Research, and the experience of justice and treatment professionals nationwide, is calling into question the notion that an individual with an addiction has to want help to benefit from it. Analyses of clients who are mandated into treatment through the order of a court or other justice official are demonstrating that some people can be prodded on the path to change and see good results.
One particularly telling study looked at 2,095 men undergoing treatment for substance use disorders at one of 15 inpatient programs operated by the Department of Veterans Affairs (VA). The majority of the study sample consisted of individuals who had entered treatment voluntarily and had no prior criminal justice involvement. But 7% of the subjects were on probation or parole and were mandated to participate in treatment, while 11% were justice-involved but still participating in treatment voluntarily. A group of researchers found that the mandated group did as well as the others during treatment, and at one-year follow-up actually reported better rates of abstinence and avoidance of substance-related consequences in their lives.
“One of the National Institute on Drug Abuse's principles of effective treatment is that treatment doesn't have to be voluntary to be effective,” lead researcher John F. Kelly, PhD, associate director of addiction research at Massachusetts General Hospital, said in an interview with Addiction Professional. “These outcomes are very promising. The arrest rates for mandated clients went and stayed down after treatment, and employment was up.”
Severity doesn't explain outcomes
The research group, encompassing Kelly, John W. Finney, PhD, and Rudolf Moos, PhD, found that successful results for the mandated group held up even after controlling for other factors that could have explained the change this group experienced. The researchers controlled for a less severe clinical profile for the mandated group at treatment intake, as those individuals reported the lowest level of negative consequences from alcohol and drug consumption and the fewest symptoms of depression and anxiety.
“The mandated group was a little better off, so we might have anticipated a better prognosis,” Kelly says. “We wondered whether the outcomes could be explained by a better profile, but when we controlled for those variables, we still found that they responded as well to treatment.”
The key, Kelly explains, wasn't in the profile the client carried into treatment, but in the gains the client was able to make through treatment exposure and interaction with peers in a treatment context. Treatment in the VA programs consisted primarily of group therapy and individual case management, with some of the programs embracing a 12-Step philosophy and others taking more of a cognitive-behavioral approach. “The VA programs are not that different from other kinds of programs across the country,” Kelly says.
The men in the analyzed VA programs received treatment for either 21 or 28 days. Assessments were conducted at intake and discharge, as well as one year and five years after treatment. The researchers found that treatment perceptions and self-reports of treatment satisfaction were similar for all three subgroups in the study.
Strikingly, by the time of one-year follow-up, arrest rates for the two groups that had been involved in the justice system before treatment both had fallen from prior levels. The mandated clients exhibited an arrest rate of 20%, less than the 32% arrest rate for clients not mandated to treatment but previously justice-involved and identical to the rate for clients with no criminal justice history. Results of the study were published in the April 2005 Journal of Substance Abuse Treatment.
Need for more detail
Kelly believes more detailed research is needed before anyone could conclude that mandated treatment should occur on a much grander scale overall. He says the analysis he coauthored left some details unexplored, such as the nature of the mandate for the clients required to enter treatment and a lack of information on how much posttreatment monitoring the clients received.
Also, the terms “voluntary” and “mandated” may be difficult to distinguish in certain cases. If a person is not court-ordered to treatment but is there because a broken relationship or lost job may be imminent, how much does that truly differ from treatment handed down by a judge?
Kelly concludes that the VA study remains significant in demonstrating that mandated clients can enjoy benefits of treatment almost from the start. “Once the client is exposed to treatment, it has an effect,” he says.