Ethics of Mandated Treatment

See all required articles to use attached.The use of mandated, or legally coerced, treatment is widespread. Yet research demonstrating the efficacy of this type of treatment is limited, and mandating mental health treatment is one of the most contested issues in the field of psychology. To justify the continued use of mandated treatment, policymakers, practitioners, and researchers are obligated to demonstrate the effectiveness and limitations of such treatment programs.You have been called in to consult on cases that may require mandated treatment. After reviewing scenario 1&2 attached Begin your research with the required articles attached. Using the specific situations presented in each of the scenarios 1 and 2 conduct further research to help inform your recommendations for each individual. A minimum of one other resource per scenario, beyond those already required that are attached, must be included.construct clear and concise arguments using evidence-based psychological concepts and theories to present your recommendations as to whether or not treatment should be mandated for the individuals in each of the scenarios. As you write your recommendations, be certain to provide insights into the following questions (1)What are the ethical principles and implications raised by legally mandating clients into treatment? (2)What evidence exists regarding the effectiveness of treatment with and without coercion for this type of situation? (3)What would be the challenges in evaluating the effectiveness of mandated treatment?(4)How might mandated treatment impact your clinical decision making as the mental health professional assigned to these cases?(5)What client factors might limit or augment the potential benefits of treatment if it were mandated?Integrating concepts from your research and the required articles, offer insights across different content domains as to why you have reached these conclusions. Explain how you used the APA Ethical Code of Conduct to guide your decisions. Evaluate the generalizability of your specific research findings to the situations presented and provide a rationale as to why this research supports your recommendations?

American Psychological Association. (2010). Ethical principles of psychologists and code of conduct: Including 2010 amendments. Retrieved from http://www.apa.org/ethics/code/index.aspx

Caplan A. (2008). Denying autonomy in order to create it: the paradox of forcing treatment upon addicts. Addiction, 103(12), 1919–1921. https://doi.org/10.1111/j.1360-0443.2008.02369.x

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. https://doi.org/10.1037/lhb0000039

Snyder, C. M. J., & Anderson, S. A. (2009). An examination of mandated versus voluntary referral as a determinant of clinical outcome. The Journal of Marital and Family Therapy, 35(3), 278.

Sullivan, M. A., Birkmayer, F., Boyarsky, B. K., Frances, R. J., Fromson, J. A., Galanter, M., Levin, F. R., Lewis, C., Nace, E. P., Suchinsky, R. T., Tamerin, J. S., Tolliver, B., & Westermeyer, J. (2008). Uses of Coercion in Addiction Treatment: Clinical Aspects. American Journal on Addictions, 17(1), 36–47.

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.

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

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

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

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

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

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

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

Sarah M. Manchak
University of Cincinnati School of Criminal Justice

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

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

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

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

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

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

Therapist Control and Assertive or Involuntary
Treatment

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

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

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

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

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

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Law and Human Behavior © 2013 American Psychological Association
2014, Vol. 38, No. 1,

–57 0147-7307/14/$12.00 DOI: 10.1037/lhb0000039

mailto:manchash@uc.edu

http://dx.doi.org/10.1037/lhb0000039

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

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

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

Does Therapist Control Necessarily Reduce
Affiliation?

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

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

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

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

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

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

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48 MANCHAK, SKEEM, AND ROOK

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

49CHARACTERIZING MANDATED TREATMENT RELATIONSHIPS

Present Study

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

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

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

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

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

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

Method

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

Procedure

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

Participants

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

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

50 MANCHAK, SKEEM, AND ROOK

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

Measure

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

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

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

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

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

Distilling Voluntary Comparison Data

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

Table 3
Demographic Characteristics of Enrolled Samples vs. Court Populations

Demographics
Total

enrolled

Court 1 Court 2 Court 3 Court 4

Enrolled
(n � 61)

Court
(n � 168)

Enrolled
(n � 28)

Court
(n � 70)

Enrolled
(n � 9)

Court
(n � 33)

Enrolled
(n � 27)

Court
(n � 110)

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

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

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

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

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

51CHARACTERIZING MANDATED TREATMENT RELATIONSHIPS

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

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

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

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

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

Results

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

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

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

Is Greater Control Associated With Less Affiliation?

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

52 MANCHAK, SKEEM, AND ROOK

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

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

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

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

Discussion

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

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

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

Table 4
Therapist Transitive Cluster Scores for Voluntary and Mandated
Samples

Cluster

Distilled
voluntary

data
(N � 89)a

Mandated
sample

(n � 125)a
Cohen’s

d [95% CI]

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

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

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

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

Table 5
Client Intransitive Cluster Scores for Voluntary and Mandated
Samples

Cluster
Distilled
voluntary

data
(N � 85)a

Mandated
sample
(n � 125)a
Cohen’s
d [95% CI]

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

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

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

53CHARACTERIZING MANDATED TREATMENT RELATIONSHIPS

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

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

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

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

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

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

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

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

Limitations

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

54 MANCHAK, SKEEM, AND ROOK

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

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

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

Implications

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

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

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

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Received January 4, 2013
Revision received March 26, 2013

Accepted March 28, 2013 �

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57CHARACTERIZING MANDATED TREATMENT RELATIONSHIPS

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

Therapist Control and Assertive or Involuntary Treatment
Does Therapist Control Necessarily Reduce Affiliation?
Present Study
Method
Procedure
Participants
Measure
Distilling Voluntary Comparison Data
Results
Are Mandated Treatment Relationships Characterized by Greater Control Than Voluntary Treatment R …
Is Greater Control Associated With Less Affiliation?
Discussion
Finding 1: Therapist Control and Client Submission Are Much Stronger in Mandated Than Voluntary …
Finding 2: Despite Pronounced Control Dynamics, Mandated Relationships Are Predominantly Affilia …
Limitations
Implications
References

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

THE PRIMACY OF AUTONOMY IN
PROVIDER–PATIENT RELATIONSHIPS

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

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

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

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

INFRINGING AUTONOMY TO
CREATE AUTONOMY

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

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

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

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

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

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

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

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

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

PRECEDENTS FOR MANDATING
TREATMENT IN THE NAME
OF AUTONOMY

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

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

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

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

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

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

Acknowledgement

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

Declaration of interest

None.

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

A RT H U R CA P L A N

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

Bioethics, University of Pennsylvania, PA, USA.
E-mail: 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. The White House. The President’s New Freedom Initiative; The
2007 Progress Report. Available at: http://www.whitehouse.
gov/infocus/newfreedom/newfreedom-report-2007.html
(accessed 14 September 2008).

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

1920 Editorial

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

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

8. Comer S., Sullivan M. A., Yu E., Rothenberg J. L., Kleber H.
D., Kampman K. et al. Injectable, sustained release naltrex-
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chiatry 2006; 63: 210–18.

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R. A. Naltrexone in the treatment of alcohol dependence.
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World Institute on Disability; 1990, 135–54.

Editorial 1921

Substance Use & Misuse, 43:

1785

–1801
Copyright © 2008 Informa Healthcare USA, Inc

ISSN: 1082-6084 (print); 1532-2491 (online)
DOI: 10.1080/1082608080229748

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

Justice Treatment Referrals

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

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

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

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

Introduction

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

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

Address correspondence to Robert Walker, Center on Drug and Alcohol Research, University of
Kentucky, 915B South Limestone Street, Lexington, KY 40536. E-mail: 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 out-
comes is intensified by the fact that only a small percent of persons needing treatment
ever receive it (SAMHSA, 2006). For example, in 2005 there were an estimated 22.2 mil-
lion people over the age of 12 in the United States with substance abuse or dependence
problem, but only 3.9 million had received any substance abuse services in the past 12
months, and 2.2 million had received services from a self-help group, and 1 million
(4.5%) had received services at a mental health center in the past 12 months (SAMHSA,
2006).

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

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

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

Indicators of Recovery at Intake 1787

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

Recovery activity or intent toward recovery, while subject to influence through motiva-
tional approaches (Miller and Rollnick, 2002), is distinct from actions taken by treatment
providers, since these two factors are within clients’ sphere of experience and control. The
two are independent of treatment per se (McLellan, Chalk, and Bartlett, 2007). Recovery is

term with many different denotations that has overlap with treatment outcomes but has clear
connotations associated with using mutual help (McLellan, et al., 2007; Tims, Leukefeld,
and Platt, 2001). Recovery activity is also a client-level factor rather than a treatment ac-
tivity or program-related factor. For the purposes of this study recovery is understood as
abstinence from alcohol or drugs.

Study Objectives

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

1788 Walker et al.

Method

Procedures

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

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

Participants

received $20 for completing the follow-up interview. All study procedures were approved
by the University of Kentucky institutional review board.

Participants

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

Measures

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

Indicators of Recovery at Intake 1789

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

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

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

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

Data Analysis

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

1790 Walker et al.

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

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

Results

Sample Descriptives by Referral Condition

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

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

Indicators of Recovery at Intake 1791

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

referral group

No CJ DUI CJ,
referral charge non-DUI Statistical

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

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

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

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

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

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

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

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

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

∗ p < .01; ∗∗ p < .001.

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

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

Multivariate Analysis

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

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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 follow up-period. No other
variables were significantly associated with reporting illicit drug use during the follow-up
period (Nagelkerke R2 = 0.166).

Discussion

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

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

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

Indicators of Recovery at Intake 1795

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

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

Study’s Limitations

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

1796 Walker et al.

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

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

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

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

RÉSUMÉ

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

criminelle, et des raisons non-criminelles

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

Indicators of Recovery at Intake 1797

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

RESUMEN

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

y razones no criminales

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

1798 Walker et al.

THE AUTHORS

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

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

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

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

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

Indicators of Recovery at Intake 1799

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

Glossary

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

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

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The American Journal on Addictions, 17:

–47, 2008
ISSN: 1055-0496 print / 1521-0391 online
DOI: 10.1080/10550490701756369

Uses of Coercion in Addiction Treatment: Clinical Aspects

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

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

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

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

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

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

try, NYSPI, Substance Use Research Center, Unit 120, 1051 Riverside
Dr, New York, NY 10032. E-mail: 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 treat-
ment because the substance use disorder is impairing his
or her perception of the gravity of the disorder and its
consequences?

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

� indications for compelling an individual to seek
treatment,

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

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

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

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

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

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

HISTORY OF COERCED TREATMENT

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

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

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

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

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

Sullivan et al. January–February 2008 37

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

COERCION AS A MEANS OF INITIATING
TREATMENT

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

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

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

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

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

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

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

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

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

COERCION IN THE CONTEXT OF THERAPY

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

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

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

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

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

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

Sullivan et al. January–February 2008 39

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

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

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

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

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

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

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

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

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

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

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

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

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

PHARMACOLOGICAL METHODS OF COERCION

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

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

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

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

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

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

has raised both philosophical and clinical objections.39,40

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

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

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

Sullivan et al. January–February 2008 41

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sullivan et al. January–February 2008 43

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CONCLUSION

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

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

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

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

as an adaptive mechanism?

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

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

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