|
Article Excerpt
"Proliferation of social control tactics to facilitate addiction treatment is a world-wide social experiment without a compelling evidence base on its utility."
(Wild, 2006:46)
This study examines clients' perceived self-choice in entering alcohol and drug treatment in relation to reported informal, formal and legal pressures to enter treatment. (1) Social pressures are often important in the process of seeking treatment. This may be due to the fact that alcohol and drug problems are, by large, defined by consequences of and difficulties arising from drinking or drug use. Consequently, problems are often defined by someone else than the "problem carrier" (Weisner 1990b), which influences how people get to treatment and individuals are often pressed to enter treatment (Polcin & Weisner 1999). In a review of types of legally enforced and other coerced treatment, Weisner (1990a) defines coercion "as a form of institutionalized pressure (with negative consequences as an alternative) that results in an individual entering treatment. In the cases in which it refers to pressures by the family, coercion means those procedures in which there is an organized strategy involving some institutional contact." (p. 579). Based on this definition, she defines a continuum of coercion in treatment entry ranging from civil commitment at the most severe end of the scale through referrals from the criminal justice system and workplace referrals to early intervention or family intervention programs at the other end of the continuum. She stresses that there are variations in each category with respect to the level of coercion used. However, the continuum can be extended to include informal pressures from families and friends as important sources of coercion. In fact, studies have shown that few people come to treatment without having been pressured by family or friends about their drinking or drug use (cf. Cunningham, Sobell, Sobell & Gaskin 1994; Jakobsson 2003; Hingson, Mangione, Meyers & Scotch 1982; Polcin & Weisner 1999; Room 1989).
In agreement with the above, Wild (2006) argues that "social pressure" refers to three types of social control strategies that can--and often are--used to facilitate treatment. These are: (a) Informal social control, which refers to persuasive interpersonal tactics (e.g. threats, ultimatums) initiated by family members and friends to convince the user to enter treatment; (b) Formal social controls, including institutionalized strategies to facilitate treatment, such as mandatory referral to employee assistance programmes, social assistance programmes that require clients to attend treatment to avoid losing benefits or custody of children; and finally (c) Legal social controls, initiated by the criminal justice system, include civil commitment, court-ordered treatment and diversion-to-treatment as adjuncts or alternatives to criminal sanctions.
Most of the international literature on coercion in substance abuse treatment comes from North America. The literature on coercion and treatment is often focused on legal mandates, non-empirical commentaries, and ethical issues around coercion and treatment (Wild, Roberts & Cooper 2002; Douglas, Marlowe, Glass, Merikle, Festinger, De Matteo, Marczyk & Platt 2002). The literature has also been dominated by studies of coercion using referral source as the measure of coercion. This is problematized in a study by Wild, Newton-Taylor & Alletto (1998) about perceived coercion among clients entering treatment. Wild and his colleagues stress that the individual client's perceptions of coercion is more important than referral source when studying the impact of coercion in treatment.
In a review of help-seeking, Sheehan (1991) puts forward the idea that an interplay of a number of factors, both internal and external, is central to help-seeking. She also points to the relevance of the wider social context. In a study among 50 patients entering an alcohol treatment unit in London, Thom (1987) found that one major reason for coming to treatment was some form of external pressure. The response of others was sometimes seen as unwelcome "nagging" At other times the attempts at persuasion were reported as supportive and as important elements in treatment entry. She found that those who gave "pressure from others" as the main reason for coming to treatment seemed to seek release from the pressure without hoping for changes in their alcohol use. Oppenheimer, Sheehan & Taylor (1988) studied reasons for coming to treatment among 150 drug users in London. The most important reasons found in this study were the experience of becoming dependent on drugs, and feelings about the inability to manage one's life (see also Sheehan, Oppenheimer & Taylor 1986). Another study about problematic alcohol and drug users' reasons for seeking treatment, by Cunningham et al. (1994), also identified a cognitive appraisal process as a reason for seeking treatment.
Treatment-seeking studies have been rare in Sweden. However, Blomqvist (Blomqvist & Christophs 2005) has initiated Swedish research on how people resolve alcohol problems with and without treatment (which includes help-seeking), by prospectively following a group of people (224 were recruited when they first sought treatment, 103 were found through advertising without prior treatment seeking experiences). Initial analyses show that the explanatory variables for seeking treatment and actually starting treatment are somewhat different, and the pattern is different for women and men. For men, the initial help-seeking stage is related to pressures from the surroundings, whereas the decision to start treatment is more related to the severity of problems. External motivation to change alcohol use (pressures from others and especially from a partner), but not internal motivation, is important for seeking help and starting treatment. Women's decisions to seek treatment, on the other hand, were more closely related to motherhood and a wish to keep a functioning working life. The number of women was too low for performing analyses on women's decisions to actually start treatment (Blomqvist & Christophs 2005).
Another qualitative Swedish study on alcohol treatment entry also showed gender differences. In this study, interviews were conducted with people who entered outpatient alcohol treatment. Women reported pressures from family and friends about their drinking. This pressure could, in line with Thorn's study, both prevent and promote help-seeking. Men stressed the importance of their own motivation and said that they wanted to change their behavior to avoid hurting others. Men denied having problems and said that it was their own choice to come (Jakobsson 2003).
With respect to self-choice in entering treatment, most practitioners think motivation is important in the treatment process. Treatment (cf. Motivational Interviewing in Rollnick & Allison 2001) does to a large extent build on motivation, and the "stage of change" (2) of the client (Prochaska & DiClemente 1982). It is stressed that motivation to change should not be imposed from without, but come from within the client (Rollnick & Allison 2001) and that treatment should be congruent with the clients' readiness for change (cf. Lam, Hilburger, Kornbleuth, Jenkins, Brown & Racenstein 1996). Self-choice is also stressed with respect to expected outcome (cf. SOU 2004). In her review, Weisner (1990a) touches on the question of coercion versus self-referral. The relation between motivation, self-choice, and informal pressures and coercion has been looked at in a few studies. These studies show that clients enter treatment for both coercive and non-coercive reasons (cf. Marlowe, Kirby, Bonieskie, Glass, Dodds, Husband, Platt & Fastinger 1996; Douglas et al. 2002; Wild et al. 1998). For instance, in the study by Wild et al. (1998), about one-third of clients that were legally mandated to treatment didn't perceive any coercion, whereas over 70 percent of the clients that were not mandated to treatment experienced coercion during treatment entry. Wild, Cunningham & Ryan (2006) have continued this line of research. In a study among 300 treatment-seeking individuals, external motivation (coercive social pressures) was positively correlated with legal referral and social network pressures to enter treatment, and inversely related to problem severity. Treatment motivation (personal choice and commitment) was positively correlated with self-referral and problem severity, and inversely related to perceived coercion.
There have been a number of studies, not always in agreement, relevant to understanding the help-seeking process. But it cannot be said that there is a well-defined literature with clear conclusions. Little is known about coercive referral sources (see Weisner 1990a) and we do not fully understand how pressures and coercion relate to self-choice. As mentioned, some studies show that coercion does not necessarily exclude self-choice, and vice versa (cf. Wild et al. 1998). However, the literature often seems to treat coercion as opposite to self-choice in a literature which has focused on referral source, instead of looking at the clients' own perceptions of coercion and self-choice in coming to treatment. Wild (2006) argues that informal control tactics, like pressures from significant others, have been neglected in research on coercion in alcohol and drug treatment. In addition, the study (above) by Blomqvist & Christophs (2005) implies that pressures from the surroundings bring people to seek treatment. However, it is not yet clear how these pressures are related to whether or not the treatment-seeking individual feels that coming to treatment, after being pressured, is his or her own decision. To sum up, more research is needed in the field of social pressures to seek treatment and perceived treatment motivation or engagement (cf. Wild 2006). This field also has to be further broadened to also look more in detail at coercion and self-choice among drug users, since most of the research has focussed on alcohol treatment.
Aim and research questions
This article is part of a large treatment system study in Stockholm County, Women and Men in Swedish Alcohol and Drug Treatment (see Room, Palm, Romelsjo, Stenius & Storbjork 2003), which offers the opportunity...
|
