- Email: [email protected]
The relationship of legal coercion to readiness to change among adults with alcohol and other drug problems
Journal of Substance Abuse Treatment 26 (2004) 35 – 41
Regular article
The relationship of legal coercion to readiness to change among adults with alcohol and other drug problems Thomas K. Gregoire, Ph.D. *, Anna Celeste Burke, Ph.D. Ohio State University, College of Social Work, 1947 College Rd., Columbus, OH, USA Received 16 May 2003; received in revised form 7 August 2003; accepted 14 September 2003
Abstract Prior research on legally coerced treatment for substance abuse tends to find no difference between coerced and non-coerced clients with respect to treatment retention and treatment outcomes. There is less known about the relationship between coercion and a client’s motivation to change. We considered the relationship of legal coercion and readiness to change among 295 consecutive admissions to five publicly funded outpatient treatment programs. A logistic regression analysis indicated that legal coercion was associated with greater readiness to change after controlling for addiction severity, prior treatment history, and gender. Persons entering treatment due to legal coercion were over three times more likely to have engaged in recovery-oriented behavior in the month preceding admission. Entering treatment more prepared to benefit from the experience could contribute to outcomes that are more positive. D 2004 Elsevier Inc. All rights reserved. Keywords: Coercion; Motivation; Readiness to change
1. Introduction Practitioners in the addictions field have long expressed concern about the impact of client motivation on outcomes in substance abuse treatment. Many people entering treatment are not yet ready to make the changes required for recovery and are unprepared or unwilling to modify their behavior (Prochaska, DiClemente, & Norcross, 1992). A lack of motivation is a common phenomenon in treatment, and client motivation is a critical determining factor in treatment outcome (DiClemente, Bellino, & Neavins, 1999). Clients typically approach the addiction treatment experience with some degree of ambivalence. Uncertainty about change often represents a central theme in the treatment process (Miller & Rollnick, 1991), and client denial is a common by-product of this ambivalence (Shaffer & Simoneau, 2001). Clients’ social networks can play a significant role in precipitating a treatment experience (Marlowe et al. 1996). This social pressure can also influence motivation to modify substance use behavior (Miller, 1985). Often an individual’s entry into treatment results from pressure placed upon clients
* Corresponding author. Tel. +1-614-292-9426; fax +1-614-292-6949. E-mail address: [email protected] (T.K. Gregoire). 0740-5472/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/S0740-5472(03)00155-7
by courts, employers, and/or family members. Considering a sample of public and private HMO treatment admissions, Polcin and Weisner (1999) found that 40% reported that some type of coercion contributed to their treatment admission. Gerdner and Holmberg’s (2000) sample of alcoholics had a similar percentage of legally coerced admissions (42%) and 50% of the admissions in Joe, Simpson, and Broome’s (1999) study reported moderate or high legal pressure to enter treatment. Although there are many sources of social pressure to obtain rehabilitation, legal coercive pressure over the course of the treatment experience may have the most potential for influencing client behavior toward outcomes since it is perhaps the most consistent type of coercion, less subject to a change than coercion by a family member or employer, and less subject to influence by client manipulation. It should be noted that in the following synopses of prior studies, the term voluntary has been placed in quotations simply to designate that those patients were not legally coerced, but that they may have been under the influence of some other, unmeasured form of social coercion. Studies of legally coerced treatment for substance abuse are mixed but many support the notion that coerced clients can benefit from addiction treatment (Farabee, Prendergast, & Anglin, 1998). Most prior research considers either treatment retention or treatment outcomes. Some evidence
36
T.K. Gregoire, A.C. Burke / Journal of Substance Abuse Treatment 26 (2004) 35–41
suggests coerced individuals are more likely to complete treatment than are non-coerced individuals (Hiller, Knight, Broome, & Simpson, 1998; Loneck, Garrett, & Banks, 1996). In four other studies there were no significant differences noted in treatment retention between legally coerced and ‘‘voluntary’’ clients (Allan, 1987; Brizer, Maslansky, & Galanter, 1990; Rosenberg & Liftik, 1976; Simpson & Friend, 1988). In their study of outpatient drug free treatment programs, Joe et al. (1999) found that legal coercion had a positive impact on session attendance, but a slightly negative impact upon a client’s therapeutic involvement. Among a sample of inpatient clients, however, legal pressure had no impact on either therapeutic involvement or treatment retention (Joe et al., 1999). Studies examining the impact of coercion on treatment outcomes reach mixed conclusions. Mark (1988) reported that legally coerced persons had better outcomes at 6-month followup than persons who ‘‘voluntarily’’ entered treatment. Hiller, Knight, Devereux, and Hathcoat (1996) found lower re-arrest rates among substance-abusing probationers mandated to attend residential treatment. Similarly, Anglin, Brecht, and Maddahian (1989) reported positive effects of treatment on legally coerced clients. Brecht, Anglin, and Wang (1993) found treatment improved drug use outcomes and obtained similar results for clients regardless of coercion level. Other studies reported no difference between legally coerced and ‘‘voluntary’’ clients for 6-month (Flores, 1982) or 18-month outcomes (Watson, Brown, Tilleskjopr, Jacobs, & Pucel, 1988). As noted above, prior studies have tended to consider the impact of legal coercion upon treatment retention or treatment outcome. While this knowledge is useful in assessing the impact of coercion, knowledge of treatment retention may simply represent a client’s reluctance to experience the alternative consequences. To the extent that legal authorities monitor continued abstinence from alcohol and other drugs, those outcomes may also be a consequence of the coercive experience, not representative of a client’s initiative, nor their behavior of choice upon removal of the coercion. While it seems relatively clear that coerced persons remain in treatment, and abstain at rates comparable to ‘‘volunteers,’’ we know less about the role that coercion plays in influencing a client’s motivation to change. The review by Farabee and colleagues (1998) of 11 studies examining the impact of coercion on treatment retention and outcomes noted that none of these studies assessed motivation to change. Knowledge about the relationship between coercion and a client’s motivation to change may be useful in understanding the impact of coercion on client recovery. Perhaps the most prevalent model of motivation to change in substance abuse is the Transtheoretical Model (Prochaska et al., 1992). This model characterizes the process by which persons engage in change with or without professional help. The model suggests that recovery is typically not a linear process but rather involves cycling
back and forth through a number of stages. What distinguishes the stages are a person’s perception of his or her problem and the person’s current level of behavior change. Prior research suggests that a client’s stage of change predicts subsequent alcohol use (Heather, Rollnick, & Bell, 1993), cocaine use (Prochaska et al., 1994) and treatment dropout (Simpson & Joe, 1993). The Transtheoretical model posits five stages of change. Individuals in the precomtemplation stage, the initial stage of change, do not intend to modify their behavior, and in fact may not acknowledge they have a problem. When persons in this stage find their way into substance abuse treatment, coercion usually plays a role. As long as they remain in this stage, they are unlikely to benefit from the experience. Persons identified as contemplators are probably aware that a problem exists and may be thinking about addressing the problem. However, contemplators have yet to make a commitment to action. Many persons become stuck in this stage for long periods. These individuals are described as ‘‘. . .not quite ready yet’’ (Prochaska et al., 1994, p. 1103). The preparation stage reflects an intention to take some form of change action during the next 30 days. It also refers to those persons who have made an unsuccessful attempt to change within the past 12 months. In the action stage persons have initiated new behavior. Placement in this stage requires that an individual must have modified behavior for at least one day. In the case of substance use, this means a person has modified their use of alcohol or other drugs. The final stage is maintenance. During this stage, beginning at 6 months after behavior change, persons take steps to avoid relapse and consolidate gains. This study sought to examine the relationship of legal coercion to a client’s stage of change. More specifically, this study aims: (1) To examine variation in readiness to change among adults entering publicly funded alcohol and other drug treatment programs. (2) To determine what relationship, if any, exists between mode of entry into treatment and readiness to change.
2. Materials and methods 2.1. Subjects Study subjects consisted of consecutive admissions to outpatient treatment in five public substance abuse programs located throughout Ohio. During their initial assessment session agency staff asked subjects to participate in a followup study. The study consisted of data collection at admission, discharge, and between 9 and 12 months following treatment. Those clients who agreed to participate provided their informed consent. Participants received a tendollar gift certificate to a local discount store for their participation at each data collection interval. A total of 295 persons, 92% of those asked, agreed to participate in the study.
T.K. Gregoire, A.C. Burke / Journal of Substance Abuse Treatment 26 (2004) 35–41
The mean age for participants was 32.5 years (SD = 9.35) and 77.6% were men. With respect to race and ethnicity, 71.9% were White, 19.4% African-American, 7.7% were Hispanic. The median income from all sources, including illegally obtained income, during the 30 days prior to admission was $570.00. The median income from employment in the past month was $300.00. Just fewer than 78% reported they had regular full or part time employment. This treatment episode represented the initial substance abuse treatment experience for 32.6% of participants. Among only those persons with a prior treatment history, the mean number of treatment episodes was 2.9 (SD = 3.04). With respect to legal coercion, 75.5% reported that the criminal justice system precipitated this treatment admission. Alcohol was the sole drug of choice for 41% of the participants. An additional 18% regularly used alcohol along with some other substance. Marijuana use was the primary problem for 16% of our participants while 11% endorsed cocaine as their drug of choice. Slightly less than 4% indicated either opiate use or the regular use of multiple drugs. 2.2. Measures and procedures We measured readiness to change by adapting the 12item Readiness to Change Questionnaire (RCQ; Rollnick, Heather, Gold, & Hall, 1992). This self-administered instrument uses responses to items on a five point Likert scale regarding clients’ beliefs about their current alcohol use to place individuals in a pre-contemplation, contemplation or action stage of change. We followed the author’s scoring instructions. Clients received scores in each of the three stages. We assigned clients to a particular stage based on their highest score. The RCQ was modified to represent readiness to change either alcohol or substance use. Although other tools exist to measure readiness to change among substance abusers, the RCQ was modified and used in this study because it is brief to administer and score, available in the public domain at no cost to service providers, and requires no training to use. Rollnick et al. (1992) reported test-retest reliabilities for the three scales as follows: pre-contemplation .82, contemplation .86, and action .78. The authors also provided support for the concurrent validation of the questionnaire by demonstrating a significant relationship between the stage of change and endorsement of the need to modify behavior measured in a health history-screening instrument. In support of the predictive validity of the questionnaire, Heather et al. (1993) found that stage of change was an accurate predictor of alcohol consumption among heavy drinkers at a 6-month followup. We employed the fifth edition of the Addiction Severity Index (ASI; McLellan et al., 1992) to collect most of the demographic data and to assess pre-treatment alcohol and other drug severity. This instrument records data on recent
37
and lifetime substance use, and other problem areas. The ASI yields composite severity scores for seven problem domains: Medical, legal, employment, alcohol, drug, family and social status, and psychiatric status. A number of studies support the reliability and validity of this instrument for use with a wide range of populations (Alterman, Brown, Zabellero, & McKay, 1994; Argeriou, McCarty, Mulvey, & Daley, 1994; McLellan et al., 1985). Employing pre-treatment ASI scores makes it possible to account for the influence of pre-treatment severity upon treatment readiness. A number of prior studies suggest that a relationship exists between motivation to change and problem severity (Carpenter, Meile, & Hasin, 2002; Dent, Shepherd, Alexander, & London, 1995; Finney & Moos, 1995; Ryan, Plant, & O’Malley, 1995).
3. Results Because there were only eight persons in the precontemplation stage, we combined members of this group with persons in the contemplation stage. Given that the participants consisted entirely of persons enrolled in substance abuse treatment it is not entirely surprising that such a small percentage would be in the pre-contemplation stage. In their validation study of the RCQ, Heather et al. (1993) found no significant differences in current alcohol consumption between persons in the pre-contemplation and contemplation group. Similarly, we found no differences between the pre-contemplation and contemplation groups on any of the seven ASI composite scores. After deleting four cases due to missing data, collapsing the two categories resulted in two groups consisting of persons who scored in the action phase (n = 229) and another non-action group (n = 62) that will subsequently be referred to as the contemplation group. 3.1. Differences in action and contemplation group Table 1 displays differences between the action and contemplation group. Persons in the contemplators group were slightly older. This difference approached significance t(283) = 1.92, p = .058. A higher percentage of women scored in the action stage m2(1,289) = 4.34, p =.037. There was no significant difference based on stage of change for the number of prior substance treatment abuse treatment episodes t(275) = .644, p = .520. Table 1 Client characteristics by stage of change
Age* Number of prior AOD treatments* Male** * Mean (SD). ** % (N ).
Contemplation
Action
34.7 (10.8) 2.2 (3.5) 24.3 (55)
31.8 (8.8) 2.0 (2.7) 75.7 (171)
38
T.K. Gregoire, A.C. Burke / Journal of Substance Abuse Treatment 26 (2004) 35–41
3.2. Legal status
Table 3 ASI composite scores by stage of change
Table 2 describes the legal status of persons in each group. There were no significant difference in the percentage of action or contemplation group members who had charges pending for driving under the influence; m2(1,291) = 0.71, p =.400, or for any other charge; m2(1,268) = .041, p =.840. Neither were there differences in the probability of having spent any of the past thirty days in a controlled environment; m2(1,291) = .674, p = .433 or the mean days spent in such a setting; t(276) = .960, p = .338. A significantly higher percentage of persons who reported that their admission was precipitated by the legal system scored in the action stage; m2(1,286) = 20.63, p > .001. Among those endorsing action stage items, 82.1% reported legal coercion while 53.2% of the contemplators reported legal pressure to enter treatment. A significantly higher percentage of persons in the action group reported that they were currently on probation or parole than did members of the contemplation group; m2(1,274) = 15.94, p > .001. Legal coercion appeared to be primarily a function of the clients’ probation and parole status. Among those persons who reported they were coerced into treatment, 79%, were currently on probation or parole, while only 17% of the noncoerced clients reporting being in this status. This difference was statistically significant; m2(1,275) = 83.34, p > .001. There seemed to be minimal legal coercion in response to pending charges for alcohol or other drug offenses. There was no significant difference in pending charges among coerced or non-coerced persons for DUI or other alcohol or drug offense. Only 6.8% of the coerced and 5.6% of the non-coerced clients reported pending charges for DUI or other alcohol or drug offense.
Medical Employment Alcohol Drug Legal Family Psychiatric
Contemplation
Action
0.164 0.537 0.382 0.096 0.242 0.221 0.206
0.157 0.556 0.177 0.080 0.243 0.185 0.141
who reported being in a controlled environment for the 30 days prior to the interview. For the most part, there were no significant differences in ASI scores at admission. However, as Table 3 indicates, persons who endorsed items consistent with the contemplation stage had significantly higher composite scores for alcohol problems; t (190) = 5.913, p > .001. At least in this bivariate analysis, persons in the contemplation stage had more severe recent alcohol problems than those in the action group. In addition to assessing differences in recent severity using composite scores, we considered differences in lifetime severity to determine whether current motivation might be just a function of lifetime severity. In this analysis, we included those clients who reported recently being in a controlled environment. Table 4 displays means and SDs for lifetime use for alcohol, cocaine and cannabis use. Employing t-tests, there were no significant differences between the contemplation and action groups in mean years of lifetime alcohol use to intoxication, lifetime cocaine use or lifetime marijuana use (the three most commonly reported substances). 3.4. Stage of change and coercion
3.3. Addiction severity Addiction severity composite scores are continuous measures that can range from zero to one. Because scores of confined individuals were likely to be artificially lowered, composite score differences between the contemplation and action groups were tested after excluding clients Table 2 Legal Status by stage of change
DUI pending* Other pending charges* Probation/parole* Legally coerced admission* In controlled setting for past 30 days* Mean days in controlled setting**
Contemplation
Action
9.7 (62) 31.0 (58)
5.7 (229) 28.6 (210)
45.6 (61) 53.2 (62)
70.0 (213) 82.1 (224)
30.0 (62)
39.1 (229)
5.3 (10.6)
The multivariable analysis consisted of a logistic regression with the stage of change as the dependent variable. We restricted this analysis to those persons who were not confined for the 30 days prior to completion of the ASI interview. Shen, McLellan, and Merrill (2000) found that both lifetime and recent addiction severity influenced motivation. As this model sought to assess the impact of coercion upon motivation, it was important to account for pre-treatment differences in severity. Doing so helped address the concern that differences in motivation might be just a function of the severity of the problem, and not associated with legal pressure. Variables included to account for both current Table 4 Years of subtance use by stage of change
6.8 (10.9)
N = numbers of respondents in each group. N differs due to missing data. * % (N ). ** Mean (SD).
Alcohol-to intoxication Cocaine Marijuana
Contemplation
Action
Mean
SD
Mean
SD
9.4 5.2 8.0
7.7 6.9 7.1
8.7 5.3 7.9
7.7 6.1 6.5
T.K. Gregoire, A.C. Burke / Journal of Substance Abuse Treatment 26 (2004) 35–41 Table 5 Logistic regression predicting stage of change (N = 174) Variable Coercion Male Alcohol composite Yrs alcohol used to intoxication N of prior treatments Constant
B 1.262 2.220 4.754 .023 .073 3.348
SE B
Odds ratio
.527 .773 1.120 .027 .077 .855
3.534* .109* .009 .977 1.075 28.436*
* p < .05.
and lifetime severity were the ASI alcohol composite score, the number of years of alcohol use to intoxication, and the number of lifetime addiction treatment episodes. We also based our decision to include the number of prior treatment episodes on evidence of a positive relationship between prior treatment and motivation (Kofoed, Kania, Walsh, & Atkinson, 1986). Gender was included because of the bivariate trend observed in coercion by gender. With the deletion of those confined in the prior 30 days, there were 174 cases available for the logistic regression. The test of the full model with the five predictors against the constants only model was statistically significant; m2(5,174) = 40.929, p <.001. The model correctly predicted 80.6% of the cases, an improvement in predictive efficiency of 32% over the constants only model. The Nagelkerke pseudo R2 and Cox and Snell pseudo R2 were .332 and .226 respectively. As a further measure of goodness of fit, the model produced a non-significant Hosmer and Lemeshow Test, m2(8) = 13.891, p = .085, which is the desired outcome for this test. Table 5 displays the results of this analysis. Even when controlling for current and lifetime substance use severity, persons who indicated that the court had compelled them to accept treatment were more likely to reside in the action group. Legally coerced persons were three and one half times more likely to endorse items representing current behavioral change than were clients who entered treatment without legal system coercion. In the bivariate analysis, men were less likely to reside in the action group than were women. We also noted this difference in the multivariate analysis with men less likely than women to endorse the action items. Treatment history was not associated with current readiness to change at admission. With respect to addiction severity, only the pretreatment alcohol composite score was associated with the stage of change assignment. There was no relationship between the longer-term severity items, number of prior treatments, and the number of years of drinking alcohol to intoxication.
4. Discussion Our findings suggest that involvement with the legal system may be associated with an increased motivation to
39
change, even when controlling for problem severity at admission. A number of authors have demonstrated the effectiveness of coercion in treatment retention (Allan, 1987; Brizer et al., 1990; Rosenberg & Liftik, 1976; Simpson & Friend, 1988). Evidence presented here that legal coercion is associated with greater readiness to change suggests that treatment retention resulting from legal coercion may, at least in part, reflect underlying change among coerced clients. Of course, it is possible that rather than heightening readiness to change, legal coercion resulted in a self-selection process that referred only more motivated clients to treatment. Persons identified in the Transtheoretical framework as pre-contemplators or contemplators tend toward inactivity when it comes to changing their substance use behavior (Prochaska et al., 1992). Individuals who enter treatment in either of these stages tend to have poorer treatment outcomes (Prochaska et al., 1992). We would not expect persons in these pre-action stages to fare as well as those who enter treatment prepared to take action. By enhancing readiness to change, legal coercion may ultimately improve outcomes for clients mandated to seek treatment for alcohol and other drug problems. Subsequent studies could determine whether clients remain in the action stage of change upon removal of coercive pressure. These studies might also determine what impact, if any, remaining in the action stage has on post-treatment outcomes. It is possible that persons coerced into treatment reported taking more action steps prior to admission because they were remanded to controlled settings to await treatment. As indicated previously, however, there were no significant differences based on stage of change in the percentage of persons in a controlled environment during the past month. Hence, these data lend credence to the notion that actions by coerced clients to reduce their substance use are likely to be a function of the clients’ change efforts rather than changes imposed upon them by external constraints. These data also indicate that more severe problems in the alcohol use domain were associated with a reduced likelihood of engagement in active change efforts. This finding is understandable given the way in which the alcohol severity score is measured. The alcohol severity scale is partially comprised of client estimates regarding the number of ‘‘drinking’’ days in the past 30 days and the number of drinking days that resulted in intoxication. A finding of lower alcohol severity among action-oriented persons may be a consequence of their recent efforts to reduce their drinking, perhaps precipitated by their legal involvement. Measures of lifetime severity did not differ based on stage of change in either the bivariate or the multivariable analysis. This suggests that membership in the action group, hence motivation, was not simply a function of problem severity. The differences we observed did not appear to be a function of prior treatment experience. Lifetime treatment history was not significant in the logistic regression. The two stages of change groups did not differ in their recent
40
T.K. Gregoire, A.C. Burke / Journal of Substance Abuse Treatment 26 (2004) 35–41
treatment experience. There was no significant difference between the action and contemplation groups regarding participation in treatment during the past 30 days. Nor was there any reported difference between members of the action and contemplation groups in the number of days during the past 30 that they had participated in treatment, including involvement in self-help groups. Differences in readiness to change were also evident based on gender. Women were more likely to be in the action stage, independently of either severity or the presence of legal coercion. While nothing in the data presented here points to an obvious interpretation of this finding, the substance abuse literature is replete with evidence for gender differences (Karoll, 2002). Society in general has a much harsher response to women with substance abuse problems as compared to males with similar problems (van der Walde, Urgenson, Weltz, & Hanna, 2002). Perhaps, for the women in this sample, this social stigma, along with the recognition of a problem, lead to a greater likelihood of taking steps to address drinking or drug use. Clearly, this study was not without its limitations. As the data reported result from treatment admission assessments, they do not make it possible to determine the stage of change a client may have been in prior to the application of legal coercion. However, it does seem unlikely that individuals compelled to seek treatment would be in such a predicament if they had already entered the action stage and taken steps to modify their substance use behavior. Nonetheless, it is not possible to offer conclusions about the causal connections between legal coercion and movement toward the action stage of change. It is also important to note that we obtained these data from subjects admitted to publicly funded outpatient treatment. Although outpatient treatment is the most common treatment modality, it may be that coercion operates in a different manner among persons in more (e.g. residential treatment) or less (e.g. aftercare) restrictive environments. Participants in this study also tended to be lower-income individuals and it is not possible to know how legal coercion might affect the thinking and behavior of persons with more resources at their disposal. As noted earlier, the potential for selection bias existed with respect to motivation. Poorly motivated persons may have elected to experience legal sanction rather than submit themselves to treatment. Those individuals would not be present in these data. Finally, although this study focused on legal coercion, many other factors influence the decision to obtain treatment and address problems. In fact, Marlowe et al. (1996) found that factors such as psychological and financial pressure to obtain treatment were more significant in the treatment decision than legal coercion. No measures were available to determine the relative importance of these other factors in shaping readiness to change alcohol and other drug use. These limitations notwithstanding, these findings appear to suggest that legal coercion is associated with a person’s readiness to change independent of addiction severity or
prior treatment experience, and regardless of gender. As the use of drug courts and other alternative sentencing schemes increase, these findings suggest that appropriate use of coercion may increase a client’s readiness for treatment. As treatment lengths of stay shrink and resources for treatment dwindle, entering treatment more prepared to benefit from the experience could contribute to outcomes that are more positive.
Acknowledgments The Ohio Department of Alcohol and Drug Addiction Services provided partial funding for this work. A previous version of this paper was presented at the Sixth Annual Conference of the Society for Social Work and Research, January 20, 2002, in San Diego, CA.
References Allan, C. (1987). Seeking help for drinking problems from a community based voluntary agency: Patterns of compliance among men and women. British Journal of Addiction, 82, 1143 – 1147. Alterman, A., Brown, L., Zabellero, A., & McKay, J. (1994). Interviewer severity ratings and composite scores of the ASI: A further look. Drug and Alcohol Dependence, 34 (3), 201 – 209. Anglin, M. D., Brecht, M. L., & Maddahian, E. (1989). Pretreatment characteristics and treatment performance of legally coerced versus voluntary methadone maintenance admissions. Criminology, 27 (3), 537 – 557. Argeriou, M., McCarty, D., Mulvey, K., & Daley, M. (1994). Use of the Addiction Severity Index with homeless substance abusers. Journal of Substance Abuse Treatment, 11 (4), 359 – 365. Brecht, M. L., Anglin, M. D., & Wang, J. C. (1993). Treatment effectiveness for legally coerced versus voluntary methadone maintenance clients. American Journal of Drug and Alcohol Abuse, 19 (1), 89 – 106. Brizer, D., Maslansky, R., & Galanter, M. (1990). Treatment retention of patients referred by public assistance to an alcoholism clinic. American Journal of Drug and Alcohol Abuse, 16 (3 – 4), 259 – 264. Carpenter, K., Meile, G., & Hasin, D. (2002). Does motivation to change mediate the effect of DSM-IV substance use disorders on treatment utilization and substance use? Addictive Behaviors, 27, 207 – 225. Dent, T., Shepherd, R., Alexander, G., & London, M. (1995). Do Cage scores predict readiness to reduce alcohol consumption in medical inpatients? Alcohol & Alcoholism, 30 (5), 577 – 580. DiClemente, C., Bellino, L., & Neavins, T. (1999). Motivation for change and alcoholism treatment. Alcohol Research & Health, 23 (2), 86 – 92. Farabee, D., Prendergast, M., & Anglin, M. D. (1998). The effectiveness of coerced treatment for drug-abusing offenders. Federal Probation, 62 (1), 3 – 10. Finney, J., & Moos, R. (1995). Entering treatment for alcohol abuse: A stress and coping model. Addiction, 90, 1223 – 1240. Flores, P. (1982). The efficacy of the use of coercion in getting DWI offenders into treatment. Journal of Alcohol and Drug Education, 28 (1), 18 – 27. Gerdner, A., & Holmberg, A. (2000). Factors affecting motivation to treatment in severely dependent alcoholics. Journal of Studies on Alcohol, 61, 548 – 560. Heather, N., Rollnick, S., & Bell, A. (1993). Predictive validity of the Readiness to Change Questionnaire. Addiction, 88, 1667 – 1677. Hiller, M. L., Knight, K., Broome, K. M., & Simpson, D. D. (1998). Legal
T.K. Gregoire, A.C. Burke / Journal of Substance Abuse Treatment 26 (2004) 35–41 pressure and treatment retention in a national sample of long-term residential programs. Criminal Justice Behavior, 25 (4), 463 – 481. Hiller, M. L., Knight, K., Devereux, J., & Hathcoat, M. (1996). Post-treatment outcomes for substance abusing probationers mandated to residential treatment. Journal of Psychoactive Drugs, 28 (3), 291 – 296. Joe, G., Simpson, D., & Broome, K. (1999). Retention and patient engagement models of different treatment modalities in DATOS. Drug and Alcohol Dependence, 57, 113 – 125. Karoll, B. (2002). Women and alcohol-use disorders: A review of important knowledge and its implications for social work practitioners. Journal of Social Work, 2 (3), 337 – 356. Kofoed, L., Kania, J., Walsh, T., & Atkinson, R. (1986). Outpatient treatment of patients with substance abuse and coexisting psychiatric disorders. American Journal of Psychiatry, 143 (7), 867 – 872. Loneck, B., Garrett, J., & Banks, S. (1996). A comparison of the Johnson Intervention with four other models of referral to outpatient treatment. American Journal of Drug and Alcohol Abuse, 22 (2), 233 – 246. Mark, F. (1988). Does coercion work? The role of referral source in motivating alcoholics in treatment. Alcoholism Treatment Quarterly, 5 (3 – 4), 5 – 22. Marlowe, D., Kirby, K., Bonieskie, L., Glass, D., Dodds, L., Husband, S., Platt, J., & Festinger, D. (1996). Assessment of coercive and noncoercive pressures to enter drug abuse treatment. Drug and Alcohol Dependence, 42, 77 – 84. McLellan, A. T., Luborsky, L., Cacciola, J., Griffith, J., Evans, F., Barr, H., & O’Brien, P. (1985). New data from the Addiction Severity Index: Reliability and validity in three centers. Journal of Nervous and Mental Disease, 173, 412 – 423. McLellan, A. T., Kushener, H., Metzger, D., Peters, R., Smith, I., Grissom, G., Pettinati, H., & Argeriou, M. (1992). The fifth edition of the Addiction Severity Index. Journal of Substance Abuse Treatment, 9, 199 – 213. Miller, W. (1985). Motivation for treatment: A review with special emphasis on alcoholism. Psychological Bulletin, 98 (1), 84 – 107. Miller, W., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behaviors. New York: The Guildford Press.
41
Polcin, D., & Weisner, C. (1999). Factors associated with coercion in entering treatment for alcohol problems. Drug & Alcohol Dependence, 54 (1), 63 – 68. Prochaska, J., DiClemente, C., & Norcross, J. (1992). In search of how people change. American Psychologist, 47 (9), 1102 – 1114. Prochaska, J., Velicer, W., Rossi, J., Goldstein, M., Marcus, B., Rakowski, W., Fiore, C., Harlow, L., Redding, C., & Rosenbloom, D. (1994). Stages of change and decisional balance for 12 problem behaviors. Health Psychology, 13 (1), 39 – 46. Rollnick, S., Heather, N., Gold, R., & Hall, W. (1992). Development of a short ‘readiness to change’ questionnaire for use in brief, opportunistic interventions among excessive drinkers. British Journal of Addiction, 87, 743 – 754. Rosenberg, C., & Liftik, J. (1976). Use of coercion in outpatient treatment of alcoholism. Journal of Studies on Alcohol, 37, 58 – 65. Ryan, R., Plant, R., & O’Malley, S. (1995). Initial motivations for alcohol treatment: Relations with patient characteristics, treatment involvement, and dropout. Addictive Behaviors, 20 (3), 279 – 297. Shaffer, H., & Simoneau, G. (2001). Reducing resistance and denial by exercising ambivalence during treatment of addiction. Journal of Substance Abuse Treatment, 20, 99 – 105. Shen, Q., McLellan, A. T., & Merrill, J. (2000). Client’s perceived need for treatment and its impact on outcome. Substance Abuse, 21 (3), 179 – 192. Simpson, D., & Joe, G. (1993). Motivation as a predictor of early dropout from drug abuse treatment. Psychotherapy, 30, 357 – 368. Simpson, D., & Friend, H. (1988). Legal status and long-term outcomes for addicts in the DARP follow-up project. NIDA Research Monograph Series, 86, 81 – 98. van der Walde, H., Urgenson, F., Weltz, S., & Hanna, F. (2002). Women and alcoholism: A biopsychosocial perspective and treatment approaches. Journal of Counseling & Development, 80 (2), 145 – 153. Watson, C., Brown, K., Tilleskjor, C., & Jacobs, L. (1988). The comparative recidivism rates of voluntary and coerced admission male alcoholics. Journal of Clinical Psychology, 44 (4), 573 – 581.
Regular article
The relationship of legal coercion to readiness to change among adults with alcohol and other drug problems Thomas K. Gregoire, Ph.D. *, Anna Celeste Burke, Ph.D. Ohio State University, College of Social Work, 1947 College Rd., Columbus, OH, USA Received 16 May 2003; received in revised form 7 August 2003; accepted 14 September 2003
Abstract Prior research on legally coerced treatment for substance abuse tends to find no difference between coerced and non-coerced clients with respect to treatment retention and treatment outcomes. There is less known about the relationship between coercion and a client’s motivation to change. We considered the relationship of legal coercion and readiness to change among 295 consecutive admissions to five publicly funded outpatient treatment programs. A logistic regression analysis indicated that legal coercion was associated with greater readiness to change after controlling for addiction severity, prior treatment history, and gender. Persons entering treatment due to legal coercion were over three times more likely to have engaged in recovery-oriented behavior in the month preceding admission. Entering treatment more prepared to benefit from the experience could contribute to outcomes that are more positive. D 2004 Elsevier Inc. All rights reserved. Keywords: Coercion; Motivation; Readiness to change
1. Introduction Practitioners in the addictions field have long expressed concern about the impact of client motivation on outcomes in substance abuse treatment. Many people entering treatment are not yet ready to make the changes required for recovery and are unprepared or unwilling to modify their behavior (Prochaska, DiClemente, & Norcross, 1992). A lack of motivation is a common phenomenon in treatment, and client motivation is a critical determining factor in treatment outcome (DiClemente, Bellino, & Neavins, 1999). Clients typically approach the addiction treatment experience with some degree of ambivalence. Uncertainty about change often represents a central theme in the treatment process (Miller & Rollnick, 1991), and client denial is a common by-product of this ambivalence (Shaffer & Simoneau, 2001). Clients’ social networks can play a significant role in precipitating a treatment experience (Marlowe et al. 1996). This social pressure can also influence motivation to modify substance use behavior (Miller, 1985). Often an individual’s entry into treatment results from pressure placed upon clients
* Corresponding author. Tel. +1-614-292-9426; fax +1-614-292-6949. E-mail address: [email protected] (T.K. Gregoire). 0740-5472/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/S0740-5472(03)00155-7
by courts, employers, and/or family members. Considering a sample of public and private HMO treatment admissions, Polcin and Weisner (1999) found that 40% reported that some type of coercion contributed to their treatment admission. Gerdner and Holmberg’s (2000) sample of alcoholics had a similar percentage of legally coerced admissions (42%) and 50% of the admissions in Joe, Simpson, and Broome’s (1999) study reported moderate or high legal pressure to enter treatment. Although there are many sources of social pressure to obtain rehabilitation, legal coercive pressure over the course of the treatment experience may have the most potential for influencing client behavior toward outcomes since it is perhaps the most consistent type of coercion, less subject to a change than coercion by a family member or employer, and less subject to influence by client manipulation. It should be noted that in the following synopses of prior studies, the term voluntary has been placed in quotations simply to designate that those patients were not legally coerced, but that they may have been under the influence of some other, unmeasured form of social coercion. Studies of legally coerced treatment for substance abuse are mixed but many support the notion that coerced clients can benefit from addiction treatment (Farabee, Prendergast, & Anglin, 1998). Most prior research considers either treatment retention or treatment outcomes. Some evidence
36
T.K. Gregoire, A.C. Burke / Journal of Substance Abuse Treatment 26 (2004) 35–41
suggests coerced individuals are more likely to complete treatment than are non-coerced individuals (Hiller, Knight, Broome, & Simpson, 1998; Loneck, Garrett, & Banks, 1996). In four other studies there were no significant differences noted in treatment retention between legally coerced and ‘‘voluntary’’ clients (Allan, 1987; Brizer, Maslansky, & Galanter, 1990; Rosenberg & Liftik, 1976; Simpson & Friend, 1988). In their study of outpatient drug free treatment programs, Joe et al. (1999) found that legal coercion had a positive impact on session attendance, but a slightly negative impact upon a client’s therapeutic involvement. Among a sample of inpatient clients, however, legal pressure had no impact on either therapeutic involvement or treatment retention (Joe et al., 1999). Studies examining the impact of coercion on treatment outcomes reach mixed conclusions. Mark (1988) reported that legally coerced persons had better outcomes at 6-month followup than persons who ‘‘voluntarily’’ entered treatment. Hiller, Knight, Devereux, and Hathcoat (1996) found lower re-arrest rates among substance-abusing probationers mandated to attend residential treatment. Similarly, Anglin, Brecht, and Maddahian (1989) reported positive effects of treatment on legally coerced clients. Brecht, Anglin, and Wang (1993) found treatment improved drug use outcomes and obtained similar results for clients regardless of coercion level. Other studies reported no difference between legally coerced and ‘‘voluntary’’ clients for 6-month (Flores, 1982) or 18-month outcomes (Watson, Brown, Tilleskjopr, Jacobs, & Pucel, 1988). As noted above, prior studies have tended to consider the impact of legal coercion upon treatment retention or treatment outcome. While this knowledge is useful in assessing the impact of coercion, knowledge of treatment retention may simply represent a client’s reluctance to experience the alternative consequences. To the extent that legal authorities monitor continued abstinence from alcohol and other drugs, those outcomes may also be a consequence of the coercive experience, not representative of a client’s initiative, nor their behavior of choice upon removal of the coercion. While it seems relatively clear that coerced persons remain in treatment, and abstain at rates comparable to ‘‘volunteers,’’ we know less about the role that coercion plays in influencing a client’s motivation to change. The review by Farabee and colleagues (1998) of 11 studies examining the impact of coercion on treatment retention and outcomes noted that none of these studies assessed motivation to change. Knowledge about the relationship between coercion and a client’s motivation to change may be useful in understanding the impact of coercion on client recovery. Perhaps the most prevalent model of motivation to change in substance abuse is the Transtheoretical Model (Prochaska et al., 1992). This model characterizes the process by which persons engage in change with or without professional help. The model suggests that recovery is typically not a linear process but rather involves cycling
back and forth through a number of stages. What distinguishes the stages are a person’s perception of his or her problem and the person’s current level of behavior change. Prior research suggests that a client’s stage of change predicts subsequent alcohol use (Heather, Rollnick, & Bell, 1993), cocaine use (Prochaska et al., 1994) and treatment dropout (Simpson & Joe, 1993). The Transtheoretical model posits five stages of change. Individuals in the precomtemplation stage, the initial stage of change, do not intend to modify their behavior, and in fact may not acknowledge they have a problem. When persons in this stage find their way into substance abuse treatment, coercion usually plays a role. As long as they remain in this stage, they are unlikely to benefit from the experience. Persons identified as contemplators are probably aware that a problem exists and may be thinking about addressing the problem. However, contemplators have yet to make a commitment to action. Many persons become stuck in this stage for long periods. These individuals are described as ‘‘. . .not quite ready yet’’ (Prochaska et al., 1994, p. 1103). The preparation stage reflects an intention to take some form of change action during the next 30 days. It also refers to those persons who have made an unsuccessful attempt to change within the past 12 months. In the action stage persons have initiated new behavior. Placement in this stage requires that an individual must have modified behavior for at least one day. In the case of substance use, this means a person has modified their use of alcohol or other drugs. The final stage is maintenance. During this stage, beginning at 6 months after behavior change, persons take steps to avoid relapse and consolidate gains. This study sought to examine the relationship of legal coercion to a client’s stage of change. More specifically, this study aims: (1) To examine variation in readiness to change among adults entering publicly funded alcohol and other drug treatment programs. (2) To determine what relationship, if any, exists between mode of entry into treatment and readiness to change.
2. Materials and methods 2.1. Subjects Study subjects consisted of consecutive admissions to outpatient treatment in five public substance abuse programs located throughout Ohio. During their initial assessment session agency staff asked subjects to participate in a followup study. The study consisted of data collection at admission, discharge, and between 9 and 12 months following treatment. Those clients who agreed to participate provided their informed consent. Participants received a tendollar gift certificate to a local discount store for their participation at each data collection interval. A total of 295 persons, 92% of those asked, agreed to participate in the study.
T.K. Gregoire, A.C. Burke / Journal of Substance Abuse Treatment 26 (2004) 35–41
The mean age for participants was 32.5 years (SD = 9.35) and 77.6% were men. With respect to race and ethnicity, 71.9% were White, 19.4% African-American, 7.7% were Hispanic. The median income from all sources, including illegally obtained income, during the 30 days prior to admission was $570.00. The median income from employment in the past month was $300.00. Just fewer than 78% reported they had regular full or part time employment. This treatment episode represented the initial substance abuse treatment experience for 32.6% of participants. Among only those persons with a prior treatment history, the mean number of treatment episodes was 2.9 (SD = 3.04). With respect to legal coercion, 75.5% reported that the criminal justice system precipitated this treatment admission. Alcohol was the sole drug of choice for 41% of the participants. An additional 18% regularly used alcohol along with some other substance. Marijuana use was the primary problem for 16% of our participants while 11% endorsed cocaine as their drug of choice. Slightly less than 4% indicated either opiate use or the regular use of multiple drugs. 2.2. Measures and procedures We measured readiness to change by adapting the 12item Readiness to Change Questionnaire (RCQ; Rollnick, Heather, Gold, & Hall, 1992). This self-administered instrument uses responses to items on a five point Likert scale regarding clients’ beliefs about their current alcohol use to place individuals in a pre-contemplation, contemplation or action stage of change. We followed the author’s scoring instructions. Clients received scores in each of the three stages. We assigned clients to a particular stage based on their highest score. The RCQ was modified to represent readiness to change either alcohol or substance use. Although other tools exist to measure readiness to change among substance abusers, the RCQ was modified and used in this study because it is brief to administer and score, available in the public domain at no cost to service providers, and requires no training to use. Rollnick et al. (1992) reported test-retest reliabilities for the three scales as follows: pre-contemplation .82, contemplation .86, and action .78. The authors also provided support for the concurrent validation of the questionnaire by demonstrating a significant relationship between the stage of change and endorsement of the need to modify behavior measured in a health history-screening instrument. In support of the predictive validity of the questionnaire, Heather et al. (1993) found that stage of change was an accurate predictor of alcohol consumption among heavy drinkers at a 6-month followup. We employed the fifth edition of the Addiction Severity Index (ASI; McLellan et al., 1992) to collect most of the demographic data and to assess pre-treatment alcohol and other drug severity. This instrument records data on recent
37
and lifetime substance use, and other problem areas. The ASI yields composite severity scores for seven problem domains: Medical, legal, employment, alcohol, drug, family and social status, and psychiatric status. A number of studies support the reliability and validity of this instrument for use with a wide range of populations (Alterman, Brown, Zabellero, & McKay, 1994; Argeriou, McCarty, Mulvey, & Daley, 1994; McLellan et al., 1985). Employing pre-treatment ASI scores makes it possible to account for the influence of pre-treatment severity upon treatment readiness. A number of prior studies suggest that a relationship exists between motivation to change and problem severity (Carpenter, Meile, & Hasin, 2002; Dent, Shepherd, Alexander, & London, 1995; Finney & Moos, 1995; Ryan, Plant, & O’Malley, 1995).
3. Results Because there were only eight persons in the precontemplation stage, we combined members of this group with persons in the contemplation stage. Given that the participants consisted entirely of persons enrolled in substance abuse treatment it is not entirely surprising that such a small percentage would be in the pre-contemplation stage. In their validation study of the RCQ, Heather et al. (1993) found no significant differences in current alcohol consumption between persons in the pre-contemplation and contemplation group. Similarly, we found no differences between the pre-contemplation and contemplation groups on any of the seven ASI composite scores. After deleting four cases due to missing data, collapsing the two categories resulted in two groups consisting of persons who scored in the action phase (n = 229) and another non-action group (n = 62) that will subsequently be referred to as the contemplation group. 3.1. Differences in action and contemplation group Table 1 displays differences between the action and contemplation group. Persons in the contemplators group were slightly older. This difference approached significance t(283) = 1.92, p = .058. A higher percentage of women scored in the action stage m2(1,289) = 4.34, p =.037. There was no significant difference based on stage of change for the number of prior substance treatment abuse treatment episodes t(275) = .644, p = .520. Table 1 Client characteristics by stage of change
Age* Number of prior AOD treatments* Male** * Mean (SD). ** % (N ).
Contemplation
Action
34.7 (10.8) 2.2 (3.5) 24.3 (55)
31.8 (8.8) 2.0 (2.7) 75.7 (171)
38
T.K. Gregoire, A.C. Burke / Journal of Substance Abuse Treatment 26 (2004) 35–41
3.2. Legal status
Table 3 ASI composite scores by stage of change
Table 2 describes the legal status of persons in each group. There were no significant difference in the percentage of action or contemplation group members who had charges pending for driving under the influence; m2(1,291) = 0.71, p =.400, or for any other charge; m2(1,268) = .041, p =.840. Neither were there differences in the probability of having spent any of the past thirty days in a controlled environment; m2(1,291) = .674, p = .433 or the mean days spent in such a setting; t(276) = .960, p = .338. A significantly higher percentage of persons who reported that their admission was precipitated by the legal system scored in the action stage; m2(1,286) = 20.63, p > .001. Among those endorsing action stage items, 82.1% reported legal coercion while 53.2% of the contemplators reported legal pressure to enter treatment. A significantly higher percentage of persons in the action group reported that they were currently on probation or parole than did members of the contemplation group; m2(1,274) = 15.94, p > .001. Legal coercion appeared to be primarily a function of the clients’ probation and parole status. Among those persons who reported they were coerced into treatment, 79%, were currently on probation or parole, while only 17% of the noncoerced clients reporting being in this status. This difference was statistically significant; m2(1,275) = 83.34, p > .001. There seemed to be minimal legal coercion in response to pending charges for alcohol or other drug offenses. There was no significant difference in pending charges among coerced or non-coerced persons for DUI or other alcohol or drug offense. Only 6.8% of the coerced and 5.6% of the non-coerced clients reported pending charges for DUI or other alcohol or drug offense.
Medical Employment Alcohol Drug Legal Family Psychiatric
Contemplation
Action
0.164 0.537 0.382 0.096 0.242 0.221 0.206
0.157 0.556 0.177 0.080 0.243 0.185 0.141
who reported being in a controlled environment for the 30 days prior to the interview. For the most part, there were no significant differences in ASI scores at admission. However, as Table 3 indicates, persons who endorsed items consistent with the contemplation stage had significantly higher composite scores for alcohol problems; t (190) = 5.913, p > .001. At least in this bivariate analysis, persons in the contemplation stage had more severe recent alcohol problems than those in the action group. In addition to assessing differences in recent severity using composite scores, we considered differences in lifetime severity to determine whether current motivation might be just a function of lifetime severity. In this analysis, we included those clients who reported recently being in a controlled environment. Table 4 displays means and SDs for lifetime use for alcohol, cocaine and cannabis use. Employing t-tests, there were no significant differences between the contemplation and action groups in mean years of lifetime alcohol use to intoxication, lifetime cocaine use or lifetime marijuana use (the three most commonly reported substances). 3.4. Stage of change and coercion
3.3. Addiction severity Addiction severity composite scores are continuous measures that can range from zero to one. Because scores of confined individuals were likely to be artificially lowered, composite score differences between the contemplation and action groups were tested after excluding clients Table 2 Legal Status by stage of change
DUI pending* Other pending charges* Probation/parole* Legally coerced admission* In controlled setting for past 30 days* Mean days in controlled setting**
Contemplation
Action
9.7 (62) 31.0 (58)
5.7 (229) 28.6 (210)
45.6 (61) 53.2 (62)
70.0 (213) 82.1 (224)
30.0 (62)
39.1 (229)
5.3 (10.6)
The multivariable analysis consisted of a logistic regression with the stage of change as the dependent variable. We restricted this analysis to those persons who were not confined for the 30 days prior to completion of the ASI interview. Shen, McLellan, and Merrill (2000) found that both lifetime and recent addiction severity influenced motivation. As this model sought to assess the impact of coercion upon motivation, it was important to account for pre-treatment differences in severity. Doing so helped address the concern that differences in motivation might be just a function of the severity of the problem, and not associated with legal pressure. Variables included to account for both current Table 4 Years of subtance use by stage of change
6.8 (10.9)
N = numbers of respondents in each group. N differs due to missing data. * % (N ). ** Mean (SD).
Alcohol-to intoxication Cocaine Marijuana
Contemplation
Action
Mean
SD
Mean
SD
9.4 5.2 8.0
7.7 6.9 7.1
8.7 5.3 7.9
7.7 6.1 6.5
T.K. Gregoire, A.C. Burke / Journal of Substance Abuse Treatment 26 (2004) 35–41 Table 5 Logistic regression predicting stage of change (N = 174) Variable Coercion Male Alcohol composite Yrs alcohol used to intoxication N of prior treatments Constant
B 1.262 2.220 4.754 .023 .073 3.348
SE B
Odds ratio
.527 .773 1.120 .027 .077 .855
3.534* .109* .009 .977 1.075 28.436*
* p < .05.
and lifetime severity were the ASI alcohol composite score, the number of years of alcohol use to intoxication, and the number of lifetime addiction treatment episodes. We also based our decision to include the number of prior treatment episodes on evidence of a positive relationship between prior treatment and motivation (Kofoed, Kania, Walsh, & Atkinson, 1986). Gender was included because of the bivariate trend observed in coercion by gender. With the deletion of those confined in the prior 30 days, there were 174 cases available for the logistic regression. The test of the full model with the five predictors against the constants only model was statistically significant; m2(5,174) = 40.929, p <.001. The model correctly predicted 80.6% of the cases, an improvement in predictive efficiency of 32% over the constants only model. The Nagelkerke pseudo R2 and Cox and Snell pseudo R2 were .332 and .226 respectively. As a further measure of goodness of fit, the model produced a non-significant Hosmer and Lemeshow Test, m2(8) = 13.891, p = .085, which is the desired outcome for this test. Table 5 displays the results of this analysis. Even when controlling for current and lifetime substance use severity, persons who indicated that the court had compelled them to accept treatment were more likely to reside in the action group. Legally coerced persons were three and one half times more likely to endorse items representing current behavioral change than were clients who entered treatment without legal system coercion. In the bivariate analysis, men were less likely to reside in the action group than were women. We also noted this difference in the multivariate analysis with men less likely than women to endorse the action items. Treatment history was not associated with current readiness to change at admission. With respect to addiction severity, only the pretreatment alcohol composite score was associated with the stage of change assignment. There was no relationship between the longer-term severity items, number of prior treatments, and the number of years of drinking alcohol to intoxication.
4. Discussion Our findings suggest that involvement with the legal system may be associated with an increased motivation to
39
change, even when controlling for problem severity at admission. A number of authors have demonstrated the effectiveness of coercion in treatment retention (Allan, 1987; Brizer et al., 1990; Rosenberg & Liftik, 1976; Simpson & Friend, 1988). Evidence presented here that legal coercion is associated with greater readiness to change suggests that treatment retention resulting from legal coercion may, at least in part, reflect underlying change among coerced clients. Of course, it is possible that rather than heightening readiness to change, legal coercion resulted in a self-selection process that referred only more motivated clients to treatment. Persons identified in the Transtheoretical framework as pre-contemplators or contemplators tend toward inactivity when it comes to changing their substance use behavior (Prochaska et al., 1992). Individuals who enter treatment in either of these stages tend to have poorer treatment outcomes (Prochaska et al., 1992). We would not expect persons in these pre-action stages to fare as well as those who enter treatment prepared to take action. By enhancing readiness to change, legal coercion may ultimately improve outcomes for clients mandated to seek treatment for alcohol and other drug problems. Subsequent studies could determine whether clients remain in the action stage of change upon removal of coercive pressure. These studies might also determine what impact, if any, remaining in the action stage has on post-treatment outcomes. It is possible that persons coerced into treatment reported taking more action steps prior to admission because they were remanded to controlled settings to await treatment. As indicated previously, however, there were no significant differences based on stage of change in the percentage of persons in a controlled environment during the past month. Hence, these data lend credence to the notion that actions by coerced clients to reduce their substance use are likely to be a function of the clients’ change efforts rather than changes imposed upon them by external constraints. These data also indicate that more severe problems in the alcohol use domain were associated with a reduced likelihood of engagement in active change efforts. This finding is understandable given the way in which the alcohol severity score is measured. The alcohol severity scale is partially comprised of client estimates regarding the number of ‘‘drinking’’ days in the past 30 days and the number of drinking days that resulted in intoxication. A finding of lower alcohol severity among action-oriented persons may be a consequence of their recent efforts to reduce their drinking, perhaps precipitated by their legal involvement. Measures of lifetime severity did not differ based on stage of change in either the bivariate or the multivariable analysis. This suggests that membership in the action group, hence motivation, was not simply a function of problem severity. The differences we observed did not appear to be a function of prior treatment experience. Lifetime treatment history was not significant in the logistic regression. The two stages of change groups did not differ in their recent
40
T.K. Gregoire, A.C. Burke / Journal of Substance Abuse Treatment 26 (2004) 35–41
treatment experience. There was no significant difference between the action and contemplation groups regarding participation in treatment during the past 30 days. Nor was there any reported difference between members of the action and contemplation groups in the number of days during the past 30 that they had participated in treatment, including involvement in self-help groups. Differences in readiness to change were also evident based on gender. Women were more likely to be in the action stage, independently of either severity or the presence of legal coercion. While nothing in the data presented here points to an obvious interpretation of this finding, the substance abuse literature is replete with evidence for gender differences (Karoll, 2002). Society in general has a much harsher response to women with substance abuse problems as compared to males with similar problems (van der Walde, Urgenson, Weltz, & Hanna, 2002). Perhaps, for the women in this sample, this social stigma, along with the recognition of a problem, lead to a greater likelihood of taking steps to address drinking or drug use. Clearly, this study was not without its limitations. As the data reported result from treatment admission assessments, they do not make it possible to determine the stage of change a client may have been in prior to the application of legal coercion. However, it does seem unlikely that individuals compelled to seek treatment would be in such a predicament if they had already entered the action stage and taken steps to modify their substance use behavior. Nonetheless, it is not possible to offer conclusions about the causal connections between legal coercion and movement toward the action stage of change. It is also important to note that we obtained these data from subjects admitted to publicly funded outpatient treatment. Although outpatient treatment is the most common treatment modality, it may be that coercion operates in a different manner among persons in more (e.g. residential treatment) or less (e.g. aftercare) restrictive environments. Participants in this study also tended to be lower-income individuals and it is not possible to know how legal coercion might affect the thinking and behavior of persons with more resources at their disposal. As noted earlier, the potential for selection bias existed with respect to motivation. Poorly motivated persons may have elected to experience legal sanction rather than submit themselves to treatment. Those individuals would not be present in these data. Finally, although this study focused on legal coercion, many other factors influence the decision to obtain treatment and address problems. In fact, Marlowe et al. (1996) found that factors such as psychological and financial pressure to obtain treatment were more significant in the treatment decision than legal coercion. No measures were available to determine the relative importance of these other factors in shaping readiness to change alcohol and other drug use. These limitations notwithstanding, these findings appear to suggest that legal coercion is associated with a person’s readiness to change independent of addiction severity or
prior treatment experience, and regardless of gender. As the use of drug courts and other alternative sentencing schemes increase, these findings suggest that appropriate use of coercion may increase a client’s readiness for treatment. As treatment lengths of stay shrink and resources for treatment dwindle, entering treatment more prepared to benefit from the experience could contribute to outcomes that are more positive.
Acknowledgments The Ohio Department of Alcohol and Drug Addiction Services provided partial funding for this work. A previous version of this paper was presented at the Sixth Annual Conference of the Society for Social Work and Research, January 20, 2002, in San Diego, CA.
References Allan, C. (1987). Seeking help for drinking problems from a community based voluntary agency: Patterns of compliance among men and women. British Journal of Addiction, 82, 1143 – 1147. Alterman, A., Brown, L., Zabellero, A., & McKay, J. (1994). Interviewer severity ratings and composite scores of the ASI: A further look. Drug and Alcohol Dependence, 34 (3), 201 – 209. Anglin, M. D., Brecht, M. L., & Maddahian, E. (1989). Pretreatment characteristics and treatment performance of legally coerced versus voluntary methadone maintenance admissions. Criminology, 27 (3), 537 – 557. Argeriou, M., McCarty, D., Mulvey, K., & Daley, M. (1994). Use of the Addiction Severity Index with homeless substance abusers. Journal of Substance Abuse Treatment, 11 (4), 359 – 365. Brecht, M. L., Anglin, M. D., & Wang, J. C. (1993). Treatment effectiveness for legally coerced versus voluntary methadone maintenance clients. American Journal of Drug and Alcohol Abuse, 19 (1), 89 – 106. Brizer, D., Maslansky, R., & Galanter, M. (1990). Treatment retention of patients referred by public assistance to an alcoholism clinic. American Journal of Drug and Alcohol Abuse, 16 (3 – 4), 259 – 264. Carpenter, K., Meile, G., & Hasin, D. (2002). Does motivation to change mediate the effect of DSM-IV substance use disorders on treatment utilization and substance use? Addictive Behaviors, 27, 207 – 225. Dent, T., Shepherd, R., Alexander, G., & London, M. (1995). Do Cage scores predict readiness to reduce alcohol consumption in medical inpatients? Alcohol & Alcoholism, 30 (5), 577 – 580. DiClemente, C., Bellino, L., & Neavins, T. (1999). Motivation for change and alcoholism treatment. Alcohol Research & Health, 23 (2), 86 – 92. Farabee, D., Prendergast, M., & Anglin, M. D. (1998). The effectiveness of coerced treatment for drug-abusing offenders. Federal Probation, 62 (1), 3 – 10. Finney, J., & Moos, R. (1995). Entering treatment for alcohol abuse: A stress and coping model. Addiction, 90, 1223 – 1240. Flores, P. (1982). The efficacy of the use of coercion in getting DWI offenders into treatment. Journal of Alcohol and Drug Education, 28 (1), 18 – 27. Gerdner, A., & Holmberg, A. (2000). Factors affecting motivation to treatment in severely dependent alcoholics. Journal of Studies on Alcohol, 61, 548 – 560. Heather, N., Rollnick, S., & Bell, A. (1993). Predictive validity of the Readiness to Change Questionnaire. Addiction, 88, 1667 – 1677. Hiller, M. L., Knight, K., Broome, K. M., & Simpson, D. D. (1998). Legal
T.K. Gregoire, A.C. Burke / Journal of Substance Abuse Treatment 26 (2004) 35–41 pressure and treatment retention in a national sample of long-term residential programs. Criminal Justice Behavior, 25 (4), 463 – 481. Hiller, M. L., Knight, K., Devereux, J., & Hathcoat, M. (1996). Post-treatment outcomes for substance abusing probationers mandated to residential treatment. Journal of Psychoactive Drugs, 28 (3), 291 – 296. Joe, G., Simpson, D., & Broome, K. (1999). Retention and patient engagement models of different treatment modalities in DATOS. Drug and Alcohol Dependence, 57, 113 – 125. Karoll, B. (2002). Women and alcohol-use disorders: A review of important knowledge and its implications for social work practitioners. Journal of Social Work, 2 (3), 337 – 356. Kofoed, L., Kania, J., Walsh, T., & Atkinson, R. (1986). Outpatient treatment of patients with substance abuse and coexisting psychiatric disorders. American Journal of Psychiatry, 143 (7), 867 – 872. Loneck, B., Garrett, J., & Banks, S. (1996). A comparison of the Johnson Intervention with four other models of referral to outpatient treatment. American Journal of Drug and Alcohol Abuse, 22 (2), 233 – 246. Mark, F. (1988). Does coercion work? The role of referral source in motivating alcoholics in treatment. Alcoholism Treatment Quarterly, 5 (3 – 4), 5 – 22. Marlowe, D., Kirby, K., Bonieskie, L., Glass, D., Dodds, L., Husband, S., Platt, J., & Festinger, D. (1996). Assessment of coercive and noncoercive pressures to enter drug abuse treatment. Drug and Alcohol Dependence, 42, 77 – 84. McLellan, A. T., Luborsky, L., Cacciola, J., Griffith, J., Evans, F., Barr, H., & O’Brien, P. (1985). New data from the Addiction Severity Index: Reliability and validity in three centers. Journal of Nervous and Mental Disease, 173, 412 – 423. McLellan, A. T., Kushener, H., Metzger, D., Peters, R., Smith, I., Grissom, G., Pettinati, H., & Argeriou, M. (1992). The fifth edition of the Addiction Severity Index. Journal of Substance Abuse Treatment, 9, 199 – 213. Miller, W. (1985). Motivation for treatment: A review with special emphasis on alcoholism. Psychological Bulletin, 98 (1), 84 – 107. Miller, W., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behaviors. New York: The Guildford Press.
41
Polcin, D., & Weisner, C. (1999). Factors associated with coercion in entering treatment for alcohol problems. Drug & Alcohol Dependence, 54 (1), 63 – 68. Prochaska, J., DiClemente, C., & Norcross, J. (1992). In search of how people change. American Psychologist, 47 (9), 1102 – 1114. Prochaska, J., Velicer, W., Rossi, J., Goldstein, M., Marcus, B., Rakowski, W., Fiore, C., Harlow, L., Redding, C., & Rosenbloom, D. (1994). Stages of change and decisional balance for 12 problem behaviors. Health Psychology, 13 (1), 39 – 46. Rollnick, S., Heather, N., Gold, R., & Hall, W. (1992). Development of a short ‘readiness to change’ questionnaire for use in brief, opportunistic interventions among excessive drinkers. British Journal of Addiction, 87, 743 – 754. Rosenberg, C., & Liftik, J. (1976). Use of coercion in outpatient treatment of alcoholism. Journal of Studies on Alcohol, 37, 58 – 65. Ryan, R., Plant, R., & O’Malley, S. (1995). Initial motivations for alcohol treatment: Relations with patient characteristics, treatment involvement, and dropout. Addictive Behaviors, 20 (3), 279 – 297. Shaffer, H., & Simoneau, G. (2001). Reducing resistance and denial by exercising ambivalence during treatment of addiction. Journal of Substance Abuse Treatment, 20, 99 – 105. Shen, Q., McLellan, A. T., & Merrill, J. (2000). Client’s perceived need for treatment and its impact on outcome. Substance Abuse, 21 (3), 179 – 192. Simpson, D., & Joe, G. (1993). Motivation as a predictor of early dropout from drug abuse treatment. Psychotherapy, 30, 357 – 368. Simpson, D., & Friend, H. (1988). Legal status and long-term outcomes for addicts in the DARP follow-up project. NIDA Research Monograph Series, 86, 81 – 98. van der Walde, H., Urgenson, F., Weltz, S., & Hanna, F. (2002). Women and alcoholism: A biopsychosocial perspective and treatment approaches. Journal of Counseling & Development, 80 (2), 145 – 153. Watson, C., Brown, K., Tilleskjor, C., & Jacobs, L. (1988). The comparative recidivism rates of voluntary and coerced admission male alcoholics. Journal of Clinical Psychology, 44 (4), 573 – 581.