As an addiction psychiatrist, I’m often faced with this situation: A desperate person reaches out to ask how they can force their family member into drug or alcohol treatment. A sister has had multiple car crashes, or a husband can’t quit drinking, or a son or daughter keeps overdosing. In New York, where I practice, there’s a simple answer: If they don’t want treatment, there’s no legal way to compel them. That’s how most clinicians practice in the U.S. But with growing nationwide concern about the opioid crisis, some people are rethinking the use of coercion in addiction treatment.
There are only a handful of U.S. states that regularly mandate people with addiction into treatment against their will (that is, outside of the more common drug court approaches, in which, after getting charged with a crime, people might be offered treatment instead of punishment). But recently, lawmakers in other states from New Hampshire to Alabama have crafted new laws expanding compulsory treatment. For example, bills proposed in Pennsylvania would allow families to commit their relatives into locked-down inpatient facilities, or require people to attend treatment after drug overdoses, or else face jail time. As other commentators have noted, on a policy level, these new laws are counterproductive because they would shunt crucial resources away from more effective measures, such as expanding our network of traditional treatments for those seeking help. But the trend toward involuntary treatment points toward an important empirical question: Does coerced treatment actually work?
Even outside of formal legal measures, coercion is already woven into the fabric of U.S. addiction treatment: Up to 75 percent of people in treatment programs say they are there because of some formal or informal pressure. The very nature of addiction makes some forms of coercion inevitable; as long as some people experience denial and resistance about their substance use problems, they will be pressured into treatment rather than seek it out on their own. So what is called “coercion” is not homogenous—it runs the gamut from friendly personal leverage to a true legal mandate or court order. It’s this spectrum that demands a close consideration so that we can reach a more nuanced understanding—and given that coercion is so ingrained in our society, to understand how we can work with it most helpfully and minimize its possible dangers.
Coerced treatment is a fiercely debated topic in addiction. Major organizations are at odds over the idea: Several U.N. programs have spoken out against compulsory treatment, calling it harmful, but the National Institute of Drug Abuse asserts that treatment need not be voluntary to be effective.
One major reason for this disagreement is a confusion in terms. Even many researchers and clinicians make the error of assuming that coercion refers only to the most absolute forms of control. But there is a big difference between formal and informal coercion. In everyday language, the word coercion implies force or threats, but in a more precise sense it simply means a hard choice. Formal, legal coercion gets more attention, but informal coercion is far more common—such as when friends, family, or employers make someone choose between seeking treatment and losing a relationship or a job.
People have studied coerced addiction treatment, but it’s a messy process to fit into the usual experimental trial framework, and the studies tend to focus on formal coercion. A 2015 structured review of the most rigorous studies found that coerced treatment was generally no better than treatment as usual. Critics of coercion have interpreted these results to say that we don’t know whether coerced treatment has any effect—or whether it works at all. But this is an odd interpretation. The key question should not be whether compulsory treatment is any better than, but if it is simply at least as effective as, usual voluntary treatment. We shouldn’t expect compulsory treatment to outperform traditional treatment.
For example, one of the largest and most rigorous studies of coerced addiction treatment was a Veterans Affairs investigation of over 2,000 patients published in 2005. Patients who had been mandated to treatment generally improved at the same rate as people entering treatment voluntarily, scoring as well or even sometimes better on measures like being abstinent, having no consequences from substance use, being employed, and avoiding re-arrest. This isn’t a negative finding, it’s an equivalence study: It shows that on average, people who were forced into treatment did at least as well as people voluntarily entering.
True, there have been conflicting findings from other studies, so we should be careful about drawing sweeping conclusions. Other research has found different types of compulsory treatment to be associated with worsened treatment outcomes and increased criminal activity, and some evidence suggests that the purported benefits of mandated treatment don’t last after the mandate is finished. The ultimate conclusion of that structured review was that we just don’t have enough evidence today. But even beyond that conclusion, the biggest, meta-level limitation to these investigations, and the reasons their findings don’t generalize to more common forms of coercion, is that they only study the most basic indicators of formal coercion.
In most studies, researchers only track whether someone has been formally, legally mandated, while ignoring informal coercion from friends and family. They also treat the mere presence of a legal referral as a monolithic indicator, as if all those mandated patients are having the same experience. It’s true that this is how we study medications: Split a population into two neat groups and try to isolate one variable. But mandated treatment is far more complicated than the binary presence or absence of a medication. For example, research shows that the presence of a legal mandate simply isn’t a reliable proxy for an individual’s perception of coercion. People’s internal experience is missing in these studies, and as it turns out, that internal experience matters a great deal.
Studies that focus on the perceptions of people with addiction are not included in the more concrete, structured reviews of coercion’s effectiveness, but investigators have found that those internal experiences have a significant effect on treatment outcomes. They are perhaps more influential than the presence of coercion itself.
For example, one set of studies based on a psychological model called Self-Determination Theory has found that for people who were mandated into treatment, their perceptions about the treatment may matter much more than the objective presence of external coercion. When asked directly, some people who were mandated said they still felt like they were in control all along, and some people entering “voluntarily” said they felt like entering treatment was not really their choice. People with more of a sense of agency have better outcomes, such as retention in treatment—it could be that this effect is greater than the presence of the legal mandate itself.
It makes sense: Of those desperate people who contact me, some decide to put serious pressure on their loved ones. They threaten their struggling family members with severing the relationship and standing back to watch them hit “rock bottom.” There’s no reason those struggling people shouldn’t feel just as trapped as those who’ve been court-ordered into treatment. “Tough love” that forces people to get help or face strict consequences is not a helpful strategy, but years of studies have shown that regular, kind, but boundary-based support is more effective. These kinds of actions—like setting clear and nonjudgmental expectations about money or other support, positively reinforcing healthy behavior, and offering help—can lead people with substance use problems toward positive change and real, self-motivated engagement in treatment. These self-determination studies help to explain why that might be so, and the findings suggest tweaks to the fundamental question: not “does coercion work?” but what kind of coercion works, and how should one work within coercive structures?
Our society is enamored with “law and order” approaches to social problems. We generally overvalue formal legal coercion through mechanisms like drug courts and compulsory treatment, and undervalue softer, less extreme forms of coercion from employers, friends, and family. One unfortunate consequence of this attitude is, even though informal coercion is much more common, its research base is weak. We need more studies outside of the all-or-nothing, confrontational approach to formal legal coercion. And pragmatically, we are probably too quick to resort to extreme measures and too tentative about navigating the middle ground, such as applying some constructive and kind pressure without being absolute or punitive. People can use informal coercion in a way that still preserves a sense of choice and agency—in which coercion isn’t a threat but simply a hard choice. Most people believe that kind of informal pressure to be wishy-washy, but there is good evidence to suggest it is more effective than stricter policies. The key is to look at people with addiction as active decision-makers and foster their own sense of engagement and motivation. We should be taking that approach with everyone, including (and especially) those who have been formally mandated into treatment. Aside from being more humane, it simply works better.