A Theory-based Analysis of Coercion in Addiction Treatment

The use of coercion to induce entry to addiction treatment is controversial and a large body of research has accumulated considering ethical issues, benefits, and repercussions. However, development of evidence-based policy and practices is hampered by limitations of existing literature. Theoretical and empirical work on self-determination suggests that perceptions of coercion have negative implications for motivation, behaviour change, and psychological well-being; however, these insights have not generally informed research on coerced treatment. The present work seeks to further understandings of the meaning and effectiveness of coerced addiction treatment through a theory-based, prospective study of coercion and treatment processes. The sample includes 276 adults admitted to an outpatient counseling program for alcohol- and drug-related problems. At admission, participants completed questionnaires on motivation, perceived coercion, and pressures to enter treatment. Two months later, a second questionnaire assessed engagement in treatment and substance problem severity (follow-up rate = 74.3%). Retention was determined via self-report and agency records. Analysis was guided by a conceptual model based on Self-Determination Theory. Perceived coercion at admission was associated with greater pressures from legal and informal sources, and lower substance problem severity. Fewer than half (45.7%) of participants were still attending treatment at 2-month follow-up. Clients who reported greater coercion were more likely to leave treatment within the first 2 months, and to qualify that decision by statements indicating a lack of perceived need for continued treatment. Greater autonomous motivation was associated with higher client confidence in treatment, and lower perceived coercion and greater informal pressure were associated with greater resolution of substance problems in the weeks following admission. This work contributes empirical evidence to ongoing debates over the legitimacy of coerced addiction treatment by reframing relevant concepts in terms of client perspectives and evaluating the impact on treatment processes. Results raise questions about previous conclusions of the effectiveness of coerced treatment and suggest many future avenues for research. In particular, research is needed to evaluate the longer-term implications of coercion and the changing nature of perceptions and motivation during treatment.Ph