treatment (CSAT; 1994),

substance-abusing clients in the criminal justice system can be grouped into four major categories:

(1) Young offenders who have recently begun abusing substances and have not yet experienced

any serious consequences of that behavior, (2) Offenders who have abused substances for five or

more years, have experienced some negative consequences of their substance abuse, but have not

yet “hit bottom,” (3) Offenders whose substance abuse has resulted in a personal crisis such as

losing a job, going to jail, or the loss of an important personal relationship, and (4) Career

criminals who abuse substances. The CSAT panel recommended that treatment priority should be

given to offenders in the first and third groups: young substance abusers who have used for a

short period of time, and substance abusers who have experienced some kind of major negative

consequence of their substance use and, therefore, would be most willing to change their

behavior. However, according to the nationwide TASC evaluation mentioned above (Anglin et

al., 1996), low-level offenders are less likely to benefit from treatment than those with more

extensive drug use and criminal histories. Therefore, we would argue that, while both of these

groups should be targeted for treatment, substance-abusing offenders early in their criminal

careers may be best served with briefer interventions, rather than mandating them to programs

targeted for more impaired populations.

The final conclusion derived from the variation in the reviewed studies is the importance

of fidelity in program implementation. As we have learned from the Title II and III NARA

hospitals, program administration must be designed to facilitate the treatment process, rather than

the converse. Programs serving criminal justice clients must maintain close linkages with these

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referral sources if the threat of criminal justice sanctions is to be taken seriously. Based on NARA

and other historical examples, Anglin and Hser (1991) recommend four important considerations

for the design and implementation of programs serving legally coerced clients:

• The period of intervention should be lengthy, since drug dependence is a chronic, recurring

condition. Prior research suggests an ideal treatment of 3 to 9 months (Gendreau, 1996;

Wexler, Falkin, Lipton, & Rosenblum, 1992), and several episodes of primary treatment,

aftercare, and relapse should be expected.

• Treatment programs should provide a high level of structure, particularly during the early

stages. This period should require either a residential stay or close urine monitoring in an

outpatient program. Other ancillary services that enhance retention should be offered on an

individual basis. These include psychological/psychiatric services, vocational training, and

GED courses.

• Programs must be flexible. Among community-based treatment clients, occasional drug use

that does not appear to seriously disrupt the overall recovery process should be handled on an

client by client basis. However, detection of relapse should be addressed immediately, by

returning the substance abuser to detoxification, if necessary, and an intensive level of

treatment (e.g., residential or methadone maintenance).

• Programs must undergo regular evaluation to determine their level of effectiveness and

to detect changes in the client population they serve. Recurring process and outcome

evaluations, ideally by an external evaluator, help to ensure program fidelity or, as dictated by

program retention and outcomes, to identify the need for change. Periodic research exposure

can also help keep treatment staff up-to-date on new treatment strategies being developed or

practiced at other programs.

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Although the majority of the studies reviewed here examined the relationship between

legal status, legal referral, or legal pressure to treatment retention and outcomes, coercion

undoubtedly accounts for some of the variance in all of these measures. We have suggested that

terms like “involuntary” and “coerced” not be used without first measuring the subjective

perception of the clients in question; these assessments should also include internal motivation.

High internal motivation for change prior to treatment is predictive of two-fold increases in the

likelihood of positive outcomes for substance use and criminality (Simpson, Joe, & Rowan-Szal,

1997). Consequently, while external motivators such as criminal justice pressure, and presumably

coercion, are often associated with positive treatment outcomes, the role of internal motivation

and treatment engagement must not be overlooked. Given that intrinsic motivation for change is

the primary distinction between voluntary and criminal justice-referred substance abuse treatment

clients (Farabee, Nelson, & Spence, 1993), treatment protocols of legally coerced substance abuse

clients should reflect our knowledge that, in the end, it is the client who decides upon the

outcome.

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References

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Drug Issues, 18(4), 527-545.

Anglin, M.D., Brecht, M., & Maddahian, E. (1989). Pretreatment characteristics and treatment

performance of legally coerced versus voluntary methadone maintenance admissions.

Criminology, 27(3), 537-557.

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