Many professionals who work with people who have alcohol and other drug (AOD) problems assume that for treatment to be successful, individuals must first “hit bottom,” personally admitting they have an AOD problem, and they must be willing to voluntarily participate in treatment. Despite these assumptions, encouraging or mandating individuals into treatment has become a widely accepted practice (Fagan, 1999).

Mandating treatment is used because studies show that typically less than 10 percent of AOD abusers enter treatment or are in self-help programs for their abuse and, once in treatment, dropout rates are high (typically 40 to 60 percent) (Higgins & Budney, 1997; Miller, Brown, Simpson, Handmaker, Bien, Luckie, Montgomery, Hester, & Tonigan, 1995). This article discusses where and how mandatory treatment is most frequently used, the effectiveness of mandated treatment, and how to increase motivation for change with this population using Prochaska and DiClemente’s (1982) stages of change and Miller’s (1995) FRAMES (i.e., feedback, responsibility, advice, menu, empathy, self-efficacy) models.
Mandated treatment: Who and where?

In the United States, mandated treatment is used primarily in the workplace and the criminal justice system. Some companies must meet state and federal guidelines that require random AOD testing, while other companies voluntarily have adopted drug-monitoring policies as a condition of employment. Many companies with these policies offer treatment under a “return to work” agreement whereby employees are required to comply with treatment conditions or they will lose their job. The area where mandatory treatment is most often utilized is in the criminal justice system (Lawental, McLellan, Grissom, Brill, & O’Brien, 1996).

Historically, many state courts have offered defendants AOD treatment as an alternative to incarceration or as a condition of probation, but beginning in the late 1980s, states created what is most frequently called “drug courts.” The key operational components of drug courts typically include:

1) the drug court is reserved for drug offenders;

2) the court provides judicial supervision of structured community-based treatment (e.g., individuals sign waivers before they begin the program to allow the court to monitor compliance and performance in treatment);

3) the court’s adjudication process is non-adversarial in nature with the concept of a DTC team (judge, prosecutor, defense counsel, treatment provider, and corrections personnel) working together;

4) the court provides timely screening and referral to treatment as soon as possible after arrest;

5) the court has clearly defined structured rules and goals for participation including regular AOD testing;

6) the court has regular status hearings before a judge to monitor treatment progress and program compliance;

7) the court uses a series of graduated sanctions and rewards for treatment compliance and noncompliance (including relapses); and

8) the court dismisses charges or reduces the sentence upon successful program completion (Belenko, 2002; Hora, Schma, & Rosenthal, 1999; Marlowe, & Kirby, 1999; Young, 2002; Tauber, Weinstein, & Taube, 1999; USDHHS, 1997).

While mandated treatment is being used in the workplace and by the courts, is it effective in reducing AOD use?

Effectiveness of mandated treatment
The research on the effectiveness of mandatory AOD treatment generally shows that it is at least as effective and nonmandated treatment and with some populations, more effective. The literature on required treatment for employee populations generally shows reduced psychiatric, medical, and legal consequences, and increased productivity in the workplace comparable to volunteer referrals (Lawental, McLellan, Grissom, Brill, & O’Brien, 1996).

Though there has been some contrary findings due to the many different types of programs and methodological problems, generally the research on the impact of drug courts shows that:

1) participants get into treatment earlier in their substance abusing careers and remain in the treatment at a rate almost double the rate for most community-based programs (about 50 percent to 70 percent remain in treatment after one year);

2) program costs are generally lower than standard criminal justice system processing;

3) drug courts provide closer and more frequent supervision than under the standard probation, parole, or pretrial supervision of these offenders;

4) drug use and criminal behavior are comparatively reduced while drug-court participants are under program supervision; and

5) some programs show increased employment and education (Anglin & Hser, 1990; Belenko, 2002; Brecht, Anglin, & Wang, 1993; Farabee, Prendergast, & Anglin, 1998; Miller & Flaherty, 2000; Taxman & Messina, 2002).

Therefore, mandated treatment can be an effective treatment strategy especially with people who are unwilling to seek treatment voluntarily. Given the evidence that mandated treatment can work, the challenge is to find ways to increase individuals’ motivation for entering and remaining in treatment and to find ways to make treatment more attractive and successful to individuals with a wide variety of AOD abusing problems.

Increasing motivation for treatment
Rarely are individuals truly required to accept AOD treatment as a part of criminal sentencing or employment. Rather, in most situations individuals are given a choice of treatment in lieu of alternative consequences for their AOD use. If an individual refuses the treatment option or does not comply with the conditions of treatment, then the alternative sanction is imposed. While technically people are mandated into treatment, in one sense they are “choosing” AOD treatment over criminal sanctions. Many so-called “self-referred” clients feel they are being coerced into treatment by people around them, while other mandated clients do not resent being forced into treatment.

Traditionally, motivation or lack of motivation was thought to be a characteristic of the person (Broome, Knight, Knight, Hiller, & Simpson, 1997; Hiller, Knight, Broome, & Simpson, 1998). Individuals who did not comply with, or failed in, treatment are often said to have been “in denial” and not motivated enough for the treatment to be effective (Klingemann, 1991; Miller, 1995; Proschaska & DiClemente, 1982). There is often the Catch-22 situation for the court-mandated individual. Mandated treatment is used because the individual is thought to be unmotivated to seek treatment, and the individual is thought to be unmotivated when mandated treatment is used.

Seeking help is influenced by the interactive influence of barriers and incentives that are structural (e. g., economic, geographic factors) or functional (e. g., psychological and social influences) in nature. Rather than being unmotivated, individuals may drop out of treatment because for a variety of reasons the program is not working for them at that time (DeLeon, 1988; Weisner, 1993). Studies show that most individuals who drop out of treatment do so within the first month and dropouts usually seek treatment again (Peterson, Swindle, Phibbs, Recine, & Moos, 1994). It is increasingly becoming clear that retention in treatment is dependent on a combination of factors including program, therapist, and individual characteristics and these variables need to be addressed in any type of treatment (Blankenship, Dansereau, & Simpson, 1999; Joe, Simpson, & Brown, 1998; Joe, Broome, Rowan-Szal, & Simpson, 2002; Wierzbicki & Pekarik, 1993). A key to understanding the factors that encourage or discourage people from seeking and remaining in treatment is to understand where they are in, what has come to be called, the “stages of change.” Understanding the stages of change outlined in the transtheoretical model (Prochaska & DiClemente, 1982) — precontemplation, contemplation, preparation, action, and maintenance and relapse prevention — both can help bring people into treatment who otherwise would be hesitant or unwilling to voluntarily seek treatment and can help people who are in treatment, either voluntarily or mandated, fully participate in treatment.

Five-stage model of change
Moving through the stages of change1 (Prochaska & DiClemente, 1982) typically is not a linear process. Most people who are trying to modify their AOD-related behaviors will relapse, repressing to an earlier stage, usually the contemplation or preparation stages. These relapse experiences can contribute information that can facilitate or hinder subsequent progression through the stages of change. Recovery is a cyclical process in which individuals often make several attempts (including on their own) to modify or cease their AOD use before coming to your program.

Effective treatment involves engaging in the right processes at the right stages. While precontemplators need help in raising their awareness, contemplators need help in resolving their ambivalence about their AOD use. At the preparation stage, individuals may need help in selecting the type of treatment that would work best for them. In the action stage, individuals may need help in carrying out treatment goals. Finally, in the maintenance stage, individuals need help in dealing with, and avoiding, relapses.

FRAMES motivation model
No matter where a person is in the stages of change, no matter how they came to treatment, either voluntarily or mandated, there are proven strategies to help to motivate people to change their thoughts and behavior. Miller (1995) identifies six keys to motivation for change (what he calls FRAMES) that are appropriate for any type of problem behavior including AOD abuse.

“Feedback” involves giving personal feedback with regard to ways in which the behavior is harming the individual. Lectures and films about detrimental effects of AOD use on people in general seem to have little or no impact on AOD behavior. Rather, personal feedback based on a thorough assessment of individuals regarding the ways in which their AOD use is harming them does seem to have strong motivational effect (Blankenship, Dansereau, & Simpson, 1999).

“Responsibility” is related to the research that consistently shows that people are most likely to take action when they perceive that they personally have chosen to do so. When individuals are told they have no choice, they often resist change, but when they are told that it is ultimately up to them to choose, then they may be more likely to change. Instead of telling individuals that they have a problem, individuals should be asked to talk about their own perceptions of the situation. Statements such as: “You have a serious problem and you need treatment” is likely to evoke from many individuals the countering argument: “No, I don’t.” Asking individuals questions such as: “Are there any things about your substance use that concern you, that you would like to change?” can help individuals resolve their ambivalence.
Different from ordering or requiring, “advice” involves giving the client clear and direct counsel as to the need for change and how it might be accomplished. The key element is a clear recommendation for change, based on accurate personal information, given in an empathic manner (Najavito & Weiss, 1994).

In order for a person to truly believe that he or she has personal responsibility in decision-making, there must first be real alternatives from among which the individual can choose. “Menu” involves individuals actively involved in choosing their own treatment approach from alternatives. The research shows that programs need to be flexible with no single treatment being appropriate for all individuals (Miller, Benefield, & Tonigan, 1993).

One of the strongest predictors of therapist success in motivating and treating individuals is “empathy.” An empathic therapist is one who is client-centered, listening to, and reflecting, the client’s statements and feelings by:

1) speaking directly, simply, and honestly,
2) avoiding making judgmental comments, asking open-ended questions including their thoughts and feelings about being in therapy, and then being a good listener,
3) acknowledging the person’s distress and ambivalence about being in therapy and addressing their AOD problems,
4) exploring the purpose and goals of treatment and ways in which recovery can best be accomplished with them,
5) discussing issues of confidentiality,
6) instilling confidence in the person about your skills as a therapist and your belief that they can meaningfully address their problems (Johnson, 1980).

Finally, “self-efficacy” involves helping individuals come to believe that meaningful change can be achieved. This is accomplished not only by helping to give them the tools they need to make meaningful changes, but it also involves treatment personnel truly believing in what they are doing, communicating both that they care about the person and that they believe the person can make meaningful changes (Strupp, 1996).

A final word
Clearly, research shows that mandated AOD treatment can work. Most professionals would agree that in most cases, the best strategy is for people to voluntarily seek and participate in treatment (Winick, 1997). The stages of change and FRAMES models offer practical ways of encouraging people to voluntarily seek and participate in treatment. For mandated clients, these models help minimize the perception that they are being forced into treatment and enhance their appreciation that the treatment is benevolently motivated. Counselors can use these models to develop individualized treatment strategies that increase client motivation for meaningful long-term change.

Ronald W. Fagan, PhD ( This e-mail address is being protected from spam bots, you need JavaScript enabled to view it ) is a Professor of Sociology in the Social Science Division of Seaver College at Pepperdine University.

Footnote
1Editor’s note: Two recent Counselor articles have explored the application of Prochaska and DiClemente’s (1982) stages of change model in depth: the Research to Practice column “Addiction Counseling Research: More Useful Snippets” by Michael J. Taleff, PhD, CSAC, MAC (October, 2003) and “Strategies for Increasing Client Motivation” by William A. Howatt, PhD, EdD, ICADC (December, 2003). Both of these
articles are available for free in the archives of www.counselormagazine.com.

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This article is published in Counselor,The Magazine for Addiction Professionals, August 2004, v.5, n.4, pp. 38-41.

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C. Wainwright   |71.230.204.xxx |2007-07-16 10:24:27 Excellent synopsis of Transtheoretical model of change and Miller's Frames model. I have observed similar outcomes to those discussed the studies to which the author refers. Client centered approaches always generate the most successful & advantageous outcomes. [smiley=happy] Reply 0   0

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