Introduction
Addiction is an urgent public health issue that is attracting the attention of many stakeholders. Policymakers, healthcare practitioners, law enforcement professionals, researchers, and educators have been involved in the discussion of various aspects of the problem. Psychotherapy is regarded as a key to addressing the issue, which has led to the development of various types of interventions for different groups (Jordan, Lampo, Parshall, & DeVuyst, 2014). It is noteworthy that the rate of addiction specifically among offenders is high (Rourke, Howard, & Martire, 2015). It has been widely believed that offenders are unlikely to seek professional help, which has resulted in the introduction of mandatory interventions addressing this population’s addiction issues (Rourke et al., 2015). However, the cost-effectiveness of these interventions is still in dispute, and ethical and legal concerns are often put forward. The purpose of this paper is to review recent studies to identify the challenges and opportunities related to the use of coercion in the counseling of mandated clients with addictions.
Coercion is one of the primary components of the mandatory programs as clients are subjected to pressure from legal institutions, as well as from relatives, friends, colleagues, and employers. At the same time, the opponents of this approach to addressing the problem of addiction emphasize that mandatory interventions violate some of the basic rights protected by the US Constitution (Manchak, Skeem, & Rook, 2014). Furthermore, critics emphasize that the cost-effectiveness of mandatory counseling interventions is doubtful due to clients’ lack of motivation and commitment to the goals of this treatment (Wolfe, Kay-Lambkin, Bowman, & Childs, 2013). As far as the ethical issues are concerned, autonomy is the central element of counseling provided to mandated clients, and it is violated. Uusitalo and Van der Eijk (2016) argue that the population in question is being deprived of their right to make decisions concerning their health and wellbeing.
As a substance abuse counselor, I am particularly interested in the effects coercion has on mandated clients’ outcomes. I have worked with clients who had either counseling or prison as their two available options, which made their intrinsic motivation rather low. One of the major ethical dilemmas for me with the use of coercion is that it is inappropriate in counseling, in my opinion. When I started working on this assignment, I expected to find the answers to my questions concerning the effectiveness, and more importantly the appropriateness of coercion in counseling provided to mandated clients. Since I mainly work with people diagnosed with substance abuse, the primary focus of this paper is on this population.
Literature Review
The review of recent literature on coercion in mandated clients’ counseling resulted in the identification of four topics. The central areas of concern include the impact of coercion on motivation, the effectiveness of coercion and existing alternatives, ethical and legal challenges to the use of coercion, and mandated clients’ perspectives on the matter. It should be noted that sources published during the past 10 years were included in this research. The focus was on peer-reviewed articles that involved the use of primary data, although meta-analyses were also considered to gain more insights into the problem. The review is based on such keywords as coercion, mandated clients, substance abuse, and compulsory treatment. Various databases were searched including Google Scholar, PubMed, Scopus, and ERIC.
The Effectiveness of Coercion and Alternatives
One of the central themes identified is associated with the analysis of different approaches and their effectiveness. Researchers and practitioners have tried to identify the major barriers to the successful implementation of various programs and models. Theoretical and practical aspects of the problem have been discussed in detail. For instance, Burrowes and Needs (2009) assessed the widely-used Stages of Change Model that was often employed when counseling mandated clients. The authors argued that the framework was ineffective as it did not reveal people’s readiness to change. The researchers developed the Readiness to Change Framework that included the Context of Change Model and the Barriers to Change Model (Burrowes & Needs, 2009). According to Burrowes and Needs (2009), coercion is associated with a context of change that has a considerable impact on clients’ outcomes. The authors noted that coercion was often perceived differently by people, so one of the preliminary stages of treatment had to be the identification of clients’ views on the matter. Such concepts as control, autonomy, affiliation, and support can guide this research.
The impact people’s attitudes towards coercion have on clients’ outcomes is well-researched. For example, Parhar, Wormith, Derkzen, and Beauregard (2008) examined 129 studies concerning different mandated treatment programs and found that such interventions did not affect recidivism. The researchers emphasized that mandated treatment was ineffective, especially when it involved custodial settings. It is noteworthy that voluntary participants paid little attention to the environment but focused on their goals, which translated into positive results for them (Parhar et al., 2008). In simple terms, people evaluated the level of coercion and developed certain behavioral patterns based on this evaluation. The authors identified motivation as the necessary premise for positive outcomes. Remarkably, Parhar et al. (2008) associated coercion with a high degree of control and limited autonomy of clients. The authors emphasized the negative aspects of coercion and the adverse effects of this approach on clients’ engagement and motivation.
In contrast to these findings, Stevens (2012) noted that some forms of coercion did not negatively affect clients’ motivation to change. It was assumed that the interventions that were offered as alternatives to imprisonment could be effective, but purely mandatory programs were likely to have no effect. Jordan et al. (2014) considered the historical context of the creation and development of mandated programs and also concluded that complete coercion was associated with negative or no meaningful outcomes for clients. More person-centered approaches proved to have a positive influence on clients and their motivation to change. The historical details provided in the article help explain the logic in coerced programs and the reasons behind different strategies that were introduced during the 20th century.
The ineffectiveness of existing mandated treatment models is also discussed by Uusitalo and Van der Eijk (2016), who claimed that coercion was unethical and demotivating. At the same time, the researchers agreed that some forms of coercion could have a positive impact on clients’ motivation. It was stressed that a supportive environment and the facilitation of clients’ autonomy were instrumental in making coercion-based interventions effective. Thomas and Bull (2013) provided qualitative data that support the findings concerning the efficiency of some types of mandatory models. The researchers conducted semi-structured interviews with five community-based service providers involved in different types of support work. The study aimed to identify practitioners’ particular views concerning coerced treatment and ways to address the major challenges associated with this practice. Thomas and Bull (2013) found that partial coercion could be an effective framework, whereas purely mandated models were ineffective. It was stressed that practitioners believed that a certain degree of client empowerment was beneficial as people’s motivation was enhanced by their involvement in the decision-making process.
Coercion and Motivation
Although the previous topic is closely linked to motivation, the relationship between coercion and motivation can be identified as another area of concern in current academic research. For example, Wolfe et al. (2013) implemented a quantitative study and aimed to explore the relationship between motivation and coercion. The community-based study involved 77 participants who completed questionnaires concerning changes in their substance use. Wolfe et al. (2013) identified no direct correlation between coercion and motivation. The researchers reported that coercion alone did not predict the outcomes of mandatory interventions as the tools and strategies that had been used by practitioners were central to clients’ behavior changes. Wolfe et al. (2013) asserted that practitioners could motivate their clients through various means such as motivational interviewing. Burrowes and Needs (2009) developed their model based on similar assumptions. The researchers believed that motivation could be facilitated within the context of coerced programs. Therefore the present review shows that coercion per se cannot be regarded as the major factor affecting clients’ outcomes and their intrinsic motivation.
Ethical Challenges and Legal Issues
Apart from the effectiveness of specific models and approaches, researchers and practitioners are interested in exploring ethical and legal issues related to coercion in the counseling of mandated clients. Rushforth (2014) noted that modern legislation, recent court rulings, and, more importantly, the US Constitution make it clear that involuntary treatment was unethical and against the democratic principles of the country. The author emphasized that the only premise for the use of coercion was the threat of violence or harm to others, but in other cases, people could not be forced into treatment. Stevens (2012) also stated that compulsory treatment could be utilized in a moment of crisis. The researcher argued that only a certain degree of coercion was possible when dealing with offenders diagnosed with substance abuse. Hall and Lucke (2010) also regarded coerced approaches as unethical as offenders were deprived of their right to choose. The authors assumed that imprisonment could be one of the ways to reduce drug use and criminal activity, as well as an alternative to community-based treatment. Hall and Lucke (2010) argued that offenders were motivated to be more engaged as they saw imprisonment as an intolerable option for them.
Hem, Molewijk, and Pedersen (2014) explored major ethical challenges in the context of formal, perceived, and informal coercion. The researchers conducted a qualitative study that involved 65 multidisciplinary practitioners who worked in the healthcare setting. The purpose of the study was to look into challenges to effective mandated counseling. It was found that healthcare professionals had to face issues related to such issues as autonomy, paternalism, communication, relationships, and collaboration. Importantly, Hem et al. (2014) pointed to a lack of ethical vocabulary as people tended to see ethical issues and their effects differently, which made various studies’ findings rather disputable. Seddon (2007) also claimed that the effectiveness of coercion in counseling could hardly be assessed due to the lack of consensus on major concepts and terms guiding modern researchers on this matter.
Stakeholders’ Perspectives
Finally, the opinions of the stakeholders have been well researched and contextualized in various ways. There is wide acknowledgment that the analysis of the views of offenders and healthcare professionals can provide valuable insights into the problem and help in the development of effective approaches. Urbanoski (2010) conducted a review of the empirical data and theoretical perspectives regarding clients’ views of compulsory treatment. It was found that the analysis of offenders’ views lacked precision, which had an impact on the value of the empirical evidence. The researcher identified considerable gaps in the knowledge base and concluded that further inquiry was necessary in such areas as the long-term effects of coercion and its influence on treatment systems, individuals, and public health.
As far as empirical studies are concerned, Kras (2012) added to the literature by examining the perspectives of offenders. The study involved 36 parolees and probationers who were coerced to attend treatment. Kras (2012) conducted in-depth interviews aiming at the analysis of offenders’ opinions concerning compulsory treatment, their supervising officers’ roles in this process, and the quality of the offender-officer relationship. The researcher stated that clients revealed quite conflicting views on the matter as they disliked attending the compulsory programs but acknowledged the benefits of their participation. The offenders stated that such programs helped them in their reintegration into the community and coping with their addiction. The role of officers also became clearer as the clients believed that law enforcement professionals contributed to the completion of the program.
Rourke et al. (2015) also concentrated on offenders’ perspectives and explored the views of mandated clients in residential alcohol and other drug (also referred to as AOD) treatment. The researchers implemented a qualitative analysis based on the self-reporting of 114 clients. The offenders who participated in the program addressed such areas as motivation, engagement, and retention. The retention rate was also analyzed to support the qualitative data. Rourke et al. (2015) noted that legal mandates and similar kinds of coercion did not necessarily have adverse effects on retention and clients’ engagement. Peer support, intrinsic motivation, and self-efficacy proved to be influential predictors of offenders’ engagement. The participants were motivated if they had some degree of autonomy and were supported by their relatives, community, or officers.
The benefits of coercion are also revealed in the study by Manchak et al. (2014), who examined offenders’ perspectives on their relationships with healthcare practitioners. It was hypothesized that the significant degree of coercion that characterizes mandated treatment would have negative effects on client-therapist affiliation. Nevertheless, Manchak et al. (2014) found that the relationships in question were not adversely affected. Instead, the treatment was associated with a significant level of autonomy-granting and affiliation.
Studies addressing the attitudes of practitioners include the article by Thomas and Bull (2013), who examined counselors’ views on the efficacy of coercion in compulsory treatment. The researchers emphasized that the participants in their study tried to ensure clients’ right to choose and their autonomy. Hem et al. (2014) concentrated on healthcare professionals’ opinions as well. The identification of ethical challenges counselors had to face was seen as a way to identify gaps in a mandated intervention and associated opportunities.
Discussion and Implications
This review provides insights into the role of coercion in the counseling of mandated clients, as well as some of the existing gaps. It is evident that the vast majority of researchers have conflicting views on the effectiveness of coerced treatment. On the one hand, it is stressed that the lack of autonomy is the primary ethical and legal issue making the approach cost-ineffective. On the other hand, almost all authors whose works are included in this paper agree that partial coercion can be beneficial for offenders diagnosed with substance abuse. It is widely acknowledged that various types of coercion can have a positive influence on clients’ intrinsic motivation, self-efficacy, and engagement. One of the most valuable insights gained from this review is the role that support and affiliation play in clients’ engagement and behavioral changes. As for ethical concerns, researchers emphasize the lack of consensus regarding these concepts and their meaning.
It is also important to mention some of the most urgent gaps yet to be addressed. Offenders’ perspectives tend to be explored, while other stakeholder’s opinions remain almost completely disregarded. Clients’ views are of course instrumental in the development of client-centered programs, but the attitudes of practitioners or offenders’ family members and other close associates can add to the knowledge base. Support often comes from other stakeholders, which makes them an important factor that should be analyzed. Another gap is associated with studies that aim to evaluate the effectiveness of coerced treatment. The available information is insufficient to estimate the cost-effectiveness of the approach. Researchers often concentrate on specific programs and projects, so the data obtained so far can hardly be generalized. The sample size of the reviewed articles is insufficient to draw relevant conclusions.
In addition to this review’s contribution to the empirical and theoretical literature, this research can be of paramount importance for counselors working with mandated clients. These healthcare professionals can make use of some of the findings and theoretical frameworks. One of the most significant findings to consider is the positive impact of partial coercion, the importance of autonomy, proper client-practitioner relationships, and external support. Counselors should ensure that their treatment is client-based, which can be achieved through the development of rapport between them and their clients. Mandated clients must have the right to choose and have some degree of autonomy, which will make them more engaged and motivated.
The present review is also valuable since it can guide practitioners who try to gain insight into the matter. The identification of the most significant gaps may motivate counselors to undertake their own studies that will expand the knowledge base concerning coercion in counseling. It is clear that quantitative data can be necessary for the identification of the cost-effectiveness of the use of different levels of coercion. Qualitative research can be beneficial for the analysis of different stakeholders’ perspectives. It is essential to include different groups such as offenders, counselors, parole and probation officers, clients’ families, and the community.
This brief literature review sheds light on various aspects of the problem under discussion. A limited degree of coercion or quasi-mandatory programs can be effective, but further research is needed in this area. Mandated clients can benefit from interventions that are associated with autonomy-granting, supportive relationships, and affiliation. This review can become the first step in the process of developing an effective intervention or a broader approach that will be used in various settings.
References
Burrowes, N., & Needs, A. (2009). Time to contemplate change? A framework for assessing readiness to change with offenders. Aggression and Violent Behavior, 14(1), 39-49. Web.
Hall, W., & Lucke, J. (2010). Legally coerced treatment for drug using offenders: Ethical and policy issues. Crime and Justice, 144, 1-12. Web.
Hem, M. H., Molewijk, B., & Pedersen, R. (2014). Ethical challenges in connection with the use of coercion: A focus group study of health care personnel in mental health care. BMC Medical Ethics, 15(82). Web.
Jordan, R. A., Lampo, D., Parshall, S. T., & DeVuyst, R. T. (2014). The 180 degree turn: Finding the human side of mandated counseling. The Person Centered Journal, 21(1-2), 55-68.
Kras, K. (2012). Offender perceptions of mandated substance abuse treatment: An exploratory analysis of offender experiences in a community-based treatment program. Journal of Drug Issues, 43(2), 124-143. Web.
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. Web.
Parhar, K. K., Wormith, J. S., Derkzen, D. M., & Beauregard, A. M. (2008). Offender coercion in treatment. Criminal Justice and Behavior, 35(9), 1109-1135. Web.
Rourke, P., Howard, J., & Martire, K. A. (2014). Legal mandates and perceived coercion in residential alcohol and other drug treatment. Psychiatry, Psychology and Law, 22(5), 756-768. Web.
Rushforth, J. (2014). Ethics and the use of coercion in the treatment of psychiatric patients. Themis: Research Journal of Justice Studies and Forensic Science, (2)1, 99-112.
Seddon, T. (2007). Coerced drug treatment in the criminal justice system: Conceptual, ethical and criminological issues. Criminology & Criminal Justice, 7(3), 269-286. Web.
Stevens, A. (2012). The ethics and effectiveness of coerced treatment of people who use drugs. Human Rights and Drugs, 2(1), 7-15.
Thomas, N. K., & Bull, M. (2013). Negotiating the challenges of coerced treatment: An exploratory study of community-based service providers in Queensland, Australia. Contemporary Drug Problems, 40(4), 569-594. Web.
Urbanoski, K. A. (2010). Coerced addiction treatment: Client perspectives and the implications of their neglect. Harm Reduction Journal, 7(13). Web.
Uusitalo, S., & Van der Eijk, Y. (2016). Scientific and conceptual flaws of coercive treatment models in addiction. Journal of Medical Ethics, 42(1), 18-21. Web.
Wolfe, S., Kay-Lambkin, F., Bowman, J., & Childs, S. (2013). To enforce or engage: The relationship between coercion, treatment motivation and therapeutic alliance within community-based drug and alcohol clients. Addictive Behaviors, 38(5), 2187-2195. Web.