psy 699 week 3 disscussion2
Required Resources
Articles
1 .American Psychological Association. (2010). Ethical principles of psychologists and code of conduct: Including 2010 amendments. (Links to an external site.)Links to an external site. Retrieved from http://www.apa.org/ethics/code/index.aspx
· insertDescription
2 .Caplan A. C. (2008). Denying autonomy in order to create it: The paradox of forcing treatment upon addicts . Addiction, 103(12), 1919–21. Retrieved from https://library.ashford.edu/ezproxy.aspx?url=http%3A//search.ebscohost.com/login.aspx?direct=true%2526AuthType=ip,cpid%2526custid=s8856897%2526db=a9h%2526AN=35118770%2526site=ehost-live
· The author of this article makes an argument that client autonomy can still be maintained when treatment is mandated.
3. Manchak, S. M., Skeem, J. L., & Rook, K. S. (2014). Care, control, or both? Characterizing major dimensions of the mandated treatment relationship . Law and Human Behavior, 38(1), 47–57. Retrieved from https://library.ashford.edu/ezproxy.aspx?url=http%3A//search.ebscohost.com/login.aspx?direct=true%2526AuthType=ip,cpid%2526custid=s8856897%2526db=pdh%2526AN=2013-24290-001%2526site=ehost-live
· The study described in this article examines whether mandated treatment relationships involve greater control than traditional treatment relationships. The principles of healthy adult attachment are also explored.
4. Snyder, C. M. J., & Anderson, S. A. (2009). An examination of mandated versus voluntary referral as a determinant of clinical outcome . Journal of Marital and Family Therapy, 35(3), 278–292. doi:10.1111/j.175-0606.2009.00118.x
· The full-text version of this article can be accessed through the ProQuest database in the Ashford University Library. In this article, the authors examine the evidence related to the effectiveness of psychotherapy with mandated clients.
5. Sullivan, M. A., Birkmayer, F., Boyarsky, B. K., Frances, R. J., Fromson, J. A., Galanter, M., . . . Westermeyer, J. (2008). Uses of coercion in addiction treatment: Clinical aspects . American Journal on Addictions, 17(1), 36–47. doi:10.1080/10550490701756369
· The full-text version of this article can be accessed through the EBSCOhost database in the Ashford University Library. While involuntary treatment in health care raises many clinical, cultural ethical, legal, philosophical, and political concerns, evidence exists that it can be an integral component of effective mental health treatment. Various dimensions of mandated treatment are explored in this article.
6.Walker, R., Cole, J., & Logan, T. K. (2008). Identifying client-level indicators of recovery among DUI, criminal justice, and non-criminal justice treatment referrals . Substance Use & Misuse, 43(12/13), 1785–1801. doi: 10.1080/10826080802297484
· The full-text version of this article can be accessed through the EBSCOhost database in the Ashford University Library. This study examined differences in treatment outcomes between mandated and non-mandated clients referred for substance misuse with a focus on client-level factors.
1.American Psychological Association. (2010). Ethical principles of psychologists and code of conduct: Including 2010 amendments. (Links to an external site.)Links to an external site. Retrieved from http://www.apa.org/ethics/code/index.aspx
2. Addicition
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 selfdetermination
[1]. Many would argue that the most significant
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 behavioral
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 mandated
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 treatment
that is forced or mandated is going to find any
traction in American public policy on the basis of a consequentialist
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 medication
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 onemust be able to reason,
remember complex information, set goals and be orientated
to time, place and personal identity; but competency
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, bringing
in its wake as it does loss of will and control, does not
permit the freedom requisite for autonomy or selfdetermination.
If a drug can break the power of addiction sufficiently
to restore or re-establish personal autonomy then mandating
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 powerlessness
and loss of control from the addict’s life, then that
fact can serve as an ethical argument allowing the mandating
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 intervention
carry minimal risk as the patient cannot consent,
but some interventions may be able to meet this admittedly
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 autonomywould 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 situations
where the ethical acceptability of the rationale of
autonomy restoration in permitting mandatory treatment
is already accepted. Consider what occurs in rehabilitation
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 disfiguring
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 peoplewho 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 seewhat 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 keymoral 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 competency
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 treatment,
naltrexone, paternalism, right-to-refuse treatment.
ARTHUR CAPLAN
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: caplan@mail.med.upenn.edu
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. TheWhite 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.
1920 Editorial
© 2008 The Author. Journal compilation © 2008 Society for the Study of Addiction Addiction, 103, 1919–1921
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 naltrexone
for the treatment of opioid dependence. Arch Gen Psychiatry
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.
3. 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 autonomygranting.
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, Cohen,
& 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 connectedness
(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 therapeutic
alliance (Horvath & Symonds, 1991; Martin et al., 2000;
Tryon, Blackwell, & Hammel, 2007), the Working Alliance Inventory
(WAI; Horvath & Greenberg, 1989), emphasizes an interpersonal
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: manchash@uc.edu
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
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, withholding
assistance, and occasionally threatening to pursue involuntary
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 treatment.
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 treatment,
control may become an important component of the relationship.
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 circumplex
space reflects a weighted combination of these two dimensions
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 “Protect,”
whereas those that combine moderate affiliation with moderate
autonomy granting are mapped as “Affirm.” Beyond describing
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 voluntary
psychotherapy that apply Benjamin’s circumplex measures:
the observer-rated Structural Analysis of Social Behavior
(SASB: Benjamin, 1996), or the self-report INTREX (Benjamin,
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 characterized
by therapist “Affirm” and “Protect” (i.e., affiliative
autonomy-granting and control) and corresponding client “Disclose”
and “Trust” (i.e., affiliative autonomy-taking and submission;
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 responses
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.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
48 MANCHAK, SKEEM, AND ROOK
pital stays and less symptom improvement for clients (Najavits
& Strupp, 1994).
In summary, research on voluntary treatment relationships suggests
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 involuntary
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 resistance
to treatment goals or (b) a sense of helplessness and decreased
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 (Sheehan
& 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 control
(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 relationship
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.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
CHARACTERIZING MANDATED TREATMENT RELATIONSHIPS 49
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. Second,
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 communication,
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 comparison
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 communication,
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 principles
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 mandated
treatment relationships involve greater therapist control and
corresponding greater client submission than voluntary treatment
relationships.
To address our second aim—to examine the relationship between
affiliation and control, we focus exclusively on the mandated
treatment sample and use several different indices commonly
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 relationship,
we hypothesize that higher levels of control in mandated
treatment will be associated with reduced client–therapist affiliation.
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 patients
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 announcements
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 participate.
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 disorder;
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.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
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, therapist,
substance abuse counselor), participants were asked to rate
the INTREX (Benjamin, 2000) on the provider who was considered
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 discussions.”
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 relationship
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, “transitive
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 “Disclose,”
“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 “Autonomy
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 (Benjamin,
2000). For the purposes of this study, we made minimal
changes to the wording of a few INTREX items to fit the therapeutic
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 comparison
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.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
CHARACTERIZING MANDATED TREATMENT RELATIONSHIPS 51
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 routinely
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 timelimited
dynamic psychotherapy (_25 sessions), and (3) Critchfield’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 Reconstructive
Therapy (Benjamin, 2003).
Although we were unable to directly compare our mandated
sample with these voluntary samples on several sample demographic
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 communication,
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). Additionally,
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 Critchfield
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 appears
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 (requiring
_ _ .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 described
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’ transitive
INTREX scores; the consistencies across the studies far outweigh
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 transitive
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 connect,”
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 correction
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 relationships
involve much greater therapist neutral control (Watch/Control)
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 relationships?
The results that address question are shown in Tables 4 and
5. The 12 relevant clusters are those in the therapist and client
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
52 MANCHAK, SKEEM, AND ROOK
“affiliation” and “attack” families. The results indicate that, if
anything, mandated treatment relationships are slightly more affiliative
than voluntary ones. Specifically, compared to voluntary
treatment, mandated relationships were minimally greater in therapist
pure affiliation (“Love/Approach”) and affiliative autonomygranting
(“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 average,
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 coefficients
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 treatment
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 characterized
as affiliative and autonomous. Specifically, therapist transitive
angular displacement is 72°, which corresponds to the clusters
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 affiliative,
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 directiveness,
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.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
CHARACTERIZING MANDATED TREATMENT RELATIONSHIPS 53
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 accountabilities
(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 beyond
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 associated
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 autonomygranting.
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 mandated
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 attributable
to attenuated expression of affiliation that may accompany
manualized therapy (see Henry, Strupp, Butler, Schacht, & Binder,
1993). Future research should explore differences between mandated
and more common, “real world” voluntary treatment relationships
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 relationships—
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 characterizes
a decision process, individuals tend to perceive the authority
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 probation/
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 characterization
of strong dual role relationships as fundamentally authoritative
(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 represent
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 undermined
by our inability to say with certainly that the observed
differences in mandated and voluntary treatment relationships are
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
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 relationship
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 relatively
reassuring, given that they directly challenge clinical impressions
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 mandated
(civil vs. criminal) contexts.
References
American Psychiatric Association. (1994). Diagnostic and statistical manual
of mental disorders (4th ed.). Washington, DC: Author.
Angell, B. (2006). Measuring strategies used by mental health providers to
encourage medication adherence. Journal of Behavioral Health and
Social Research, 33, 53–72. doi:10.1007/s11414-005-9000-4
Benjamin, L., Rothweiler, J., & Critchfield, K. (2006). The use of Structural
Analysis of Social Behavior (SASB) as an assessment tool. Annual
Review of Clinical Psychology, 2, 83–109. doi:10.1146/annurev.clinpsy
.2.022305.095337
Benjamin, L. S. (1996). Interpersonal diagnosis and treatment of personality
disorders (2nd ed.). New York, NY: Guilford Press.
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.
Benjamin, L. (2003). Interpersonal reconstructive therapy: Promoting
change in non- responders. New York, NY: Guilford Press.
Bordin, E. (1979). The generalizability of the psychoanalytic concept of the
working alliance. Psychotherapy: Theory, Research and Practice, 16,
252–260. doi:10.1037/h0085885
Bornstein, R., Gottdiener, W., & Winarick, D. (2009). Construct validity of
the relationship profile test: Links with defense style in substance abuse
patients and comparison with non-clinical norms. Journal of Psychopathology
and Behavioral Assessment, 32, 293–300. doi:10.1007/s10862-
009-9153-1
Coady, N., & Marziali, E. (1994). The association between global and
specific measures of the therapeutic relationship. Psychotherapy, 31,
17–27. doi:10.1037/0033-3204.31.1.17
Cohen, J. (1988). Statistical power analysis for the behavioral sciences
(2nd ed.). Hillsdale, NJ: Erlbaum.
Constantino, M. J., Arnow, B., Blasey, C., & Agras, S. (2005). The
association between patient characteristics and the therapeutic alliance in
cognitive behavioral and interpersonal therapy for bulimia nervosa.
Journal of Consulting and Clinical Psychology, 73, 203–211. doi:
10.1037/0022-006X.73.2.203
Cramer, J. A., & Rosenheck, R. (1998). Compliance with medication
regimens for mental and physical disorders. Psychiatric Services, 49,
196–201.Retrievedfromhttp://www.ps.psychiatryonline.org/cgi/content/
full/49/2/196
Critchfield, K. L., Henry, W., Castonguay, L., & Borkovec, T. (2007).
Interpersonal process and outcome in variants of cognitive-behavioral
psychotherapy. Journal of Clinical Psychology, 63, 31–51. doi:10.1002/
jclp.20329
Cronbach, L. J. (1951). Coefficient of alpha and the internal structure of
tests. Psychometrika, 16, 297–334.
Curtis, R., & Hirsch, I. (2003). Relational approaches to psychoanalytic
psychotherapy. In A. Gurman & S. Messer (Eds.), Psychotherapies:
Theory and practice (pp. 69–106). New York, NY: Guilford Press.
Dixon, L. (2000). Assertive community treatment: 25 years of gold. Psychiatric
Services, 51, 759–765. doi:10.1176/appi.ps.51.6.759
Drake, R. E., McHugo, G., Clark, R., Teague, G., Xie, H., Miles, K., &
Ackerson, T. (1998). Assertive community treatment for patients with
co-occurring severe mental illness and substance abuse disorder: A
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
CHARACTERIZING MANDATED TREATMENT RELATIONSHIPS 55
clinical trial. American Journal of Orthopsychiatry, 68, 201–215. doi:
10.1037/h0080330
Fenton, W. S., Blyler, C., & Heinssen, R. K. (1997). Determinants of
medication compliance in schizophrenia: Empirical and clinical findings.
Schizophrenia Bulletin, 23, 637–651. doi:10.1093/schbul/23.4.637
Florsheim, P., Henry, W., & Benjamin, L. (1996). Integrating individual
and interpersonal approaches to diagnosis: The Structural Analysis of
Social Behavior and Attachment Theory. In F. Kaslow (Ed.), Handbook
of relational diagnosis (pp. 81–101). Hoboken, NJ: Wiley.
Freedman, M. B., Leary, T., Ossorio, A., & Coffee, H. (1951). The
interpersonal dimensions of personality. Journal of Personality, 20,
143–161. doi:10.1111/j.1467-6494.1951.tb01518.x
Gurtman, M. (1992). Construct validity of interpersonal personality measures:
The interpersonal circumplex as a nomological net. Journal of
Personality and Social Psychology, 63, 105–118. doi:10.1037/0022-
3514.63.1.105
Gurtman, M., & Pincus, A. (2003). The Circumplex model: Methods and
research applications. In J. Schinka, W. Veliser, & I. Weiner (Eds.),
Handbook of psychology: Research methods in psychology (pp. 407–
428). Hoboken, NJ: Wiley.
Harrist, R., Quintana, S., Strupp, H., & Henry, W. (1994). Internalization
of interpersonal process in time-limited dynamic psychotherapy. Psychotherapy,
31, 49–57. doi:10.1037/0033-3204.31.1.49
Henry, W. P., Schacht, T., & Strupp, H. (1990). Patient and therapist
introject, interpersonal process, and differential psychotherapy outcome.
Journal of Consulting and Clinical Psychology, 58, 768–774. doi:
10.1037/0022-006X.58.6.768
Henry, W. P., Strupp, H., Butler, S., Schacht, T., & Binder, J. (1993).
Effects of training in time-limited dynamic psychotherapy: Changes in
therapist behavior. Journal of Consulting and Clinical Psychology, 61,
434–440. doi:10.1037/0022-006X.61.3.434
Horvath, A. O. (2000). The therapeutic relationship: From transference to
alliance. Journal of Clinical Psychology: In Session: Psychotherapy in
Practice, 56, 163–173.
Horvath, A. O., Del Re., A. C., Flueckiger, C., & Symonds, D. (2011).
Alliance in individual psychotherapy. Psychotherapy, 48, 9–16. doi:
10.1037/a0022186
Horvath, A. O., & Greenberg, L. (1989). Development and validation of
the Working Alliance Inventory. Journal of Counseling Psychology, 36,
223–233. doi:10.1037/0022-0167.36.2.223
Horvath, A. O., & Luborsky, L. (1993). The role of the therapeutic alliance
in psychotherapy. Journal of Consulting and Clinical Psychology, 61,
561–573. doi:10.1037/0022-006X.61.4.561
Horvath, A. O., & Symonds, D. (1991). Relation between working alliance
and outcome in psychotherapy: A meta-analysis. Journal of Counseling
Psychology, 38, 139–149. doi:10.1037/0022-0167.38.2.139
Karberg, J., & James, D. (2005). Substance dependence, abuse, and treatment
of jail inmates, 2002. Washington, DC: U. S. Department of
Justice, Bureau of Justice Statistics.
Kennealy, P. J., Skeem, J., Manchak, S., & Eno Louden, J. (2012). Firm,
fair, and caring officer-offender relationships protect against supervision
failure. Law and Human Behavior, 36, 496–505. doi:10.1037/h0093935
Kessler, R. C., Nelson, C., McGonagle, K., Edlund, M., Frank, R., & Leaf,
P. (1996). The epidemiology of co-occurring and addictive mental
disorders: Implications for prevention and service utilization. American
Journal of Orthopsychiatry, 66, 17–31. doi:10.1037/h0080151
Kiesler, D. (1983). The 1982 Interpersonal Circle: A taxonomy for complementarity
in human transactions. Psychological Review, 90, 185–214.
doi:10.1037/0033-295X.90.3.185
Klinkenberg, W. D., Calsyn, R. J., & Morse, G. A. (1998). The helping
alliance in case management for homeless persons with severe mental
illness. Community Mental Health Journal, 34, 569–578. doi:10.1023/
A:1018758917277
Klockars, C. (1972). A theory of probation supervision. Journal of Criminal
Law, Criminology, and Police Science, 64, 549–557. Retrieved
from http://www.jstor.org/stable/1141809
Krupnick, J., Sotsky, S., Elkin, I., Simmens, S., Moyer, J., & Watkins, J.
(1996). The role of the therapeutic alliance in psychotherapy and pharmacotherapy
outcomes: Findings in the National Institute of Mental
Health Treatment of Depression Collaborative Research Program. Journal
of Consulting and Clinical Psychology, 9, 269–277. doi:10.1037/
0022-006X.64.3.532
Leary, T. (1957). Interpersonal diagnosis of personality. New York, NY:
Ronald Press.
Lind, E., & Tyler, T. (1988). The social psychology of procedural justice.
New York, NY: Plenum Press.
Luborsky, L., Chandler, M., Auerbach, A., Cohen, J., & Bachrach, H.
(1971). Factors influencing the outcomes of psychotherapy: A review of
quantitative research. Psychological Bulletin, 75, 145–185. doi:10.1037/
h0030480
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of therapeutic
alliance with outcome and other variables: A meta-analytic review.
Journal of Consulting and Clinical Psychology, 68, 438–450. doi:
10.1037/0022-006X.68.3.438
McCabe, R., & Priebe, S. (2004). The therapeutic relationship in the
treatment of severe mental illness: A review of methods and findings.
International Journal of Social Psychiatry, 50, 115–128. doi:10.1177/
0020764004040959
Monahan, J., Hoge, S., Lidz, C., Roth, L., Bennett, N., Gardner, W., &
Mulvey, E. (1995). Coersion and commitment: Understanding involuntary
mental hospital admission. International Journal of Law and Psychiatry,
18, 249–263. doi:10.1016/0160-2527(95)00010-F
Monahan, J., Redlich, A., Swanson, J., Robbins, P., Appelbaum, P., Petrila,
J., . . . McNiel, D. E. (2005). Use of leverage to improve adherence to
psychiatric treatment in the community. Psychiatric Services, 56, 37–44.
doi:10.1176/appi.ps.56.1.37
Monahan, J., Steadman, H., Silver, E., Appelbaum, P., Robbins, P., Mulvey,
E., . . . Banks, S. (2001). Rethinking risk assessment: The MacArthur
study of mental disorder and violence. New York, NY: Oxford
University Press.
Morgan, R. D., Fisher, W. H., Duan, N., Mandracchia, J. T., & Murray, D.
(2010). Prevalence of criminal thinking among state prison inmates with
serious mental illness. Law and Human Behavior, 34, 324–336. doi:
10.1007/s10979-009-9182-z
Najavits, L., & Strupp, H. (1994). Differences in the effectiveness of
psychodynamic therapists: A process-outcome study. Psychotherapy,
31, 114–123. doi:10.1037/0033-3204.31.1.114
Neale, M. S., & Rosenheck, R. A. (2000). Therapeutic limit setting in an
assertive community treatment program. Psychiatric Services, 51, 499–
505. doi:10.1176/appi.ps.51.4.499
Norcross, J. C., Hedges, M., & Prochaska, J. O. (2002). The face of 2010:
A Delphi poll on the future of psychotherapy. Professional Psychology:
Research and Practice, 33, 316–322. doi:10.1037/0735-7028.33.3.316
Paparozzi, M., & Gendreau, P. (2005). An intensive supervision program
that worked: Service delivery, professional orientation, and organizational
supportiveness. The Prison Journal, 85, 445–466. doi:10.1177/
0032885505281529
Parhar, K., Wormith, J. S., Derkzen, D., & Beauregard, A. (2008). Offender
coercion in treatment: A meta-analysis of effectiveness. Criminal
Justice and Behavior, 35, 1109–1135. doi:10.1177/0093854808320169
Regier, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z., Keith, S. J., Judd,
L. L., & Goodwin, F. K. (1990). Comorbidity of mental disorders with
alcohol and other drug abuse: Results from the epidemiologic catchment
area study. Journal of the American Medical Association, 264, 2511–
2518. doi:10.1001/jama.1990.03450190043026
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
56 MANCHAK, SKEEM, AND ROOK
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic
personality change. Journal of Consulting Psychology, 21, 95–103.
doi:10.1037/h0045357
Ross, E., Polaschek, D., & Ward, T. (2008). The therapeutic alliance: A
theoretical revision for offender rehabilitation. Aggression and Violent
Behavior, 13, 462–480. doi:10.1016/j.avb.2008.07.003
Schedin, G. (2005). Interpersonal behavior in counseling: Client and counselor
expectations and experiences related to their evaluation of session.
International Journal for the Advancement of Counselling, 27, 57–69.
doi:10.1007/s10447-005-2247-x
Schiff, M., & Levit, S. (2010). Correlates of therapeutic alliance and
treatment outcomes among Israeli female methadone patients. Research
on Social Work Practice, 20, 380–390. doi:10.1177/1049731509347854
Shearin, E. N., & Linehan, M. M. (1992). Patient-therapist ratings and
relationship to progress in dialectical behavioral therapy for borderline
personality disorder. Behavior Therapy, 23, 730–741. doi:10.1016/
S0005-7894(05)80232-1
Sheehan, K. A., & Burns, T. (2011). Perceived coercion and the therapeutic
relationship: A neglected association? Psychiatric Services, 62, 471–
476. doi:10.1176/appi.ps.62.5.471
Skeem, J., Eno Louden, J., Manchak, S., Vidal, S., & Haddad, E. (2009).
Social networks and social control of probationers with co-occurring
mental and substance abuse disorders. Law and Human Behavior, 33,
122–135. doi:10.1007/s10979-008-9140-1
Skeem, J. L., Eno Louden, J., Polaschek, D., & Camp, J. (2007). Relationship
quality in mandated treatment: Balancing care with control. Psychological
Assessment, 19, 397–410. doi:10.1037/1040-3590.19.4.397
Swartz, M. S., Wagner, H. R., Swanson, J. W., Hiday, V. A., & Burns, B. J.
(2002). The perceived coerciveness of involuntary outpatient commitment:
Findings from an experimental study. Journal of the American
Academy of Psychiatry and the Law, 30, 207–217.
Trotter, C. (1999). Working with involuntary clients: A guide to practice.
London, UK: Sage.
Tryon, G. S., Blackwell, S. C., & Hammel, E. F. (2007). A metaanalytic
examination of client-therapist perspectives of the working
alliance. Psychotherapy Research, 17, 629 – 642. doi:10.1080/
10503300701320611
Tyler, T. (1989). The psychology of procedural justice: A test of the
group-value model. Journal of Personality and Social Psychology, 57,
830–838. doi:10.1037/0022-3514.57.5.830
Tyler, T. (1994). Psychological models of the justice motive: Antecedents
of distributive and procedural justice. Journal of Personality and Social
Psychology, 67, 850–863. doi:10.1037/0022-3514.67.5.850
Watson, A. C., & Angell, B. (2007). Applying procedural justice theory to
law enforcement’s response to persons with mental illness. Psychiatric
Services, 58, 787–793. doi:10.1176/appi.ps.58.6.787
Wright, A. G., Pincus, A., Conroy, D., & Hilsenroth, M. (2009). Integrating
methods to optimize circumplex description and comparison of groups.
Journal of Personality Assessment, 91, 311–322. doi:10.1080/
00223890902935696
Received January 4, 2013
Revision received March 26, 2013
Accepted March 28, 2013 _
4. 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 ; Hoboken Vol. 35, Iss. 3, (Jul 2009): 278-92.DOI:10.1111/j.1752-0606.2009.00118.x
1. Full text
Abstract
A literature review was undertaken to examine evidence for the effectiveness of psychotherapy with mandated clients. The primary question addressed was whether or not clients mandated to therapy, whether by court order or by order of their employers, show poorer outcomes than clients who enter therapy voluntarily. To this end, research on client resistance and motivational readiness to change was reviewed. This was followed by an examination of research on the effectiveness of mandated treatment. The question of the potential influence of relationship factors such as the therapeutic alliance was also addressed. The literature review was followed by suggestions for future research on the effectiveness of treatment for clients with mandated or voluntary referral status. [PUBLICATION ABSTRACT]
Full Text
·
Headnote
A literature review was undertaken to examine evidence for the effectiveness of psychotherapy with mandated clients. The primary question addressed was whether or not clients mandated to therapy, whether by court order or by order of their employers, show poorer outcomes than clients who enter therapy voluntarily. To this end, research on client resistance and motivational readiness to change was reviewed. This was followed by an examination of research on the effectiveness of mandated treatment. The question of the potential influence of relationship factors such as the therapeutic alliance was also addressed. The literature review was followed by suggestions for future research on the effectiveness of treatment for clients with mandated or voluntary referral status.
Psychotherapy encompasses a vast array of psychotherapeutic and systemic schools of thought, each with their corresponding styles and techniques. Although models may differ, one widespread assumption is that clients enter therapy voluntarily and are at least somewhat motivated to be there (Cingolani, 1984; Haley, 1992; Harris & Watkins, 1987; Rooney, 1992). Unfortunately, this assumption fails to account for clients who enter therapy under duress. Some of these clients are legally required by the courts to attend therapy for a variety of offenses involving child abuse and neglect, domestic violence, incest, or substance abuse. Others are referred to therapy by their employers for a variety of mental health problems (often substance abuse) under threat of losing their jobs.
The question of whether traditional therapy techniques, which are generally based on working with voluntary clients, can be effective when applied to clients who do not attend treatment voluntarily has received limited attention in the field of psychotherapy and even less in the field of marriage and family therapy. Harris and Watkins (1987) noted, for instance, that "little has been written about the problems of adapting psychological theories to clients who are involuntary and reluctant to participate in a change process" (pp. 6-7). The involuntary client is likely to resist treatment in all the ways that the voluntary client might, but the coerced entry into counseling can compound the resistance and add new complications to the beginning of the therapy process. Most authors who have addressed this subject agree that mandated clients generally enter treatment with greater resistance to therapy and less motivation to change than those who begin treatment voluntarily (Begun et al., 2003; Chamberlain, Patterson, Reid, Kavanaugh, & Forgatch, 1984; Lehmer, 1986; Miller & Rollnick, 1991; Rooney, 1992; Taft, Murphy, Elliott, & Morrei, 2001). The greater the resistance, the less likely clients will change (Miller & Sovereign, 1989) or remain in therapy (Chamberlain et al., 1984).
It would seem that mandated versus voluntary referral status, and the accompanying issues of client resistance and motivation to change, constitute key determinants to psychotherapy outcome. The purpose of this article is to examine this issue by reviewing research on client resistance and motivational readiness to change. This is followed by an examination of research on the effectiveness of mandated treatment. The potential influence of relationship factors such as the therapeutic alliance is also discussed. The article concludes with suggestions for future research on the effectiveness of treatment for clients with mandated versus voluntary referral status.
CLIENT RESISTANCE
The literature is relatively uniform in suggesting that mandated clients are more resistant to treatment than voluntary clients (Chamberlain et al., 1984; Haley, 1992; Lehmer, 1986; Miller & Rollnick, 1991; Rooney, 1992; Taft et al., 2001). DiClemente (1991) suggested that this resistance is the result of "the four R's": client reluctance, rebellion, resignation, and rationalization. A broader view is that this phenomenon is a normal reaction to compulsory treatment, as people are likely to resist their loss of freedom and independence (Weakland & Jordan, 1990; Woody & Grinstead, 1992). They also might reasonably be expected to revolt against being labeled by an outside party as having a mental problem, having a course of therapy imposed on them, or perceiving their therapist as an agent of the state (Ackerman, Colapinto, Scharf, Weinshel, & Winawer, 1991; Adams, 1992; Haley, 1992; Weakland & Jordan, 1990; Woody & Grinstead, 1992).
Another often-overlooked contributing factor to the concept of resistance is that minority groups appear to be disproportionately represented among court-mandated clients (O'Hare, 1996; Rooney, 1992). Cultural factors inherent in this clientele are often not well understood by their predominantly White therapists, and this may cause strain in the therapist-client relationship. Moreover, perceived client "resistance" may actually be, within certain cultural subgroups, a normative reaction to mandated therapy with a therapist who represents the majority establishment. Waldman's (1999) study of involuntary therapy with minority groups found that clients perceived the therapy and the therapist as being part of the punishment imposed by an oppressive, White, European American system. Cultural factors inherent in this clientele are often not well understood by their therapists, such as the following: (a) the importance of maintaining family secrets, keeping up appearances with outsiders, and a heightened suspicion of White institutions, among African Americans (Boyd-Franklin, 1989); (b) the importance to certain Hispanic groups of loyalty to family, women's obligation (through the concept of marianismo) to revere, protect, and never criticize their husbands, and the strong, macho self-concept in the men (Boyd-Franklin & Garcia-Preto, 1994); and (c) the possible conflict between the cultural importance of not "losing face," maintaining emotional restraint, and the confessional character of psychotherapy, for Asian American clients (Zane, Nagayama-Hall, Sue, Young, & Nunez, 2004).
The concern is that therapists who lack adequate cultural training may not view their clients' problems through the appropriate "cultural lens" (Abu Baker, 1999; Falikov, 1988), and thus fail to normalize diverse clients' negative perceptions about therapy and/or their White therapists. This may then begin an unfruitful therapeutic interaction whereby therapists (a) add to the already-existing client resistance, beyond that which is already normative for mandated clients, and (b) trigger their own feelings of defensiveness when their clients present as unreceptive or unmotivated.
Some have hypothesized that failure to expect and normalize clients' resistance has historically resulted in therapists internalizing their clients' reluctance as rejection, and becoming defensive as a result (Vriend & Dyer, 1973). Therapists, like most people, are not good at handling hostility and rejection, and more importantly are not properly trained to anticipate and deal with it (Strupp, 1980). Others have suggested that negative client responses may in fact be the result of a lack of fit between the mind-set of mandated clients and the voluntary therapy concepts which are applied by their therapists. Frustration over negative reactions can cause practitioners to project their frustration onto their clients, essentially blaming their clients for their "resistance," and reacting with anger when clients are hostile or unmotivated, rather than understanding that their clients' negative reaction is a normal part of involuntary therapy (Cingolani, 1984; Rooney, 1992).
Despite these constraints, resistance is increasingly being viewed as amenable to therapeutic intervention (Donovan & Rosengren, 1999; Miller & Rollnick, 1991). Some have suggested that resistance can be purposely utilized in the service of therapeutic change (Watzlawick, Weakland, & Fisch, 1974). Others have gone so far as to suggest that resistance is therapy (Anderson & Stewart, 1983). Most agree that the goal is to transform the therapy as quickly as possible from an involuntary process to a voluntary one by establishing a strong therapeutic alliance with the client system and thereby facilitating change, without increasing the client's resistance or the therapist's defensiveness. Many have suggested specific techniques for doing so. Although a discussion of the specific therapeutic interventions that have been proposed for working with mandated clients is beyond the scope of this article, readers may be interested in some of the most frequently cited resources (Abu Baker, 1999; Bastien & Adelman, 1984; Caesar & Friday-Roberts, 1991; Colapinto, 1995; Haley, 1987; Miller & Rollnick, 1991; Rooney, 1992; Schottenfeld, 1989; Watzlawick et al., 1974; Weakland & Jordan, 1990).
MOTIVATION TO CHANGE
Internal motivation to change has often been presumed to be a prerequisite to successful treatment (Orlinsky & Howard, 1986; Schottenfeld, 1989). Yet, surprisingly little research has addressed the differences in treatment outcomes between clients with an intrinsic motivation to change versus those who have been influenced externally, such as by court referral (Rotgers, 1992).
Mandated clients generally have been found to have lower levels of motivation and initial readiness for change than voluntary clients (Begun et al., 2003). As intrinsic motivation appears to predict better treatment outcomes (Orlinsky & Howard, 1986; Schottenfeld, 1989), logic would argue that mandated clients should have poorer outcomes than their voluntary counterparts. Interestingly, research has not shown a strong correlation between initial motivation and successful outcome (Bastien & Adelman, 1984; Lehmer, 1986; Satel, 2000). As a result, the presumption that intrinsic motivation must be present at the outset of therapy in order for it to succeed has not been supported (Rounsaville & Kleber, 1985).
A notable contribution toward clarifying this issue is the "transtheoretical" model of motivational readiness to change, developed by Prochaska, DiClemente, and Norcross (1992). The model proposes that individuals pass through a series of five stages of change in their attempt to address problem behaviors. Thus, motivational readiness to change is viewed as a progressive continuum rather than a "yes" or "no" (present or absent) phenomenon. Clients move from (a) precontemplation (no acknowledgment of a problem, and no intention to change), to (b) contemplation (awareness of the existence of the problem, thinking about changing in the next 6 months, but ambivalent, with no commitment to changing the problematic behavior), to (c) preparation to change (seriously thinking about changing in the next month, and perhaps completing small, preparatory changes), to (d) taking action (specific changes to address the problem behavior have been initiated within the past 6 months), and finally, to (e) maintenance (consolidating changes and taking steps to prevent relapse; Prochaska et al., 1992).
Most research on the model has involved verifying clients' internal characteristics at each stage (Prochaska et al., 1994) and confirming that the individual's stage of change can predict treatment outcome (DiClemente et al., 1991; Edens & Willoghby, 2000). Precontemplators and contemplators have been shown to be less motivated to change than those in the action or maintenance stages (DiClemente & Hughes, 1990), and less likely to develop a strong therapeutic alliance (Connors et al., 2000). McConnaughy, Prochaska, and Velicer (1983) further concluded that clients who were high on Precontemplation and very low on Action were most likely to enter therapy because of family, legal, or employer pressures rather than an internal motivation to change, and to terminate therapy prematurely. Other studies have confirmed the relationships between clients who remain in the precontemplation stage of change and weak therapeutic alliance, premature termination, and poor improvement in therapy (Satterfield, Buelow, Lyddon, & Johnson, 1995; Smith, Subich, & Kalodner, 1995).
The "transtheoretical" stage of change model appears to have considerable relevance to many of the client populations that are mandated by outside referral sources such as the courts, the state, or employers. For instance, domestic violence perpetrators have generally been found to enter counseling at the precontemplation or contemplation stages of change (Taft et al., 2001), as have substance abusers (DiClemente, 1991) and sex offenders (Garland & Dougher, 1991; Serran, Fernandez, Marshall, & Mann, 2003).
Court-referred clients have generally been found to be less motivated to change than voluntary clients (Begun et al., 2003; Chamberlain et al., 1984; Lehmer, 1986; Miller & Rollnick, 1991; Rooney, 1992; Taft et al., 2001; Woody & Grinstead, 1992). Poor motivation may be an entirely expected reaction if these clients are precontemplators or contemplators, and thus not cognitively ready to undertake a course of therapy aimed at changing their behavior. Behaviorally focused interventions would be more appropriate for voluntary clients who would be more likely to enter therapy in the action stage of change (Prochaska et al., 1992). These findings suggest that a critical consideration for therapy with mandated clients is to match interventions to the client's level of motivational readiness to change.
This conclusion dovetails with Cingolani's (1984) and Rooney's (1992) hypotheses that negative client responses to mandated therapy may be the result of the lack of fit between the mindset of involuntary clients and the interventions that are applied by therapists who have been trained in treatment models based solely on work with voluntary clients. Outcome research with the stages of change model has consistently found that tailoring interventions on the basis of a client's motivational readiness to change positively affects treatment outcomes (Prochaska, DiClemente, Velicer, & Rossi, 1993; Prochaska & Velicer, 1997; Velicer & Prochaska, 1999; Velicer et al., 1993).
Although there do not yet appear to be any marital and family therapy applications to the Prochaska et al. (1992) model of change, some marriage and family therapy treatment models, such as functional family therapy, have focused on the importance of client and family motivation, by making the enhancement of motivation the first stage of treatment (Sexton & Alexander, 2003).
EFFECTIVENESS OF MANDATED TREATMENT
Several authors have expressed doubt that mandated treatment can be effective due to resistance factors and the apparent lack of internal motivation to change in mandated clients (Rosenfeld, 1992). However, the view that intrinsic motivation to change must be present at the outset of treatment in order for it to be successful has been largely dispelled in light of the undeniable treatment successes in so many areas of mandated therapy, including domestic violence, child abuse, incest perpetrator therapy, and, most particularly, substance abuse.
A comprehensive review of all literature related to mandated treatment for each of these presenting problems is beyond the scope of the present review. However, selected findings are discussed in the following sections to offer the reader an appreciation of the extent to which mandated treatment has been found to be effective.
Domestic Violence
The vast majority of domestic violence perpetrators enter therapy against their will, whether by court order or under pressure from their partners (Taft et al., 2001). As in other instances of mandated treatment, some have questioned whether treatment under these conditions can be effective. For instance, Rosenfeld (1992) found that most treatment studies of domestic abusers reported only minimal decreases in violent incidents posttreatment compared with men who received no treatment. This led Rosenfeld (1992) to question whether it was realistic to expect court mandates to foster motivation to change or even regular attendance in treatment. This view was supported by other findings that indicated voluntary referrals exhibited higher levels of motivation to change than mandated referrals (Bowen & Gilchrist, 2004).
On the other hand, batterers who were ordered to treatment and completed it were significantly less likely to commit further domestic violence offenses than those who did not complete the treatment. Batterers who completed treatment were more likely to be first-time offenders, be employed, have a higher income, and be more educated than dropouts, suggesting that perhaps their compliance was the result of having more to lose (Sherman, Smith, Schmidt, & Rogan, 1992). In another study, batterers who did not complete treatment were more likely to be unemployed and have more extensive criminal records than those who completed treatment. The authors suggested that dropouts represented a more socially disenfranchised group, less subject to normal social controls and incentives (Babcock & Steiner, 1999).
The issue of attending and remaining in treatment is an important one in the area of domestic violence treatment because studies have shown that the more sessions batterers attend, the better the treatment outcomes, and the lower the rates of violence recidivism (Babcock & Steiner, 1999; Chen, Bersani, Myers, & Denton, 1989; Taft et al., 2001). And yet, dropout rates are generally exceedingly high (40-60% within the first 3 months of treatment; Cadsky, Hanson, Crawford, & Lalonde, 1996) and many batterers (up to 90% by some estimates) never show up for treatment (Gondolf & Foster, 1991). Many of the above authors have advocated utilizing the court's power to require batterers to attend a full course of treatment. In one recent study, 14% of the batterers who completed treatment did so only after bench warrants were ordered for their arrests. This suggests that court-mandated treatment, backed up by active court intervention in the event of breaches of probation, can increase compliance with domestic violence treatment (Babcock & Steiner, 1999).
However, forcing clients to remain in treatment is not the same as achieving the goal of reducing or eliminating violence. One promising approach involves applying Prochaska's transtheoretical model of change (Prochaska et al., 1992) to frame batterers' resistance as an incongruence between intervention techniques and the client's stage of motivational readiness to change (Daniels & Murphy, 1997; Miller & Rollnick, 1991). Most batterers' programs are behaviorally oriented and emphasize skills training strategies (e.g., anger management, taking timeouts) that presuppose clients have motivation to change. Clients in the precontemplation stage often resist treatment, either actively (arguing with the therapist about the usefulness of various skills) or passively (sidetracking with frequent crises, failing to complete homework assignments, or remaining disengaged in sessions; Daniels & Murphy, 1997). Treatment goals for such clients would be more focused on increasing their motivation to change (Bowen & Gilchrist, 2004).
Child Abuse
Court intervention and control have been found to be key therapeutic tools in both enhancing motivation to change in perpetrators, and protecting potential victims, in cases of child abuse (Landau, Salus, Stiffarm, & Kalb, 1980). Abusive and neglectful parents rarely seek help voluntarily and are often in denial about their actions (Azar, 1984). Mandated therapy for child abuse perpetrators has nevertheless been found to be successful in several reported cases. In one of the few published empirical studies, mandated participants in a treatment program for child abusers performed as well as nonmandated clients in terms of attendance, participation levels, and improvements in communication with their children Mandated parents were found to be substantially (50%) less verbally critical with their children than they had been prior to treatment (Irueste-Montes & Montes, 1988). In another study, court-mandated parents were found to be five times more likely than voluntary parents to successfully complete the treatment program (Wolfe, Aragona, Kaufman, & Sandler, 1980). Perhaps the fear of losing their children to state authorities, and ongoing supervision by such authorities, provided sufficient motivation for mandated parents to comply with treatment program objectives. Finally, a third study of only three court-mandated families examined a treatment that offered parenting and affective skills training. The treatment was found to be successful with all three families, notwithstanding the fact that they were coerced into treatment (Dawson, De Armas, McGrath, & Kelly, 1986).
Incest Perpetrators
The vast majority of treatment of incest perpetrators is conducted under court order, and the number of offenders who enter treatment voluntarily is extraordinarily small (Horton, 1992). Incest perpetrators generally present as unmotivated for treatment, and frequently deny and rationalize their behavior (Garland & Dougher, 1991). More particularly, the lack of motivation and rigid defense mechanisms employed by sex offenders are associated with high treatment dropout rates (Knopp, 1984) and high (60%) rates of recidivism (Krauth & Smith, 1988).
Motivational interventions and treatment successes are nevertheless said to be possible with this treatment population. Client motivation for change is considered to be the most important determinant of outcome in sex offender treatment, meaning that motivational enhancement techniques are critical in working with this population (Garland & Dougher, 1991). What is said to be important is recognizing where the sex offender is on the continuum of readiness to change, and meeting the client with interventions that are appropriate to that stage. Creating and enhancing motivation for change can be enhanced through such strategies as increasing the offender's empathy for the victim and emphasizing the costs (e.g., loss of family and friends, social stigma, and incarceration) of continuing with sexually deviant behavior (Garland & Dougher, 1991).
In the interim, the threat of court intervention is often needed to keep that person in treatment (Horton, 1992; Ryan, 1986). The threat of what might be termed the "legal ax" seems to be essential to successful treatment outcomes. Encouraging offenders to visualize this ax waiting to fall (e.g., revocation of probation and subsequent incarceration) has been shown to enhance the potential for offenders to address their inappropriate behaviors (Horton, Johnson, Roundy, & Williams, 1990).
Substance Abuse
While there has been some research and scholarly writings on the subject of mandated clients in other treatment groups, the vast majority of research has been conducted in the area of substance abuse. It is a commonly held presumption that substance abusers, like other mandated clients, are resistant to treatment, unmotivated to change, noncompliant with treatment recommendations, likely to terminate treatment prematurely, and unlikely to achieve positive outcomes (Donovan & Rosengren, 1999). This is due in part to the conventional wisdom that substance abusers have to "hit bottom" and be intrinsically motivated to change before they can change (Donovan & Rosengren, 1999).
One of the primary distinctions between mandatory and voluntary substance abuse treatment clients has been shown to be intrinsic motivation to change (Farabee, Nelson, & Spence, 1993; Farabee, Prendergast, & Anglin, 1998). Lack of motivation to change in substance abuse treatment has been associated with lower treatment retention rates (De Leon & Jainchill, 1986) and poorer outcomes (Simpson, Joe, & Rowan-Szal, 1997). Conversely, high pretreatment motivation to change has been associated with twice the likelihood of a positive outcome in substance abuse treatment (Simpson et al., 1997). As Leukefeld and Tims (1988) noted, "A stable recovery cannot be maintained by external (legal) pressure only; motivation and commitment must come from internal pressure. The role of external pressure from this point of view is to influence the person to enter treatment" (p. 243).
While some outcome research reports that mandated clients did better than voluntary clients (Chopra, Preston, & Gerson, 1979; Dunham & Mauss, 1982), others (Smart, 1974) report that voluntary clients fared better. The majority, however, have found similarly beneficial outcomes for both groups (Anglin, Brecht, & Maddahian, 1989; Brecht, Anglin, & Wang, 1993; De Leon, 1988; Flores, 1983; Freedberg & Johnston, 1978; Hubbard et al., 1989; McGlothlin, 1979; Watson, Brown, Tilleskjor, Jacobs, & Pucel, 1988). Illustrative of these findings was a study by Anglin et al. (1989), who found that outcomes (length of stay in treatment, posttreatment gains) did not differ for addicts with legally coerced versus voluntary treatment entry. They suggested that given these findings, it made little sense to promote a social policy that allowed drug-dependent individuals to choose when to enter treatment and when to leave. Instead, a less costly and more efficient process would be to implement a more externally constraining system that does not rely on the individual's fluctuating motivational state. In a literature review covering up to the year 2000, Miller and Flaherty (2000) concluded that the preponderance of the literature confirms the efficacy of mandated addiction treatment and that coercion helped motivate clients to comply with treatment.
The inconsistent findings that have emerged in this literature may be due to the fact that outcome research in the area of substance abuse treatment has suffered from various methodological shortcomings (Howard & McCaughrin, 1996; Rotgers, 1992; Shearer, 2000). These include differences in outcome measures (e.g., measuring recidivism rates rather than client drinking levels, measuring employee job performance rather than level of substance use) and differences in comparison groups (e.g., comparing young, mandated, relatively healthy individuals with voluntary, older, chronic addicts). Differences may also be due to definitional inconsistencies as to what constitutes a mandated client (De Leon, 1988; Rotgers, 1992), addicts' personal characteristics that affect response to treatment (such as the existence of personality disorders), or variations in treatment plans (Anglin et al., 1989). Others point to the inevitable problem of lack of control groups and random assignments (Howard & McCaughrin, 1996) and selection or recruitment bias (Dunham & Mauss, 1982). As it is virtually impossible to secure random assignment to treatment conditions, any quasi-experimental design which is implemented will be unable to definitively determine which effects on the outcome variable are due to treatment effects, rather than preexisting differences in the groups such as severity of the drinking problem, age, education, or social class. Finally, others point out that treatment programs vary widely and thus program sources of variance obscure the measurement of treatment effectiveness for legally referred clients (Inciardi, 1994).
In what has been described as one of the only research studies that has tried to address many of these methodological problems, and "probably the best designed and executed study of coercion and treatment outcome to date" (Rotgers, 1992), Walsh et al. (1991) compared results of three treatment options for employees referred by their employee assistance plan for alcohol problems (compulsory inpatient; mandatory Alcoholics Anonymous [AA] meetings only; or voluntary option to do either). The employees were randomly assigned to these treatment programs and followed for 2 years. All three groups were found to have improved in terms of job functioning and reduced drinking, with the inpatient clients faring the best. As the employer could back up the referral to treatment with firing if drinking continued, the researchers opined that clients' motivation for succeeding in the more intensive inpatient condition might have been confounded with employer coercion.
Research shows that length of time in treatment affects outcome, and mandated clients do appear to remain in treatment longer than voluntary clients (De Leon, Melnick, & Tims, 2001; Goldsmith & Latessa, 2001; Leukefeld & Tims, 1988; Satel, 2000). In an interesting study, Dunham and Mauss (1982) compared the differential rates of alcoholism treatment success rates for courtmandated and voluntary clients in a community alcoholism treatment center, statistically controlling for pretreatment differences. Clients were divided into four groups: self-referrals, informal agency (AA, physician) referrals, driving while impaired (DWI; court) referrals, and other legal/court referrals. While it was found that certain socioeconomic traits had a powerful impact on outcome (i.e., no prior treatment experience, active employment, education, not dependent on social assistance, stable marriage and family life), type of referral was a stronger predictor of outcome. The more coercion that was applied, the better the outcome. Treatment success was greater for those referred from the justice system than those attending voluntarily. The success rate for DWI clients was almost double that of voluntary clients (43% vs. 22%). The authors concluded that the certainty of the consequences for noncompliance with treatment for the DWI clients, and their having the most to lose (as they had the best occupations, highest education, etc.), was an important factor. Dehmel, Klett, and Buhringer (1986) also found that more socially integrated clients (e.g., employed, stable home, and family life) had a greater likelihood of completing treatment.
Although it may appear daunting to be able to establish a positive therapeutic alliance with mandated clients, and successfully treat them when they are there against their will, the evidence to the contrary is surprising. Granted, voluntary clients tend to exhibit much more motivation and willingness to engage in the treatment process (O'Hare, 1996), and intrinsic motivation appears to predict better treatment outcomes (Joe, Simpson, & Broome, 1998; Orlinsky & Howard, 1986; Schottenfeld, 1989). However, mandated clients can be motivated to change, or become so after therapy has begun. Perhaps this is because outcomes are less dependent on legal status than on the quality of the interaction between client and therapist (Rooney, 1992), or the therapist's ability to help raise a client's level of motivation (Donovan & Rosengren, 1999; Miller & Rollnick, 1991).
It appears that under the right therapeutic conditions, clients mandated to attend therapy can be helped to change their initial perceptions and become engaged in the therapy process (Leukefeld & Tims, 1988; Satel, 2000). By "meeting the clients where they are," taking into account any cultural issues, assessing initial levels of motivational readiness to change (or lack thereof), and using appropriately timed interventions, therapists can assuage resistance and transform the mandated process into an essentially voluntary and productive one. As stated by Howard and McCaughrin (1996), "A possible way to reduce treatment failure among court-mandated clients is to not treat them and voluntary clients in a homogenous manner. Positive attitudes and treatment practices specific to court-mandated clients work best in producing successful treatment outcomes" (p. 919). Finally, the research literature suggests that what mandated clients may lack in terms of initial motivation may be more than compensated for by their tendency to stay in treatment longer than their voluntary counterparts, allowing time for intrinsic motivation to develop and therapeutic techniques to take effect. Length of time in treatment affects outcome, and mandated clients appear to remain in treatment longer than their voluntary counterparts.
THERAPEUTIC ALLIANCE
Bordin (1979) defined the "therapeutic" or "working" alliance as the therapeutic bond between the client and therapist, based on their agreement on the goals and tasks of therapy. He hypothesized that the strength of that alliance was a significant mediator, if not the most important mediator, of therapeutic outcome. Family therapists expanded on this by adding that the therapeutic alliance is developed by building a bond and joining not only with the individual client but also with each family member (Fennel & Weinhold, 1997; Minuchin, 1974). Sprenkle and Blow (2004) referred to the "expanded therapeutic alliance" as a common factor that is unique to marriage and family therapy. The therapist must form an alliance with the family as a whole, each subsystem, and each family member.
While it is beyond the scope of this article to discuss the therapeutic alliance literature in more detail, what is clear is that the therapeutic alliance has been shown to be an essential element of the treatment process regardless of the type of therapy approach being used, the type of client population being targeted, or the type of client referral (mandated or voluntary; Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000; Sprenkle & Blow, 2004). While it may take longer to develop a therapeutic alliance with a mandated client (Honea-Boles & Griffin, 2001), the literature discussed above clearly shows that it is possible to do so. How the therapist responds to the client's resistance, some say, will determine outcome (Miller & Rollnick, 1991). What appears to be key in developing a therapeutic alliance with any client system, mandated or not, is (a) getting off to a good start early in the therapeutic process, (b) intervening with motivationally enhancing techniques with those clients who exhibit a low level of motivational readiness to change, (c) being sensitive to the cultural background of the individual client or client system, and (d) achieving an empathic emotional bond, consensus on the goals of therapy, and a mutual understanding of the tasks to be implemented (Horvath & Symonds, 1991; Pinsoff, 1994).
While we do not know with specificity what makes a therapeutic encounter successful (or not), we do know that positive outcomes are consistently associated with a strong therapeutic alliance. We have found no research to date that has examined whether the strength of the alliance or the mandated versus voluntary referral status is more predictive of outcome. This would seem to be a topic worthy of investigation.
CONCLUSIONS
As we have seen in the research described above, mandated therapy can in many cases be as successful as voluntary therapy, across diverse problem types. While mandated clientele are more likely to exhibit resistance and lack intrinsic motivation to change at the outset of treatment, the above-described treatment outcome successes indicate that these factors are not, in and of themselves, determinative of outcome. Instead, it appears that the resistance and lack of motivation found in the mandated client population can be subject to therapeutic intervention and improvement.
Why outcomes among the two treatment populations are often reported to be similar has yet to be fully explained. However, we offer here several possible explanations:
Perhaps there are not many differences between mandated and voluntary clients after all, because most clients are coerced, whether it be legally or informally (through their families or employers), to be in therapy (Bowen & Gilchrist, 2004; Haley, 1963). Informal psychosocial pressures coming from spouses, family, and employers may have substantially more influence over decisions to enter treatment than legal pressures (Marlowe, Merikle, Kirby, Festinger, & McLellan, 2001; Marlowe et al., 1996).
Another possibility is that mandated clients who enter therapy unwilling or unmotivated to change may become as engaged as voluntary clients as therapy progresses. Perhaps this is because outcomes are less dependent on legal status than on the quality of the therapeutic alliance between client and therapist (Rooney, 1992), and/or the therapist's ability to help raise a client's level of motivation (Donovan & Rosengren, 1999; Miller & Rollnick, 1991).
Finally, what mandated clients may lack in terms of initial intrinsic motivation, they may make up for with more consistent and longer attendance in treatment than their voluntary counterparts, with intrinsic motivation developing along the way.
Clearly, there is a great deal yet to be understood as to what makes therapy work (or not) in mandated client populations.
DIRECTIONS FOR FUTURE RESEARCH
It will be important to address the following methodological issues to advance research on the effectiveness of therapy with mandated versus voluntary referral clients.
Mandated Versus Voluntary Referral Categorization
Future research should properly assess, on a continuum, to what extent a client is voluntarily entering the therapeutic relationship. While mandated clients are clearly mandated to be in therapy, we must question whether the so-called "voluntary" clients are really there entirely of their own volition. As we have noted earlier, the purely voluntary client may be relatively rare, as there is usually some form of third-party pressure, or at least something to lose, if the client does not proceed with treatment. In one study, substance-abusing clients reported family pressure to be the primary motivator for entering treatment (Marlowe et al., 2001). In another study, male batterers who entered treatment "voluntarily" reported that they were there not due to an intrinsic desire to change, but as a strategy to avoid losing their partner (Burton, Regan, & Kelly, 1998).
Typically, clients have been categorized in the research as either "mandated" by virtue of court or agency referral, or "voluntary." The resulting comparison groups may not actually be independent for statistical purposes. Furthermore, dichotomizing a variable which may in fact be considered a continuous variable reduces statistical power in data analyses. As noted by Marlowe et al. (2001), statistical power is substantially reduced (by up to a third) when a continuous variable is dichotomized. It seems more reasonable to assume that coercion is a continuous variable, with patients experiencing varying degrees and types of coercive pressures. This would allow for the use of more sensitive statistical techniques.
Another suggestion is to measure the subjective perception of clients in terms of the impact of external coercion on their level of internal motivation (Farabee et al., 1998). Being legally coerced into therapy does not equate with the amount of pressure clients feel or their initial level of motivation to change. Such measurements could take into account less formal motivators to enter treatment (e.g., spouse, family, and employer pressure) that have been shown to be as important if not more important than legal pressure (Marlowe et al., 1996, 2001). Finally, follow-up interviews with clients would be another way to retrospectively record their actual motivations to enter treatment.
Differences in Outcome Measures and Comparison Groups
Future research should address the problem which has arisen in the past when researchers utilized different outcome measures (e.g., recidivism rates rather than client drinking levels, employee job performance rather than level of substance use) and unequal (nonrandomized) comparison groups (e.g., young, mandated, relatively healthy individuals versus older, voluntary, chronic addicts). What is needed is greater methodological or statistical control of pretreatment differences in problem severity, as well as differences in age, gender, and social class, among others.
Client and Therapist Factors
While no study can measure all variables potentially influencing outcome, ideally future research would control for the existence of certain client factors such as personality disorders, and therapist factors such as therapist cultural training or preconceptions about treating "mandated" clients. Future research might also benefit from attending to clients' motivational readiness to change, the potential impact of therapist interventions to raise levels of client motivational readiness to change, and the quality of the therapeutic alliance.
Client Motivational Readiness to Change
Given the implications of the Prochaska et al. (1992) transtheoretical model of the stages of change, it would appear that the treatment outcome of any client will depend at least in part on the client's level of motivational readiness to change, and whether or not the therapist utilized techniques appropriate to that client's stage of change. Virtually all studies of mandated clients which discuss motivation suggest that motivationally enhancing techniques should be used with clients displaying low motivation to change. However, relatively few outcome studies have considered the fit between clients' motivational stage and the techniques applied by their therapists, or investigated whether their therapists tried to match their interventions to the clients' level of motivation.
Therapeutic alliance. As noted earlier, some evidence indicates that clients in the precontemplation or contemplation stages of readiness to change (who are also often mandated) are less likely to develop a strong therapeutic alliance than clients at other levels of motivation to change (Connors et al., 2000). This has been found to be the case in studies involving adolescents as well as those involving adults (Simpson, Joe, Rowan-Szal, & Greener, 1997). Thus, simply assessing the quality of the therapeutic alliance without understanding the client's motivational readiness to change seems insufficient.
In concluding, we would like to emphasize that the issue of mandated versus voluntary referral status has implications for most, if not all, practicing therapists. The majority of therapists will encounter clients who have been mandated to attend therapy by the courts or other state agencies. Even if one does not work regularly with clients mandated to attend therapy by such entities, most therapists will regularly encounter clients who have been effectively pressured by family members, employers, or others to enter therapy and who initially exhibit resistance and low motivation to change. Notwithstanding this, it appears that the vast majority of therapists have not been trained to work with mandated clientele (Cingolani, 1984; Larrabee, 1982; Rooney, 1992). Their training and education appear to be based on voluntary client principles, as most models of individual and family therapy do not address this matter directly (for example, by incorporating readiness to change assessments or motivational intervention strategies into their approaches).
As we have noted, there is a body of research that suggests mandated treatment with a variety of clients with various presenting problems can be effective. However, additional work is necessary in several areas. Future research will need to attend to the above-described methodological issues. The quality of the therapeutic alliance between client and therapist and clients' level of motivational readiness for change should be studied together to determine which of these constructs is most influential in determining treatment outcomes. Only in this way can future research establish which specific techniques work best to influence positive outcomes within the mandated client population. Finally, therapists would need to be provided with appropriate training to work with this clientele. That training would include an understanding that the majority of their clientele could very well be in the room under some form of duress. As a result, client resistance and/or hostility should be anticipated as a normal part of the therapeutic process. Such a stance would then help therapists to avoid internalizing such a client reaction as rejection. Cultural training would be incorporated so as to not trigger or compound client resistance due to unexamined cultural factors. When a high degree of resistance is encountered or if a positive therapeutic alliance cannot be achieved, therapists would be trained to examine the "fit" or "lack of fit" between their interventions and their clients' level of motivational readiness to change.
References
REFERENCES
Abu Baker, K. (1999). The importance of cultural sensitivity and therapist self-awareness when working with mandatory clients. Family Process, 38(1), 55-67.
Ackerman, F., Colapinto, J. A., Scharf, C. N., Weinshel, M., & Winawer, H. (1991). The involuntary client: Avoiding pretend therapy. Family Systems Medicine, 9, 261-266.
Adams, S. G. (1992). Family therapy and the legal system: One therapist's ideas and experiences. Topics in Family Psychological Counseling, 1(2), 23-29.
Anderson, C. M., & Stewart, S. (1983). Mastering resistance: A practical guide to family therapy. New York: Guilford Press.
Anglin, M. D., Brecht, M. L., & Maddahian, E. (1989). Pretreatment characteristics and treatment performance of legally coerced versus voluntary methadone maintenance admissions. Criminology, 27, 537-557.
Azar, S. T. (1984). Methodological considerations in treatment outcome research in child maltreatment. Presented at the National Conference of Family Violence Researchers, Durham, N.H.
Babcock, J. C, & Steiner, R. (1999). The relationship between treatment, incarceration, and recidivism of battering: A program evaluation of Seattle's coordinated community response to domestic violence. Journal of Family Psychology, 13(1), 46-59.
Bastien, R. T., & Adelman, H. S. (1984). Noncompulsory versus legally mandated placement, perceived choice, and response to treatment among adolescents. Journal of Consulting and Clinical Psychology, 52, 171-179.
Begun, A. L., Murphy, C. M., Bolt, D., Weinstein, B., Strodthoff, T., Short, L., et al. (2003). Characteristics of the Safe at Home instrument for assessing readiness to change intimate partner violence. Research on Social Work Practice, 13, 80-107.
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16, 252-259.
Bowen, E., & Gilchrist, E. (2004). Do self-referred and domestic violence offenders share the same characteristics? A preliminary comparison of motivation to change, locus of control and anger. Legal and Criminological Psychology, 9, 279-294.
Boyd-Franklin, N. (1989). Black families in therapy: A multisystems approach. New York: Guilford Press.
Boyd-Franklin, N., & Garcia-Preto, N. (1994). Family therapy: The case of African American and Hispanic women. In L. Comaz-Diaz & B. Greene (Eds.), Women of color: Integrating ethnic and gender identities in psychotherapy. New York: Guilford Press.
Brecht, M. L., Anglin, M. D., & Wang, J. C. (1993). Treatment effectiveness for legally coerced versus voluntary methadone maintenance clients. Journal of Drug and Alcohol Abuse, 19(1), 89-99.
Burton, S., Regan, L., & Kelly, L. (1998). Supporting women and challenging men: Lessons from the domestic violence intervention project. Bristol: Policy Press.
Cadsky, O., Hanson, R. K., Crawford, M., & Lalonde, C. (1996). Attrition from male batterer treatment programs: Client-treatment congruence and lifestyle instability. Violence and Victims, 11, 51-64.
Caesar, P. L., & Friday-Roberts, M. F. (1991). A conversational journey with clients and helpers: Therapist as tourist not tour guide. Journal of Strategic and Systemic Therapies, 10(3), 38-51.
Chamberlain, P., Patterson, G, Reid, J., Kavanaugh, K., & Forgatch, M. (1984). Observation of client resistance. Behavior Therapy, 15, 144-155.
Chen, H., Bersani, C., Myers, S. C., & Denton, R. (1989). Evaluating the effectiveness of a court-sponsored abuser program. Journal of Family Violence, 4, 309-322.
Chopra, K., Preston, D., & Gerson, L. (1979). The effect of constructive coercion on the rehabilitation process. Journal of Occupational Medicine, 21, 749-761.
Cingolani, J. (1984). Social conflict perspective on work with involuntary clients. Social Work, 29, 442-446.
Colapinto, J. A. (1995). Dilution of family process in social services: Implications for treatment of neglectful families. Family Process, 34, 59-74.
Connors, G. J., DiClemente, C. C., Dermen, K. H., Kadden, R., Carroll, K. M., & Frone, M. R. (2000). Predicting the therapeutic alliance in alcoholism treatment. Journal of Studies on Alcohol, 61, 139-149.
Daniels, J. W., & Murphy, C. M. (1997). Stages and processes of change in batterers' treatment. Cognitive and Behavioral Practice, 4, 123-145.
Dawson, B., De Armas, A., McGrath, M., & Kelly, J. (1986). Cognitive problem solving training to improve the child care judgment of child neglectful parents. Journal of Family Violence, 1, 209-221.
De Leon, G. (1988). Legal pressure in therapeutic communities. The Journal of Drug Issues, 18, 625-640.
De Leon, G., & Jainchill, N. (1986). Circumstances, motivation, readiness, and suitability as correlates of treatment tenure. Journal of Psychoactive Drugs, 18, 203-208.
De Leon, G., Melnick, G., & Tims, F. M. (2001). The role of motivation and readiness for change in treatment and recovery. In F. M. Tims, C. G. Leukefeld, & J. J. Hart (Eds.), Relapse and recovery in addictions (pp. 143-171). New Haven, CT: Yale University Press.
Dehmel, S., Klett, F., & Buhringer, G. (1986). Description and first results of an outpatient drug-free treatment program for opiate dependents. In W. R. Miller & N. Heather (Eds.), Treating addictive behavior (pp. 263277). New York: Plenum Press.
DiClemente, C. C. (1991). Motivational interviewing and the stages of change. In W. R. Miller & S. Rollnick (Eds.), Motivational interviewing: Preparing people for change (pp. 191-202). New York: Guilford Press.
DiClemente, C. C., & Hughes, S. L. (1990). Stages of change profiles in alcoholism treatment. Journal of Substance Abuse, 2, 217-235.
DiClemente, C. C., Prochaska, J. O., Fairhurst, S. K., Velicer, W. F., Velasquez, M. M., & Rossi, J. S. (1991). The process of smoking cessation: An analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology, 59, 295-304.
Donovan, D. M., & Rosengren, D. B. (1999). Motivation for behavior change treatment among substance abusers. In J. E. Tucker, D. M. Donovan, & G. A. Marlatt (Eds.), Changing addictive behavior: Bridging clinical and public health strategies (pp. 127-159). New York: Guilford Press.
Dunham, R. G., & Mauss, A. L. (1982). Reluctant referrals: The effectiveness of legal coercion in outpatient treatment for problem drinkers. Journal of Drug Issues, 12, 5-20.
Edens, J. F., & Willoghby, F. W. (2000). Motivational patterns of alcohol dependent patients: A replication. Psychology of Addictive Behaviors, 14, 397-400.
Falikov, C. J. (1988). Learning to think culturally. In H. A. Liddle, D. C. Breunlin, & R. C. Schwartz (Eds.), Handbook of family therapy training and supervision (pp. 335-357). New York: Guilford Press.
Farabee, D., Nelson, R., & Spence, R. (1993). Psychosocial profiles of criminal justice- and non-criminal justicereferred substance abusers in treatment. Criminal Justice and Behavior, 20, 336-346.
Farabee, D., Prendergast, M., & Anglin, M. D. (1998). The effectiveness of coerced treatment for drug abusing offenders. Federal Probation, 62(1), 3-10.
Fennel, D. L., & Weinhold, B. K. (1997). Counseling families. Denver, CO: Love.
Flores, P. (1983). The efficacy of the use of coercion in getting DWI offenders into treatment. Journal of Alcohol and Drug Education, 28, 18-27.
Freedberg, E. J., & Johnston, W. E. (1978). Effects of various sources of coercion on outcome of treatment of alcoholism. Psychological Reports, 43, 1271-1278.
Garland, R. J., & Dougher, M. J. (1991). Motivational intervention in the treatment of sex offenders. In W. T. Miller & S. Rollnick (Eds.), Motivational interviewing: Preparing people to change addictive behavior (pp. 303-313). New York: Guilford Press.
Goldsmith, R. J., & Latessa, E. (2001). Coerced treatment of addictions in the criminal justice system. Psychiatric Annals, 31(11), 657-663.
Gondolf, E. W., & Foster, R. A. (1991). Preprogram attrition in batterer programs. Journal of Family Violence, 6, 337-350.
Haley, J. (1963). Strategies of psychotherapy. New York: Grune and Stratton.
Haley, J. (1987). Problem solving therapy (2nd ed.). San Francisco: Jossey-Bass.
Haley, J. (1992). Compulsory therapy for both client and therapist. Topics in Family Psychological Counseling, 1(2), 1-7.
Harris, G. A., & Watkins, D. (1987). Counseling the involuntary client. College Park, MD: Amercian Correctional Association.
Honea-Boles, P., & Griffin, J. E. (2001). The court-mandated client: Does limiting confidentiality preclude a therapeutic encounter? TCA Journal, 2, 149-160.
Horton, A. L. (1992). The transition from punishment to compulsory treatment for incest perpetrators: An emerging holistic model for family treatment. In J. Carlson (Ed.), Topics in family psychology and counseling 1(2), Compulsory Family Therapy (pp. 23-29). Frederick, MD: Aspen.
Horton, A. L., Johnson, B. L., Roundy, L. M., & Williams, D. (1990). The incest perpetrator: A family member no one wants to treat. London: Sage.
Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 38, 139-149.
Howard, D. L., & McCaughrin, W. C. (1996). The treatment effectiveness of outpatient substance misuse organizations between court mandated and voluntary clients. Substance Use and Misuse, 31, 895-926.
Hubbard, R. L., Marsden, M. E., Rachal, J. V., Harwood, H. J., Cavanaugh, E. R., & Ginzburg, H. M. (1989). Drug abuse treatment: A national study of effectiveness. Chapel Hill: University of North Carolina Press.
Inciardi, J. A. (1994). Screening and assessment for alcohol and other drug abuse among adults in the criminal justice system (TIP 7). Rockville, MD: Center for Substance Abuse Treatment.
Irueste-Montes, A. M., & Montes, F. (1988). Court ordered vs. voluntary treatment of abusive and neglectful parents. Child Abuse and Neglect, 12(1), 33-39.
Joe, G. W., Simpson, D. D., & Broome, K. M. (1998). Effects of readiness for drug abuse treatment on client retention and assessment of process. Addiction, 93, 1177-1190.
Knopp, F. H. (1984). Retraining adult sex offenders: Methods and models. Syracuse, NY: Safer Society Press.
Krauth, B., & Smith, R. (1988). Questions and answers on issues related to the incarcerated male sex offender: An administrator's overview. Washington, DC: U.S. Department of Justice.
Landau, H. R., Salus, M. K., Stiffarm, S., & Kalb, N. L. (1980). Child protection: The role of the courts. DHHS Publication No. (OHDS) 80-30256. Washington, DC: U.S. Department of Health and Human Services.
Larrabee, M. J. (1982). Working with reluctant clients through affirmative techniques. Personnel and Guidance Journal, 61, 105-109.
Lehmer, M. (1986). Court-ordered therapy: Making it work. American Journal of Forensic Psychology, 4(2), 16-24.
Leukefeld, C. G., & Tims, F. M. (1988). Compulsory treatment of drug abuse: Research and clinical practice. NIDA Research Monograph 86. Rockville, MD.
Marlowe, D. B., Kirby, K. C., Bonieskie, L. M., Glass, D. J., Dodds, L. J., Husband, S. D., et al. (1996). Assessment of coercive and noncoercive pressures to enter drug abuse treatment. Drug and Alcohol Dependence, 42, 77-84.
Marlowe, D. B., Merikle, E. P., Kirby, K. C., Festinger, D. S., & McLellan, A. T. (2001). Multidimensional assessment of perceived treatment entry pressures among substance abusers. Psychology of Addictive Behaviors, 15, 97-108.
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables. Journal of Consulting and Clinical Psychology, 68, 438-450.
McConnaughy, E. A., Prochaska, J. O., & Velicer, W. F. (1983). Stages of change in psychotherapy: Measurement and sample profiles. Psychotherapy: Theory, Research and Practice, 20, 368-375.
McGlothlin, W. H. (1979). Criminal justice clients. In R. L. Dupont, A. Goldstein, & J. O'Donnell (Eds.), Handbook of drug abuse (pp. 203-209). Washington, DC: Government Printing Office.
Miller, N. S., & Flaherty, J. A. (2000). Effectiveness of coerced addiction treatment (alternative consequences): A review of the clinical research. Journal of Substance Abuse Treatment, 18, 9-16.
Miller, W. R., & Rollnick, S. (1991). Dealing with resistance. In W. R. Miller & S. Rollnick (Eds.), Motivational interviewing: Preparing people for change (pp. 100-112). New York: Guilford Press.
Miller, W. R., & Sovereign, R. G. (1989). The check-up: A model for early intervention in addictive behaviors. In T. Loberg, W. R. Miller, P. E. Nathan, & G. A. Marlatt (Eds.), Addictive behaviors: Prevention and early intervention (pp. 219-231). Amsterdam: Swets & Zeitlinger.
Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.
O'Hare, T. (1996). Court-ordered versus voluntary clients: Problem differences and readiness for change. Social Work, 41, 417-422.
Orlinsky, D. E., & Howard, K. I. (1986). Process and outcome in psychotherapy. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed., pp. 311-381). New York: Wiley.
Pinsoff, W. M. (1994). An integrative systems perspective on the therapeutic alliance: Theoretical, clinical, and research implications. In A. O. Horvath & L. Greenberg (Eds.), The working alliance: Theory, research, and practice (pp. 173-199). New York: John Wiley.
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102-1114.
Prochaska, J. O., DiClemente, C. C., Velicer, W. F., & Rossi, J. S. (1993). Standardized, individualized, interactive, and personalized self-help programs for smoking cessation. Health Psychology, 12, 399-405.
Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12(1), 38-48.
Prochaska, J. O., Velicer, W. F., Rossi, J. S., Goldstein, M. G., Marcus, B. H., Rakowski, W., et al. (1994). Stages of change and decisional balance for 12 problem behaviors. Health Psychology, 13, 39-46.
Rooney, R. H. (1992). Strategies for working with involuntary clients. New York: Columbia University Press.
Rosenfeld, B. D. (1992). Court-ordered treatment of spouse abuse. Clinical Psychology Review, 12, 205-226.
Rotgers, F. (1992). Coercion in addictions treatment. In J. W. Langebucher, B. S. McCrady, W. Frankenstein, & P. E. Nathan (Eds.), Annual review of addiction research and treatment 2 (pp. 403-416). New York: Pergamon Press.
Rounsaville, B. J., & Kleber, H. D. (1985). Untreated opiate addicts: How do they differ from those seeking treatment? Archives of General Psychiatry, 42, 1072-1077.
Ryan, T. S. (1986). Problems, errors and opportunities in the treatment of father-daughter incest. Journal of Interpersonal Violence, 1(1), 113-124.
Satel, S. L. (2000). Drug treatment: The case for coercion. National Drug Court Review, 3(1), 1-43.
Satterfield, W. A., Buelow, S. A., Lyddon, W. J., & Johnson, J. T. (1995). Client stages of change and expectations about counseling. Journal of Counseling Psychology, 42, 476-478.
Schottenfeld, R. S. (1989). Involuntary treatment of substance abuse disorders- impediments to success. Psychiatry, 52, 164-176.
Serran, G., Fernandez, Y., Marshall, W. L., & Mann, R. E. (2003). Process issues in treatment application to sexual offender programs. Professional Psychology: Research and Practice, 34, 368-374.
Sexton, T. L., & Alexander, J. F. (2003). Functional family therapy: A mature clinical model for working with at-risk adolescents and their families. In T. L. Sexton, G. R. Weeks, & M. S. Robbins (Eds.), Handbook of family therapy: The science and practice of working with families and couples (pp. 323-350). New York: Bruner-Routledge.
Shearer, R. (2000). Coerced substance abuse counseling revisited. Journal of Offender Rehabilitation, 30(3/4), 153-171.
Sherman, L. W., Smith, D., Schmidt, J. D., & Rogan, D. P. (1992). Crime, punishment, and stake in conformity: Legal and informal control of domestic violence. American Sociological Review, 57, 680-690.
Simpson, D. D., Joe, G. W., & Rowan-Szal, G. A. (1997). Drug abuse treatment retention and process effects on follow-up outcomes. Drug and Alcohol Dependence, 47, 227-235.
Simpson, D. D., Joe, G. W., Rowan-Szal, G. A., & Greener, J. M. (1997). Drug abuse process components that increase retention. Journal of Substance Abuse Treatment, 14, 565-572.
Smart, R. (1974). Employed alcoholics treated voluntarily and under constructive coercion: A follow-up study. Quarterly Journal of Studies on Alcohol, 35, 196-209.
Smith, K. J., Subich, L. M., & Kalodner, C. (1995). The transtheoretical model's stages and processes of change and relation to premature termination. Journal of Counseling Psychology, 42, 34-39.
Sprenkle, D. H., & Blow, A. J. (2004). Common factors and our sacred models. Journal of Marital and Family Therapy, 30, 113-130.
Strupp, H. H. (1980). Success and failure in time-limited psychotherapy. Archives of General Psychiatry, 37, 708-716.
Taft, C. T., Murphy, C. M., Elliott, J. D., & Morrei, T. M. (2001). Attendance-enhancing procedures in group counseling for domestic abusers. Journal of Counseling Psychology, 48, 51-60.
Velicer, W. F., & Prochaska, J. O. (1999). An expert system intervention for smoking cessation. Patient Education and Counseling, 36, 119-129.
Velicer, W. F., Prochaska, J. O., Bellis, J. M., DiClemente, C. C., Rossi, J. S., Fava, J. L., et al. (1993). An expert system intervention for smoking cessation. Addictive Behaviors, 18, 269-290.
Vriend, J., & Dyer, W. W. (1973). Counseling the reluctant client. Journal of Consulting Psychology, 20, 240-246.
Waldman, F. (1999). Violence or discipline? Working with multicultural court-ordered clients. Journal of Marital and Family Therapy, 25, 503-515.
Walsh, D. C., Hingson, R. W., Merrigan, D. M., Lerenson, S. M., Cupples, L. A., Heeren, T., et al. (1991). A randomized trial of treatment options for alcoholic workers. New England Journal of Medicine, 325, 775-782.
Watson, C. G., Brown, K., Tilleskjor, C., Jacobs, L., & Pucel, J. (1988). The comparative recidivism rates of voluntary and coerced admission male alcoholics. Journal of Clinical Psychology, 44, 573-581.
Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change: Principles of problem formulation and problem resolution. New York: Norton.
Weakland, J. H., & Jordan, L. (1990). Working briefly with reluctant clients: Child protective services as an example. Family Therapy Case Studies, 5(2), 51-68.
Wolfe, D., Aragona, J., Kaufman, J., & Sandler, J. (1980). The importance of adjudication in the treatment of child abusers: Some preliminary findings. Child Abuse and Neglect, 4, 127-135.
Woody, J. D., & Grinstead, N. (1992). Compulsory treatment for families: Issues of compliance. Topics in Family Psychology and Counseling, 1(2), 39-50.
Zane, N., Nagayama-Hall, G. C., Sue, S., Young, K., & Nunez, J. (2004). Research on psychotherapy with culturally diverse populations. In A. E. Bergin & D. E. Garfield (Eds.), Handbook of psychotherapy and behavior change (5th ed., pp. 767-804). New York: John Wiley & Sons.
AuthorAffiliation
Christine M. J. Snyder
Town of Cheshire, Connecticut, Youth & Social Services
Stephen A. Anderson
University of Connecticut
AuthorAffiliation
Christine M. J. Snyder, LMFT, Town of Cheshire, Connecticut, Youth & Social Services; Stephen A. Anderson, PhD, Professor and Director, Marriage and Family Therapy Program, University of Connecticut.
Address correspondence to Christine M. J. Snyder, LMFT, Town of Cheshire, Connecticut, Youth & Social Services, 84 South Main Street, Cheshire, Connecticut 06410; E-mail: csnyder@cheshirect.org
Word count: 9465
Copyright Blackwell Publishing Ltd. Jul 2009
Top of Form
Search ProQuest...Search button
Bottom of Form
Add to Selected items
· Cited by (53)
· Documents with shared references (32849)
·
Mandated Disciplinary Counseling: Working Effectively With Challenging Clients
Kiracofe, Norman M; Buller, Allison E.Journal of College Counseling; Alexandria Vol. 12, Iss. 1, (Spring 2009): 71-84.
·
How Substance Abuse Recovery Skills, Readiness to Change and Symptom Reduction Impact Change Processes in Wilderness Therapy Participants
Bettmann, Joanna E; Russell, Keith C; Parry, Kimber J.Journal of Child and Family Studies; New York Vol. 22, Iss. 8, (Nov 2013): 1039-1050.
·
Co-constructing cooperation with mandated clients
De Jong, Peter; Insoo Kim Berg.Social Work; Oxford Vol. 46, Iss. 4, (Oct 2001): 361-74.
·
ready, set, go: the transtheoretical model of change and motivational interviewing for "fringe" clients
Muscat, Anne C.Journal of Employment Counseling; Alexandria Vol. 42, Iss. 4, (Dec 2005): 179-191.
·
The Role of Transport Use in Adolescent Wilderness Treatment: Its Relationship to Readiness to Change and Outcomes
Tucker, Anita R; Bettmann, Joanna E; Norton, Christine L; Comart, Casey.Child & Youth Care Forum; New York Vol. 44, Iss. 5, (Oct 2015): 671-686.
Top of Form
· Subject
Child abuse & neglect
Therapist patient relationships
Clinical outcomes
Minority & ethnic groups
Family counseling
Asian Americans
Alliances
· MeSH subject
Defense Mechanisms
Humans
Motivation
Outcome & Process Assessment (Health Care)
Professional-Family Relations
Professional-Patient Relations
Prognosis
Substance-Related Disorders -- psychology
Substance-Related Disorders -- rehabilitation
Family Therapy
Mandatory Programs
Psychotherapy
Referral & Consultation
Voluntary Programs
Bottom of Form
· 1.
Assessment of the National Institute of Standards and Technology Programs...
Assessment of the National Institute of Standards and Technology Programs...
· 2.
Optimizing U. S. Air Force and Department of Defense Review of Air Force...
Optimizing U. S. Air Force and Department of Defense Review of Air Force...
· 3.
Final Report to the U.S. Department of Defense on the Defense Reinvestmen...
Final Report to the U.S. Department of Defense on the Defense Reinvestmen...
Top of Form
Title:
Care, control, or both? Characterizing major dimensions of the mandated treatment relationship. By: Manchak, Sarah M., Skeem, Jennifer L., Rook, Karen S., Law and Human Behavior, 01477307, 20140201, Vol. 38, Issue 1
Database:
PsycARTICLES
Care, Control, or Both? Characterizing Major Dimensions of the Mandated Treatment Relationship
Contents
1. Therapist Control and Assertive or Involuntary Treatment
2. Does Therapist Control Necessarily Reduce Affiliation?
4. Method
5. Procedure
6. Participants
7. Measure
8. Distilling Voluntary Comparison Data
9. Results
11. Is Greater Control Associated With Less Affiliation?
12. Discussion
14. Finding 2: Despite Pronounced Control Dynamics, Mandated Relationships Are Predominantly Affiliative
15. Limitations
16. Implications
17. References
By: Sarah M. Manchak University of Cincinnati School of Criminal Justice; Jennifer L. Skeem Department of Psychology and Social Behavior, University of California, Irvine Karen S. Rook Department of Psychology and Social Behavior, University of California, Irvine
Acknowledgement: 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.
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, Cohen, & 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 connectedness (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 therapeutic alliance (Horvath & Symonds, 1991; Martin et al., 2000; Tryon, Blackwell, & Hammel, 2007), the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989), emphasizes an interpersonal 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, 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, withholding assistance, and occasionally threatening to pursue involuntary 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 treatment. 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 treatment, control may become an important component of the relationship.
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 circumplex space reflects a weighted combination of these two dimensions 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 “Protect,” whereas those that combine moderate affiliation with moderate autonomy granting are mapped as “Affirm.” Beyond describing 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 voluntary psychotherapy that apply Benjamin’s circumplex measures: the observer-rated Structural Analysis of Social Behavior (SASB: Benjamin, 1996), or the self-report INTREX (Benjamin, 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 characterized by therapist “Affirm” and “Protect” (i.e., affiliative autonomy-granting and control) and corresponding client “Disclose” and “Trust” (i.e., affiliative autonomy-taking and submission; 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 responses 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 hospital stays and less symptom improvement for clients (Najavits & Strupp, 1994).
In summary, research on voluntary treatment relationships suggests 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 involuntary 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 resistance to treatment goals or (b) a sense of helplessness and decreased 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 (Sheehan & 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 control (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 relationship 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.
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. Second, 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 communication, 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 comparison 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 communication, 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 principles 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 mandated treatment relationships involve greater therapist control and corresponding greater client submission than voluntary treatment relationships.
To address our second aim—to examine the relationship between affiliation and control, we focus exclusively on the mandated treatment sample and use several different indices commonly 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 relationship, we hypothesize that higher levels of control in mandated treatment will be associated with reduced client–therapist affiliation.
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 patients 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 announcements 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 participate. 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 disorder; 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.
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, therapist, substance abuse counselor), participants were asked to rate the INTREX (Benjamin, 2000) on the provider who was considered 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 discussions.” 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 relationship 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, “transitive 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 “Disclose,” “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 “Autonomy 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 (Benjamin, 2000). For the purposes of this study, we made minimal changes to the wording of a few INTREX items to fit the therapeutic relationship, but maintained emphasis on reading ease (e.g., “lovingly” was changed to “caringly”). The INTREX demonstrates good split half (α = .82) and test–retest (α = .84; Benjamin, Rothweiler, & Critchfield, 2006) reliability and good (Cronbach, 1951) internal consistency in the present sample (α = .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 comparison data set from previous studies of voluntary treatment relationships. First, we conducted a two-pronged search strategy to 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 routinely 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) Critchfield’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 Reconstructive Therapy (Benjamin, 2003).
Although we were unable to directly compare our mandated sample with these voluntary samples on several sample demographic 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 communication, 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). Additionally, 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 Critchfield 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 appears 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 (requiring α < .02) was applied to maintain a family-wise error rate of α < .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 described 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’ transitive INTREX scores; the consistencies across the studies far outweigh 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 transitive 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 connect,” 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.
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 correction 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 relationships involve much greater therapist neutral control (Watch/Control) 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 neutralsubmission (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 relationships? The results that address question are shown in Tables 4 and 5. The 12 relevant clusters are those in the therapist and client “affiliation” and “attack” families. The results indicate that, if anything, mandated treatment relationships are slightly more affiliative than voluntary ones. Specifically, compared to voluntary treatment, mandated relationships were minimally greater in therapist 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 average, 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 coefficients 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 treatment 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 characterized as affiliative and autonomous. Specifically, therapist transitive angular displacement is 72°, which corresponds to the clusters 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.
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 affiliative, 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 directiveness, and thus greater control, than in typical voluntary 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 accountabilities (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 beyond 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 associated 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 mandated 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 attributable to attenuated expression of affiliation that may accompany manualized therapy (see Henry, Strupp, Butler, Schacht, & Binder, 1993). Future research should explore differences between mandated and more common, “real world” voluntary treatment relationships 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 relationships—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 characterizes a decision process, individuals tend to perceive the authority 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 probation/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 characterization of strong dual role relationships as fundamentally authoritative (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 represent 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 undermined by our inability to say with certainly that the observed differences in mandated and voluntary treatment relationships are 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 relationship 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 relatively reassuring, given that they directly challenge clinical impressions 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 mandated (civil vs. criminal) contexts.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Angell, B. (2006). Measuring strategies used by mental health providers to encourage medication adherence. Journal of Behavioral Health and Social Research, 33, 53–72. doi:10.1007/s11414-005-9000-4
Benjamin, L., Rothweiler, J., & Critchfield, K. (2006). The use of Structural Analysis of Social Behavior (SASB) as an assessment tool. Annual Review of Clinical Psychology, 2, 83–109. doi:10.1146/annurev.clinpsy.2.022305.095337
Benjamin, L. S. (1996). Interpersonal diagnosis and treatment of personality disorders (2nd ed.). New York, NY: Guilford Press.
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.
Benjamin, L. (2003). Interpersonal reconstructive therapy: Promoting change in non- responders. New York, NY: Guilford Press.
Bordin, E. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16, 252–260. doi:10.1037/h0085885
Bornstein, R., Gottdiener, W., & Winarick, D. (2009). Construct validity of the relationship profile test: Links with defense style in substance abuse patients and comparison with non-clinical norms. Journal of Psychopathology and Behavioral Assessment, 32, 293–300. doi:10.1007/s10862-009-9153-1
Coady, N., & Marziali, E. (1994). The association between global and specific measures of the therapeutic relationship. Psychotherapy, 31, 17–27. doi:10.1037/0033-3204.31.1.17
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Erlbaum.
Constantino, M. J., Arnow, B., Blasey, C., & Agras, S. (2005). The association between patient characteristics and the therapeutic alliance in cognitive behavioral and interpersonal therapy for bulimia nervosa. Journal of Consulting and Clinical Psychology, 73, 203–211. doi:10.1037/0022-006X.73.2.203
Cramer, J. A., & Rosenheck, R. (1998). Compliance with medication regimens for mental and physical disorders. Psychiatric Services, 49, 196–201. Retrieved from http://www.ps.psychiatryonline.org.proxy-library.ashford.edu/cgi/content/full/49/2/196
Critchfield, K. L., Henry, W., Castonguay, L., & Borkovec, T. (2007). Interpersonal process and outcome in variants of cognitive-behavioral psychotherapy. Journal of Clinical Psychology, 63, 31–51. doi:10.1002/jclp.20329
Cronbach, L. J. (1951). Coefficient of alpha and the internal structure of tests. Psychometrika, 16, 297–334.
Curtis, R., & Hirsch, I. (2003). Relational approaches to psychoanalytic psychotherapy. In A.Gurman & S.Messer (Eds.), Psychotherapies: Theory and practice (pp. 69–106). New York, NY: Guilford Press.
Dixon, L. (2000). Assertive community treatment: 25 years of gold. Psychiatric Services, 51, 759–765. doi:10.1176/appi.ps.51.6.759
Drake, R. E., McHugo, G., Clark, R., Teague, G., Xie, H., Miles, K., & Ackerson, T. (1998). Assertive community treatment for patients with co-occurring severe mental illness and substance abuse disorder: A clinical trial. American Journal of Orthopsychiatry, 68, 201–215. doi:10.1037/h0080330
Fenton, W. S., Blyler, C., & Heinssen, R. K. (1997). Determinants of medication compliance in schizophrenia: Empirical and clinical findings. Schizophrenia Bulletin, 23, 637–651. doi:10.1093/schbul/23.4.637
Florsheim, P., Henry, W., & Benjamin, L. (1996). Integrating individual and interpersonal approaches to diagnosis: The Structural Analysis of Social Behavior and Attachment Theory. In F.Kaslow (Ed.), Handbook of relational diagnosis (pp. 81–101). Hoboken, NJ: Wiley.
Freedman, M. B., Leary, T., Ossorio, A., & Coffee, H. (1951). The interpersonal dimensions of personality. Journal of Personality, 20, 143–161. doi:10.1111/j.1467-6494.1951.tb01518.x
Gurtman, M. (1992). Construct validity of interpersonal personality measures: The interpersonal circumplex as a nomological net. Journal of Personality and Social Psychology, 63, 105–118. doi:10.1037/0022-3514.63.1.105
Gurtman, M., & Pincus, A. (2003). The Circumplex model: Methods and research applications. In J.Schinka, W.Veliser, & I.Weiner (Eds.), Handbook of psychology: Research methods in psychology (pp. 407–428). Hoboken, NJ: Wiley.
Harrist, R., Quintana, S., Strupp, H., & Henry, W. (1994). Internalization of interpersonal process in time-limited dynamic psychotherapy. Psychotherapy, 31, 49–57. doi:10.1037/0033-3204.31.1.49
Henry, W. P., Schacht, T., & Strupp, H. (1990). Patient and therapist introject, interpersonal process, and differential psychotherapy outcome. Journal of Consulting and Clinical Psychology, 58, 768–774. doi:10.1037/0022-006X.58.6.768
Henry, W. P., Strupp, H., Butler, S., Schacht, T., & Binder, J. (1993). Effects of training in time-limited dynamic psychotherapy: Changes in therapist behavior. Journal of Consulting and Clinical Psychology, 61, 434–440. doi:10.1037/0022-006X.61.3.434
Horvath, A. O. (2000). The therapeutic relationship: From transference to alliance. Journal of Clinical Psychology: In Session: Psychotherapy in Practice, 56, 163–173.
Horvath, A. O., Del Re., A. C., Flueckiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9–16. doi:10.1037/a0022186
Horvath, A. O., & Greenberg, L. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36, 223–233. doi:10.1037/0022-0167.36.2.223
Horvath, A. O., & Luborsky, L. (1993). The role of the therapeutic alliance in psychotherapy. Journal of Consulting and Clinical Psychology, 61, 561–573. doi:10.1037/0022-006X.61.4.561
Horvath, A. O., & Symonds, D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38, 139–149. doi:10.1037/0022-0167.38.2.139
Karberg, J., & James, D. (2005). Substance dependence, abuse, and treatment of jail inmates, 2002. Washington, DC: U. S. Department of Justice, Bureau of Justice Statistics.
Kennealy, P. J., Skeem, J., Manchak, S., & Eno Louden, J. (2012). Firm, fair, and caring officer-offender relationships protect against supervision failure. Law and Human Behavior, 36, 496–505. doi:10.1037/h0093935
Kessler, R. C., Nelson, C., McGonagle, K., Edlund, M., Frank, R., & Leaf, P. (1996). The epidemiology of co-occurring and addictive mental disorders: Implications for prevention and service utilization. American Journal of Orthopsychiatry, 66, 17–31. doi:10.1037/h0080151
Kiesler, D. (1983). The 1982 Interpersonal Circle: A taxonomy for complementarity in human transactions. Psychological Review, 90, 185–214. doi:10.1037/0033-295X.90.3.185
Klinkenberg, W. D., Calsyn, R. J., & Morse, G. A. (1998). The helping alliance in case management for homeless persons with severe mental illness. Community Mental Health Journal, 34, 569–578. doi:10.1023/A:1018758917277
Klockars, C. (1972). A theory of probation supervision. Journal of Criminal Law, Criminology, and Police Science, 64, 549–557. Retrieved from http://www.jstor.org.proxy-library.ashford.edu/stable/1141809
Krupnick, J., Sotsky, S., Elkin, I., Simmens, S., Moyer, J., & Watkins, J. (1996). The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcomes: Findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology, 9, 269–277. doi:10.1037/0022-006X.64.3.532
Leary, T. (1957). Interpersonal diagnosis of personality. New York, NY: Ronald Press.
Lind, E., & Tyler, T. (1988). The social psychology of procedural justice. New York, NY: Plenum Press.
Luborsky, L., Chandler, M., Auerbach, A., Cohen, J., & Bachrach, H. (1971). Factors influencing the outcomes of psychotherapy: A review of quantitative research. Psychological Bulletin, 75, 145–185. doi:10.1037/h0030480
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438–450. doi:10.1037/0022-006X.68.3.438
McCabe, R., & Priebe, S. (2004). The therapeutic relationship in the treatment of severe mental illness: A review of methods and findings. International Journal of Social Psychiatry, 50, 115–128. doi:10.1177/0020764004040959
Monahan, J., Hoge, S., Lidz, C., Roth, L., Bennett, N., Gardner, W., & Mulvey, E. (1995). Coersion and commitment: Understanding involuntary mental hospital admission. International Journal of Law and Psychiatry, 18, 249–263. doi:10.1016/0160-2527(95)00010-F
Monahan, J., Redlich, A., Swanson, J., Robbins, P., Appelbaum, P., Petrila, J., . . .McNiel, D. E. (2005). Use of leverage to improve adherence to psychiatric treatment in the community. Psychiatric Services, 56, 37–44. doi:10.1176/appi.ps.56.1.37
Monahan, J., Steadman, H., Silver, E., Appelbaum, P., Robbins, P., Mulvey, E., . . .Banks, S. (2001). Rethinking risk assessment: The MacArthur study of mental disorder and violence. New York, NY: Oxford University Press.
Morgan, R. D., Fisher, W. H., Duan, N., Mandracchia, J. T., & Murray, D. (2010). Prevalence of criminal thinking among state prison inmates with serious mental illness. Law and Human Behavior, 34, 324–336. doi:10.1007/s10979-009-9182-z
Najavits, L., & Strupp, H. (1994). Differences in the effectiveness of psychodynamic therapists: A process-outcome study. Psychotherapy, 31, 114–123. doi:10.1037/0033-3204.31.1.114
Neale, M. S., & Rosenheck, R. A. (2000). Therapeutic limit setting in an assertive community treatment program. Psychiatric Services, 51, 499–505. doi:10.1176/appi.ps.51.4.499
Norcross, J. C., Hedges, M., & Prochaska, J. O. (2002). The face of 2010: A Delphi poll on the future of psychotherapy. Professional Psychology: Research and Practice, 33, 316–322. doi:10.1037/0735-7028.33.3.316
Paparozzi, M., & Gendreau, P. (2005). An intensive supervision program that worked: Service delivery, professional orientation, and organizational supportiveness. The Prison Journal, 85, 445–466. doi:10.1177/0032885505281529
Parhar, K., Wormith, J. S., Derkzen, D., & Beauregard, A. (2008). Offender coercion in treatment: A meta-analysis of effectiveness. Criminal Justice and Behavior, 35, 1109–1135. doi:10.1177/0093854808320169
Regier, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z., Keith, S. J., Judd, L. L., & Goodwin, F. K. (1990). Comorbidity of mental disorders with alcohol and other drug abuse: Results from the epidemiologic catchment area study. Journal of the American Medical Association, 264, 2511–2518. doi:10.1001/jama.1990.03450190043026
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95–103. doi:10.1037/h0045357
Ross, E., Polaschek, D., & Ward, T. (2008). The therapeutic alliance: A theoretical revision for offender rehabilitation. Aggression and Violent Behavior, 13, 462–480. doi:10.1016/j.avb.2008.07.003
Schedin, G. (2005). Interpersonal behavior in counseling: Client and counselor expectations and experiences related to their evaluation of session. International Journal for the Advancement of Counselling, 27, 57–69. doi:10.1007/s10447-005-2247-x
Schiff, M., & Levit, S. (2010). Correlates of therapeutic alliance and treatment outcomes among Israeli female methadone patients. Research on Social Work Practice, 20, 380–390. doi:10.1177/1049731509347854
Shearin, E. N., & Linehan, M. M. (1992). Patient-therapist ratings and relationship to progress in dialectical behavioral therapy for borderline personality disorder. Behavior Therapy, 23, 730–741. doi:10.1016/S0005-7894(05)80232-1
Sheehan, K. A., & Burns, T. (2011). Perceived coercion and the therapeutic relationship: A neglected association?Psychiatric Services, 62, 471–476. doi:10.1176/appi.ps.62.5.471
Skeem, J., Eno Louden, J., Manchak, S., Vidal, S., & Haddad, E. (2009). Social networks and social control of probationers with co-occurring mental and substance abuse disorders. Law and Human Behavior, 33, 122–135. doi:10.1007/s10979-008-9140-1
Skeem, J. L., Eno Louden, J., Polaschek, D., & Camp, J. (2007). Relationship quality in mandated treatment: Balancing care with control. Psychological Assessment, 19, 397–410. doi:10.1037/1040-3590.19.4.397
Swartz, M. S., Wagner, H. R., Swanson, J. W., Hiday, V. A., & Burns, B. J. (2002). The perceived coerciveness of involuntary outpatient commitment: Findings from an experimental study. Journal of the American Academy of Psychiatry and the Law, 30, 207–217.
Trotter, C. (1999). Working with involuntary clients: A guide to practice. London, UK: Sage.
Tryon, G. S., Blackwell, S. C., & Hammel, E. F. (2007). A meta-analytic examination of client-therapist perspectives of the working alliance. Psychotherapy Research, 17, 629–642. doi:10.1080/10503300701320611
Tyler, T. (1989). The psychology of procedural justice: A test of the group-value model. Journal of Personality and Social Psychology, 57, 830–838. doi:10.1037/0022-3514.57.5.830
Tyler, T. (1994). Psychological models of the justice motive: Antecedents of distributive and procedural justice. Journal of Personality and Social Psychology, 67, 850–863. doi:10.1037/0022-3514.67.5.850
Watson, A. C., & Angell, B. (2007). Applying procedural justice theory to law enforcement’s response to persons with mental illness. Psychiatric Services, 58, 787–793. doi:10.1176/appi.ps.58.6.787
Wright, A. G., Pincus, A., Conroy, D., & Hilsenroth, M. (2009). Integrating methods to optimize circumplex description and comparison of groups. Journal of Personality Assessment, 91, 311–322. doi:10.1080/00223890902935696
Submitted: January 4, 2013 Revised: March 26, 2013 Accepted: March 28, 2013
This publication is protected by US and international copyright laws and its content may not be copied without the copyright holders express written permission except for the print or download capabilities of the retrieval software used for access. This content is intended solely for the use of the individual user. Source: Law and Human Behavior. Vol. 38. (1), Feb, 2014 pp. 47-57) Accession Number: 2013-24290-001 Digital Object Identifier: 10.1037/lhb0000039
· HTML Full Text
· PDF Full Text (195.8KB)
Related Information
Tools
· Save
· Cite
· Export
· Share
5. 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, advantages,
and liabilities associated with this important clinical
modality. An expert panel, consisting of the Addiction Committee
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 literature
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 psychotherapy;
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 Psychiatry,
NYSPI, SubstanceUse Research Center,Unit 120, 1051 Riverside
Dr, New York, NY 10032. E-mail: sulliva@pi.cpmc.columbia.edu.
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 treatment
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 mechanisms
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 disorders
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 psychiatristsmay 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 whichmembers 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 membersmust 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
amandatory evaluation. He could retain his positionwith 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 substancefree
and in recovery.Hewas 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 howto 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 conditioned
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. Therapistswho 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 samesex
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 tamperproof
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 chainof-
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 treatmentresistant
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 selfreferred
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 selfreferred
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
urinemonitoring, 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 drugfree
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 methadonemaintained
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 management
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 managementbased
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 selfhelp
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 dehydrogenase,
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 usemay 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 wellbeing
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 beneficience.
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,wemust 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 intended
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 peoplewith mental illness, advocates
of these policies believe that mandated care can be patientcentered
in that it promotes patients’ engagement in their care
to themaximun 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 requirements;
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 deliver
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 atmosphere
that respects individual autonomy, enhances individual
dignity, and encourages independence60” may be achievable
only through coercion, for some persons.
Case example 3.A26-year-old unmarriedwoman, 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 selfmutilation,
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 amethadone 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 demonstrated
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-termAOT(sixmonths 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 NorthCarolina
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 considerations
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 monitoring
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 detoxification
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 selfdestruction,
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 appreciate
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 recovery
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 troublemaking
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 deterioration
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 serious
consideration as a therapeutic modality within addiction
psychiatry. Current public ambivalence over whether noncriminal
substance abuse should be seen as an illness or a weakness
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. Theirmotivation 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 drugtaking
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 patientcentered
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.
REFERENCES
1. Prochaska JO, DiClemente CC. Stages and processes of self-change of
smoking: Toward an integrative model of change. J Consult Clin Psychol.
1983;51:390–395.
2. Miller NS, Flaherty JA. Effectiveness of coerced addiction treatment
(alternative consequences): A review of the clinical research. J Subst
Abuse Treat. 2000;18:9–16.
3. Westermeyer J. Monitoring recovery from substance abuse: Rationales,
methods and challenges. Advances in Alcohol & Substance Abuse
1988;8:93–105.
4. Boyarsky BK, Dilts S, Frances RJ, et al. GAP Committee on Addictions.
Responsibility and choice in substance use and addiction. Psychiatr Serv.
2002;53:651–782.
5. Incidardi JA.Compulsory treatment inNewYork:Abrief narrative history
of misjudgment, mismanagement, andmisrepresentation. Journal of Drug
Issues. 1988;18:547–560.
Sullivan et al. January–February 2008 45
6. Taxman FS, Messina NP. Civil commitment: One of many coerced
treatment models. In: Leukefeld CG, Tims F, Farabee D, eds. Clinical
and Policy Responses to Drug Offenders. Lexington, Ky.: Center on Drug
and Alcohol Research; 2002.
7. Hall KT, Appelbaum PS. The origins of commitment for substance
abuse in the United States. J Am Acad Psychiatry Law. 2002;30:33–45;
discussion 46–48.
8. Andre C, Jaber-Filho JA, Carvalho M, Julliien C, Hoffman A. Predictors
of recovery following involuntary hospitalization of violent substance
abuse patients. Am J Addict. 2003;12:84–89.
9. Johnson VE. Intervention: How to Help Someone Who Doesn’t Want
Help. Minneapolis, Minn.: Johnson Institute Books; 1986.
10. Loneck B, Garrett JA, Banks SM. A comparison of the Johnson
Intervention with four other methods of referral to outpatient treatment.
Am J Drug Alcohol Abuse. 1996;22:233–246.
11. Gallegos KV, Talbott GD. Physicians and other health professionals.
In: Lowinson JH, Ruiz P, Millman R, Langrod JG, eds. Substance
Abuse: A Comprehensive Textbook. Baltimore, Md.:Williams &Wilkins,
1997:744–754.
12. Fromson JA. Addressing clinician performance problems as a systems
issue. In: Youngberg B, Hatlie MJ, eds. The Patient Safety Handbook.
Boston, Mass.: Jones and Bartlett; 2004.
13. King G, Ellinwood Jr. EH. Amphetamines and other stimulants. In:
Lowinson JH, Ruiz P, Millman R, Langrod JG, eds. Substance Abuse:
A Comprehensive Textbook. Baltimore, Md.: Williams & Wilkins;
1997:207–223.
14. Hall WC, Talbert RL, Ereshefsky L. Cocaine abuse and its treatment.
Pharmacotherapy. 1990;10:47–65.
15. Washton A. Structured outpatient group therapy. In: Lowinson JH, Ruiz
P, Millman R, Langrod JG, eds. Substance Abuse: A Comprehensive
Textbook. Baltimore, Md.: Williams & Wilkins; 1997:440–448.
16. Huestis MA, Cone EJ, Wong CJ, Umbricht A, Preston KL. Monitoring
opiate abuse in substance abuse treatment patients with sweat and urine
drug testing. J Anal Toxicol. 2000;24:509–521.
17. DuPont RL, Baumgartner WA. Drug testing by urine and hair analysis:
Complementary features and scientific uses. Forensic Sci Int. 1995;70:63–
76.
18. Department of Health and Human Services, Substance Abuse and Mental
Health Services Administration. Mandatory guidelines for federal workplace
drug testing programs. Fed Regist. 2004 (April 13);69(71):19644–
19673.
19. Wasserman DA, Korcha R, Havassy BE, Hall SM. Detection of illicit
opioid and cocaine use in methadone maintenance treatment. Am J Drug
Alcohol Abuse. 1999;25:561–571.
20. Ehrenreich H, Mangholz A, Schmitt M, et al. OLITA: An alternative
in the treatment of therapy-resistant chronic alcoholics. First evaluation
of a new approach. Eur Arch Psychiatry Clin Neurosci. 1997;247:51–
54.
21. Lawental E, McLellan AT, Grissom GR, Brill P, O’Brien C. Coerced
treatment for substance abuse problems detected through workplace urine
surveillance: Is it effective? J Subst Abuse. 1996;8:115–128.
22. Reading E. Nine years experience with chemically dependent physicians:
The New Jersey experience. MD Medical Journal. 1992;41:325–
329.
23. Gallegos K, Lubin B, Bowers C, Blevins J, et al. Relapse and recovery:
Five to ten year follow study of chemically dependent physicians—the
Georgia experience. MD Medical Journal. 1992;41:315–319.
24. Shore J. The Oregon experience with impaired physicians on probation.
JAMA. 1987;257:2931–2934.
25. McCarthy JJ, Borders OT. Limit setting on drug abuse in methadone
maintenance patients. Am J Psychiatry. 1985;142:1419–1423.
26. Liebson IA, Tommasello A, Bigelow GE. A behavioral treatment
of alcoholic methadone patients. Ann Intern Med. 1978;89:342–
344.
27. Dolan MP, Black JL, Penk WE, et al. Contracting for treatment
termination to reduce illicit drug use among methadone maintenance
treatment failures. J Consult Clin Psychol. 1985;53:549–551.
28. Nolimal D, Crowley TJ. Difficulties in a clinical application
of methadone-dose contingency contracting. J Subst Abuse Treat.
1990;7:219–224.
29. Saxton AJ, Calsyn DA, Kivlahan DR, et al. Outcome of contingency
contracting for illicit drug use in a methadone maintenance program.
Drug Alcohol Depend. 1993;31:205–214.
30. Stitzer ML, Bickel WK, Bigelow GE, et al. Effect of methadone dose
contingencies on urinalysis test results of polydrug abusing methadone
maintenance patients. Drug Alcohol Depend. 1986;18:341–348.
31. SilvermanK,Higgins ST,BroonerRK, et al. Sustained cocaine abstinence
in methadone maintenance patients through voucher-based reinforcement
therapy. Arch Gen Psychiatry. 1996;53:409–415.
32. Budney AJ, Higgins ST, Radonovich KJ, et al. Adding voucher-based
incentives to coping-skills and motivational enhancement improves
outcomes during treatment for marijuana dependence. J Consult Clin
Psychol. 2000;68:1051–1061.
33. Higgins ST, Wong CJ, Badger GJ, et al. Contingency reinforcement
increases cocaine abstinence during outpatient treatment and one year
of follow-up. J Consult Clin Psychol. 2000;68:64–72.
34. Wexler HK. The promise of prison-based treatment for dually diagnosed
inmates. J Subst Abuse Treat. 2003;25:223–231.
35. Melnick G, De Leon G, Thomas G, Kressel D, Wexler HK. Treatment
process in prison therapeutic communities:Motivation, participation, and
outcome. Am J Drug Alcohol Abuse. 2001;27:633–650.
36. Goodwin DW, Gabrielli Jr WF. Alcohol: Clinical aspects. In: Lowinson
JH, Ruiz P, Millman R, Langrod JG, eds.Substance Abuse: A Comprehensive
Textbook. Baltimore, Md.: Williams & Wilkins; 1997:142–148.
37. Brewer C. Patterns of compliance and evasion in treatment programs
which include supervised disulfiram. Alcohol Alcohol. 1986;21:385–388.
38. Galanter M. Network Therapy for Alcohol and Drug Abuse: A New
Approach in Practice. New York: Basic Books; 1993.
39. Platt JJ, Buhringer G, Kaplan CD, Brown BS, Taub DO. The prospects
and limitations of compulsory treatment for drug addiction. Special issue:
A social policy analysis of compulsory treatment for opiate dependence.
Journal of Drug Issues. 1988;18:505–525.
40. Hartjen CA, Mitchell SM, Washburne NF. Sentencing to therapy: Some
legal, ethical, and practical issues. Journal of Offender Counseling,
Services and Rehabilitation. 1981;6:21–39.
41. Anglin MD, Prendergast M, Farabee D. The effectiveness of coerced
treatment for drug-abusing offenders. Paper presented at the Office
of National Drug Control Policy’s Conference of Scholars and Policy
Makers, Washington, DC, March 23–25, 1998.
42. Leshner AI. Drug addiction research: Moving toward the 21st century.
Drug Alcohol Depend. 1998;51:5–7.
43. Anglin MD,Maugh TH.Overturning myths about coerced drug treatment.
California Psychologist. 1992;25:19–22.
44. Salmon RW, Salmon RJ. The role of coercion in rehabilitation of drug
abusers. International Journal of the Addictions. 1983;18:9–21.
45. Mill JS. 1859 On Liberty. In: The Six Great Humanistic Essays of John
Stuart Mill (A. W. Levi, Ed.). New York: Washington Square Press;
1963:127–240.
46. Kozlowski LT, Skinner W, Kent C, Pope MA. Prospects for smoking
treatment in individuals seeking treatment for alcohol and other drug
problems. Addict Behav. 1989;14:273–278.
47. Pletcher VC. Nicotine treatment at the drug dependency program of
the Minneapolis VA Medical Center: A program director’s perspective.
J Subst Abuse Treat. 1993;10:139–145.
48. Ker M, Leischow S, Markowitz IB, Merikle E. Involuntary smoking
cessation: A treatment option in chemical dependency programs for
women and children. J Psychoactive Drugs. 1996;28:47–60.
49. Anglin MD. The efficacy of civil commitment in treating narcotics
addiction. Special issue: A social policy analysis of compulsory treatment
for opiate dependence. Journal of Drug Issues. 1988;18:527–
545.
50. Anglin MD, Hser Y. Criminal justice and the drug-abusing offender:
Policy issues of coerced treatment. Behavioral Sciences and the Law.
1991;9:243–267.
46 Coercion in Addiction Treatment: Clinical Aspects January–February 2008
51. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical
Approach to EthicalDecisions in ClinicalMedicine.NewYork:McGraw-
Hill; 1998.
52. Janssens MJ,Van RooijMF, ten Have HA,Kortmann FA,VanWijmen FC.
Pressure and coercion in the care for the addicted: Ethical perspectives. J
Med Ethics. 2004;30:453–458.
53. Beauchamp TL. Philosophical Ethics. New York: McGraw-Hill; 1982.
54. Frankena WK. Ethics. Upper Saddle River, NJ: Prentice Hall; 1973.
55. Singer P. A Companion to Ethics. Malden, Mass.: Blackwell; 1993.
56. Moreno JD. Neuroethics: An agenda for neuroscience and society. Nature
Reviews Neuroscience. 2003;4:149–153.
57. National Bioethics Advisory Commission. Research Involving Persons
with Mental Disorders That May Affect Decision-making Capacity.
Rockville, Md.: National Bioethics Advisory Commission: 1999.
58. Monahan J, Swarz M, Bonnie RJ. Mandated treatment in the community
for people with mental disorders. Health Aff. 2003;22:28–38.
59. Geller JL. Clinical guidelines for the use of involuntary outpatient
treatment. Hospital and Community Psychiatry. 1990;41:749–
755.
60. Rubenstein LS. Treatment of the mentally ill: Legal advocacy enters the
second generation. Am J Psychiatry. 1986;143:1264–1269.
61. NY State Office of Mental Health. Kendra’s Law: Final Report on the
Status of Assisted Outpatient Treatment. New York: Office of Mental
Health; 2005.
62. Swartz MS, Swanson JW, Wagner RH, et al. Can involuntary outpatient
commitment reduce hospital recidivism? Am J Psychiatry.
1999;156:1968–1975.
63. Swartz MS, Swanson RH. Involuntary outpatient commitment, community
treatment orders, and assisted outpatient treatment: What’s in the
data? Can J Psychiatry. 2004;49:585–591.
64. RosenMI, Rosenheck RA, Shaner AL, Eckman TA, Gamache GR, Krebs
CW. Substance abuse and the need for money management assistance
among psychiatric inpatients. Drug Alcohol Depend. 2002;67:331–334.
65. Rosen MI, Rosenheck RA. Substance abuse and the assignment of
representative payees. Psychiatr Serv. 1999;50:95-98.
66. Nace EP, Birkmayer F, Sullivan MA, et al. Socially sanctioned coercion
mechanisms for addiction treatment. Am J Addict. 2007;16:15–23.
67. Cooper CA, Bartlett SR, Shaaw MA, Yang KK. Drug Courts: 1997
Overview of Operational Characteristics and Implementation Issues.
Vol. 1. American University Drug Court Clearinghouse and Technical
Assistance Project. Washington, D.C.: Office of Justice Programs, U.S.
Department of Justice; 1997.
68. Satel S. Drug treatment: The case for coercion. National Drug Court
Institute Review. 2000;3:1–56.
69. American University. Looking at a Decade of Drug Courts. Prepared
by the Drug Court Clearinghouse and Technical Assistance Project.
Washington, DC: U.S. Department of Justice, Office of Justice Programs;
1999.
70. Farabee D, Prendergast M, Anglin D. The effectiveness of coerced
treatment for drug-abusing offenders. Federal Probation. 1998;62:3–
10.
71. DeLeon G, Jainchill N. Circumstances, motivation, readiness, and
suitability as correlates of treatment tenure. J Psychoactive Drugs.
1986;18:203–208.
72. Hazlehurst KM. Alcohol, outstations and autonomy: An Australian
Aboriginal perspective. Journal of Drug Issues. 1986;16:209–220.
73. Bennett LA, Ames GM. The American Experience with Alcohol:
Contrasting Cultural Perspectives. New York: Plunum; 1985.
74. Levy JE, Kunitz SJ. Indian Drinking, Navajo Practices and Anglo-
American Theories. New York: John Wiley and Sons; 1974.
75. Sargent MJ. Changes in Japanese drinking patterns. Quarterly Journal of
Studies on Alcohol. 1967;28:709–722.
76. Caetano R, Suzman RM, Rosen DH, et al. The Shetland Islands:
Longitudinal changes in alcohol consumption in a changing environment.
British Journal of Addiction. 1983;78:21–36.
77. Rodin AE. Infants and gin mania in 18th century London. JAMA.
1981;245:1237–1239.
78. Goldstein RZ, Volkow ND. Drug addiction and its underlying neurobiological
basis: Neuroimaging evidence for the involvement of the frontal
cortex. Am J Psychiatry. 2002;159:1642–1652.
Bottom of Form
Copyright © 2008 Informa Healthcare USA, Inc.
ISSN: 1082-6084 (print); 1532-2491 (online)
DOI: 10.1080/10826080802297484
6. 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 outcomes;
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 Services
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 RobertWalker, Center on Drug and Alcohol Research, University of
Kentucky, 915B South Limestone Street, Lexington, KY 40536. E-mail: robert.walker@uky.edu
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
1785
1786 Walker et al.
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 outcomes
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 million
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, andRowan-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 motivation
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; Logan,
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 justice
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 addition
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 example,
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” courtreferred
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 recovery
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 motivational
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 activity
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 naturalistic
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 associated
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 statutorily
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 instrument
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 interview
approximately 12 months later. The treatment programs included outpatient, intensive
outpatient, case management, and short-term (30-day) residential settings statewide, ranging
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% received
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 Substance
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’ involvement
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 approximately
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 periodwas 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 variables.
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 (Pearson
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 demographic
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, followup,
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 χ2(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 χ2(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% χ2(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 χ2(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 followup,
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
Among clients who reported that they had used alcohol in the 12 months preceding the
intake interview (n = 634), several predictors were significantly associated with alcohol
use at follow-up. First, clients who were referred to treatment based on a DUI charge were
1.28 times more likely to report using alcohol in the 12 months after intake compared to
Table 2
Depression, indicators of motivation for treatment, and arrests for follow-up sample by criminal justice group
No CJ DUI CJ,
referral charge non-DUI Statistical
Response (n = 317) (n = 273) (n = 296) test
Mental health
Depression at intake Yes 62.7%a,b 26.4%a 34.2%b χ2(2) = 90.131∗∗
Depression at follow-up Yes 46.4%a,b 27.1%a 30.7%b χ2(2) = 27.760∗∗
Persistent depression Yes 36.6%a,b 13.6%a 18.0%b χ2(2) = 50.487∗∗
Past treatment
Ever been in substance abuse treatment
before
Yes 68.3%a 64.3% 55.5%b χ2(2) = 10.984∗
Mean no. of times treatment has been taken
(for those who had ever been in
treatment)
2.7 2.7 2.4 F(2, 549) = 0.714
Perception of chances of success
Self-reported chances of success in
treatment
Moderately to very good 77.8%a 83.1% 89.9%a χ2(4) = 17.053∗
Uncertain 18.4%a 15.1% 8.4%a
Very to moderately poor 3.8% 1.8% 1.7%
Self-help group participation
Attended AA/NA meetings in the 30 days
before intake
Yes 39.2%a 12.1%a,b 33.4%b χ2(2) = 56.942∗∗
Attended AA/NA meetings in the 30 days
before follow up
Yes 35.5%a 14.4%a,b 43.7%b χ2(2) = 58.815∗∗
Arrests
Mean no. of arrests in the 12 months before
intake
0.70 1.3 1.5 F(2, 881) = 3.846
a,b: groups differ significantly at p < .01; ∗ p < .01; ∗∗ p < .001.
1792
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 followup-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 followup
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 communitybased
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 statefunded
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 followup;
(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 intakewas 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 viewthe 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 positive
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.
R´ ESUM´E
Identification d’indicateurs de gu´erison 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 pr´esente ´etude fait partie d’un projet d’´evaluation des r´esultats du traitement concernant
tous les programmes subventionn´es par le gouvernement dans un ´etat rural aux Etats
Indicators of Recovery at Intake 1797
Unis. Un des buts de l’´etude est de g´en´erer des connaissances concernant les caract´eristiques
et les r´esultats des clients qui peuvent ˆetre utilis´es pour am´eliorer les services. Cette ´etude
utilise un ´echantillon de 888 clients recrutes entre juillet 2003 et juin 2004 en traitement
d’abus de substances subventionn´e par l’ ´ Etat et qui ont participe a un entretien de suivi 12
mois apr`es le traitement. Trois cat´egories de clients ´etaient examin´ees selon la raison pour
leur entr´ee dans le programme pour examiner les diff´erences de r´esultats: (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 diff´erence n’a ´et´e constat´ee entre
les groupes. Apres avoir contrˆoler pour l’ˆage, le sexe, la race et d’autres facteurs, l’intention
de gu´erison `a l’entr´ee et la participation aux 12 ´etapes au suivi pr´edisaient un r´esultat
positif du traitement, tandis que la d´epression persistante pr´edisait des r´esultats n´egatifs.
Cette ´etude de clients dans le traitement pour abus de substances subventionn´e par l’ ´ Etat
fournit des preuves suppl´ementaires que la raison pour entrer en traitement ne pr´edispose
pas le client pour un r´esultat positif ou n´egatif. Deuxi`emement, les facteurs au niveau
du client qui sont li´es aux pratiques de r´ecup´eration et l’intention de r´eduire ou d’arrˆeter
l’utilisation de substances pourraient n´ecessiter une plus grande attention dans le processus
clinique.
RESUMEN
Definici´on de indicadores de curaci´on en el cliente entre las personas en tratamiento
de toxicoman´ıa para conducta bajo influencia, por razones de justicia criminal,
y razones no criminales
El presente estudio forma parte de un proyecto de evaluaci´on 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 caracter´ısticas 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 despu´es
del tratamiento. Se examinaban tres categor´ıas de clientes seg´un la raz´on 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 n´umero de personas en el grupo DUI afirmaban consumir alcohol en el
seguimiento 12 meses m´as tarde, ninguna otra diferencia se constat´o entre los grupos.
Despu´es de controlar para la edad, el sexo, la raza y de otros factores, la intenci´on de
curaci´on a la entrada y la participaci´on en las 12 etapas al seguimiento predec´ıan un resultado
positivo del tratamiento, mientras que la depresi´on persistente predec´ıa resultados negativos.
Este estudio de clientes en el tratamiento para abuso de sustancias subvencionado por el
Estado proporciona pruebas suplementarias que la raz´on para entrar en tratamiento no
predispone al cliente para un resultado positivo o negativo. En segundo lugar, los factores
en el cliente que est´an vinculados a las pr´acticas de recuperaci´on y la intenci´on de reducir
o decidir la utilizaci´on de sustancias podr´ıan requerir una mayor atenci´on en el proceso
cl´ınico.
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 socialwork. His over fifty publications
span a wide range of health and behavioral health
topics including substance abuse, professional ethics in
clinical practice, partner violence perpetration and victimization,
and traumatic brain injury. He is the principal
investigator for a state-mandated substance abuse treatment
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 federally
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 currently
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 HIVrisk
behavior, violence, and crack use. Her primary interests
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 appointments
in psychiatry, psychology, and socialwork. Dr.
Logan has been funded by the NIDA, the NIAAA, and the
National Institute of Justice (NIJ) to examine victimization,
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.
References
Babor, T. F., Stephens, R. S., Marlatt, A. (1987). Verbal report methods in clinical research on
alcoholism: Response bias and its minimization. Journal of Studies on Alcoholism 48:410–424.
Cacciola, J. S., Dugosh, K., Foltz, C., Leahy, P., Stevens, R. (2005). Treatment outcomes: First time
versus treatment-experienced clients. Journal of Substance Abuse Treatment 28(Suppl.):S13–
S22.
Cavaiola, A. A., Strohmetz, D. B., Abreo, S. D. (2007). Characteristics of DUI recidivists: A 12-year
follow-up study of first time DUI offenders. Addictive Behaviors 32:855–861.
Dennison, S. J. (2005). Substance use disorders in individuals with co-occurring psychiatric disorders.
In J. H. Lowinson, P. Ruiz, R. B. Millman, & J. G. Langrod (Eds), Substance abuse:
A comprehensive textbook (4th ed.) (pp. 904–913). Philadelphia, PA: Lippincott Williams &
Wilkins.
DeYoung, D. J. (1997). An evaluation of the effectiveness of alcohol treatment, driver license actions
and jail terms in reducing drunk driving recidivism in California. Addiction 92:989–997.
Dodge, R., Sindelar, J. Sinha, R. (2005). The role of depression symptoms in predicting drug abstinence
in outpatient substance abuse treatment. Journal of Substance Abuse Treatment 28:189–196.
Farabee, D., Leukefeld, C. G. (2001). Recovery and the criminal justice system. In, F. M. Tims, C.
G. Leukefeld, & J. J. Platt, (Eds), Relapse and recovery in addictions (pp. 40–59). New Haven,
CN: Yale University Press.
Fletcher, B.W., Tims, F. M., Brown, B. S. (1997). Drug Abuse Treatment Outcome Study (DATOS):
Treatment evaluation research in the United States. Psychology of Addictive Behaviors 11:216–
229.
Floyd, A. S., Monahan, S. C., Finney, J. W., Morley, J. A. (1996). Alcoholism treatment outcome
studies, 1980–1992: The nature of the research. Addictive Behaviors 21:413–428.
Flynn, P. M., Craddock, S. G., Hubbard, R. L., Anderson, J., Etheridge, R. M. (1997). Methodological
overview and research design for the Drug Abuse Treatment Outcome Study (DATOS).
Psychology of Addictive Behaviors 11:230–243.
Gregoire, T. K., Burke, A. C. (2004). The relationship of legal coercion to readiness to change among
adults with alcohol and other drug problems. Journal of Substance Abuse Treatment 26:337–343.
Hiller,M. L., Knight, K., Rao, S. R., Simpson, D. D. (2002). Assessing and evaluating mandated correctional
substance-abuse treatment. In C. G. Leukefeld, F. Tims,&D. Farabee (Eds.), Treatment
of drug offenders (pp. 41–56). New YorkSpringer.
Holcomb, W. L., Chaiworapongsa, T., Luke, D. A., Burgdorf, K. D. (2001). An odd measure of risk:
Use and misuse of the odds ratio. Obstetrics and Gynecology 98:685–688.
1800 Walker et al.
Holroyd, K. A., O’Donnell, F. J., Stensland, M., Lipchik, G. L., Cordingley G. E., Carlson, B. W.
(2001). Management of chronic tension-type headache with tricyclic antidepressant medication,
stress management therapy, and their random combination. Journal of the American Medical
Association 285:2208–2214.
Hser, Y. I., Evans, E., Huang, D., Anglin, D. M. (2004). Relationship between drug treatment services,
retention, and outcomes. Psychiatric Services 55:767–774.
Ilgen, M. A., McKellar, J., Moos, R., Finney, J. W. (2006). Therapeutic alliance and the relationship
between motivation and treatment outcomes in patients with alcohol use disorder. Journal of
Substance Abuse Treatment 31:157–162.
Joe, G. W., Simpson, D. D., Dansereau, D. F., Rowan-Szal, G. A. (2001). Relationships between
counseling rapport and drug abuse treatment outcomes. Psychiatric Services 52:1223–1229.
Kelly J. F., Finney J. W., Moos, R. (2005). Substance use disorder patients who are mandated to
treatment: Characteristics, treatment process, and 1- and 5-year outcomes. Journal of Substance
Abuse Treatment 28:213–223.
Kosten, T. R., Rounsaville B. J., Kleber, H. D. (1983). Concurrent validity of the Addiction Severity
Index. Journal of Nervous and Mental Disorders 171:97606–97610.
Leukefeld, C. G., Tims, F. M., Platt, J. J. (2001). Future directions in substance abuse relapse and
recovery. In F.M. Tims, C. G. Leukefeld, & J. J. Platt (Eds.), Relapse and recovery in addictions
(pp. 401–410). New Haven, CN: Yale University Press.
Logan, T., Hoyt, W., McCollister, K., French, M., Leukefeld, C., Minton, L. (2004). Economic evaluation
of drug court: Methodology, results, and policy implications. Evaluation and Program
Planning 27(4):381–396.
McCaul, M. E., Svikis, D. S., Moore, R. D. (2001). Predictors of outpatient treatment retention: Patient
versus substance use characteristics. Drug and Alcohol Dependence 62:9–17.
McLellan, A. T. (1983). Patient characteristics associated with outcomes. In J. R. Cooper, F. Altman,
B. S. Brown, & D. Czechowicz (Eds.), Research on the treatment of narcotic addiction: State of
the art (pp. 500–529). Rockville, MD: U.S. Department of Health and Human Services.
McLellan, A. T., Alterman, A. I., Metzger, D. S., Grisson, G. R., Woody, G. E., Luborsky, L., et al.
(1994). Similarity of outcome predictors across opiate, cocaine, and alcohol treatments: Role of
treatment services. Journal of Consulting and Clinical Psychology 62:1141–1158.
McLellan, A. T., Chalk, M., Bartlett, J. (2007). Outcomes, performance, and quality—What’s the
difference? Journal of Substance Abuse Treatment 32:331–340.
McLellan, A. T., Kushner, H., Metzger, D., Peters, R., Smith, I., Grissom, G., et al. (1992). The fifth
edition of the Addiction Severity Index. Journal of Substance Abuse Treatment 9:199–213.
Miller, N. S., Flaherty, J. A. (2000). Effectiveness of coerced addiction treatment (alternative consequences):
A review of the clinical research. Journal of Substance Abuse Treatment 18:9–16.
Miller,W. R., Rollnick, S. (2002). What is motivational interviewing? InW. R. Miller & S. Rollnock
(Eds.), Motivational interviewing: Preparing people for change (2nd ed.) (pp. 33–42).NewYork:
The Guilford Press.
Mokdad, A. H., Bowman, B. A., Ford, E. S., Vinicor, F., Marks, J. S., Koplan, J. P. (2001). The
continuing epidemics of obesity and diabetes in the United States. Journal of the American
Medical Association 286:1195–1200.
Moos, R. H., Moos, B. S. (2003). Long-term influence of duration and intensity of treatment on
previously untreated individuals with alcohol use disorders. Addiction 98:325–337.
Moos, R. H., Moos, B. S. (2006). Participation in treatment and Alcoholics Anonymous: A 16-year
follow-up of initially untreated individuals. Journal of Clinical Psychology 62:735–750.
Moos, R., Schaefer, J., Andrassy, J., Moos, B. (2001). Outpatient mental health care, self-help groups,
and patients’ 1-year treatment outcomes. Journal of Clinical Psychology 57:273–287.
Morley, J. A., Finney, J. W., Monahan, S. C., Floyd, A. S. (1996). Alcoholism treatment outcome
studies, 1980—992: Methodological characteristics and quality. Addictive Behaviors 21:429–
443.
Moyer, A., Finney, J. W., Swearingen, C. E. (2002). Methodological characteristics and quality of
alcohol treatment outcome studies, 1970–98: An expanded evaluation. Addiction 97:253–263.
Indicators of Recovery at Intake 1801
Mykletun, A., Bjerkeset, O., Dewey, M., Prince, M., Overland, S., Stewart, R. (2007). Anxiety,
depression, and cause-specific mortality: The HUNT Study. Psychosomatic Medicine 69:323–
331.
Ninonuevo, F., Hoffman, N. G. (1993). DUI arrestees versus other outpatients in chemical dependency
treatment: Initial status and 1-year outcome. International Journal of Offender Therapy and
Comparative Criminology 37:177–186.
Osborne, J.W. (2006). Bringing balance and technical accuracy to reporting odds ratios and the results
of logistic regression analyses. Practical Assessment, Research, & Evaluation, 11(7). Retrieved
April 25, 2007, from http://pareonline.net/getvn.asp?v=11&n=7.
Pereira, M. A., Jacobs, D. R., Van Horn, L., Slattery, M. L., Kartashov, A. I., Ludwig, D. S. (2002).
Dairy consumption, obesity, and the insulin resistance syndrome in young adults. Journal of the
American Medical Association 287:2081–2089.
Ritsher, J. B., Moos, R. H., Finney, J.W. (2002). Relationship of treatment orientation and continuing
care to remission among substance abuse patients. Psychiatric Services 53:595–601.
Rounsaville, B. J., Dolinsky, Z. S., Babor, T. F., Meyer, R. (1987). Psychopathology as a predictor of
treatment outcome in alcoholics. Archives of General Psychiatry 44:505–513.
Rutherford, M. J., Cacciola, J. S., Alterman, A. I., McKay, J. R., Cook, T. G. (2000). Contrasts between
admitters and deniers of drug use. Journal of Substance Abuse Treatment 18:343–348.
Substance Abuse and Mental Health Services Administration. (2007). SAMHS stat data. Retrieved
on June 19, 2007, from http://www.nationaloutcomemeasures.samhsa.gov/.
Substance Abuse and Mental Health Services Administration. (2006). Results from the 2005 national
survey on drug use and health: National findings. Rockville, MD: Department of Health and
Human Services.
Sinha, R., Schottenfeld, R. (2001). The role of comorbidity in relapse and recovery. In F. M. Tims,
C. G. Leukfeld, & J. J. Platt (Eds.), Relapse and recovery in addictions (pp. 172–207). New
Haven, CT: Yale University Press.
Slaymaker, V. J., Owen, P. L. (2006). Employed men and women substance abusers: Job troubles and
treatment outcomes. Journal of Substance Abuse Treatment 31:347–354.
Swearingen, C. E., Moyer, A., Finney, J. W. (2003). Alcoholism treatment outcome studies, 1970–
1998: An expanded look at the nature of the research. Addictive Behaviors 28:415–436.
Timko, C., Moos, R. H., Finney, J. W., Connell, E. G. (2002). Gender differences in help-utilization
and the 8-year course of alcohol abuse Addiction 97:877–889.
Tims, F. M., Leukefeld, C. G., Platt, J. J. (2001). Relapse and recovery. In F.M. Tims, C. G. Leukefeld,
& J. J. Platt (Eds.), Relapse and recovery in addictions (pp. 3–17). New Haven, CN: Yale
University Press.
Vaillant, G. E. (1988). What can long-term follow-up teach us about relapse and prevention of relapse
in addiction? British Journal of Addiction 83:1147–1157.
Zhang, J., Yu, K. F. (1998). What’s the relative risk? A method of correcting the odds ratio in cohort
studies of common outcomes. Journal of the American Medical Association 280:1690–1691.