Coercive Treatment – A user perspective Vicky Album April – 2007

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In 2005, Lifeline Research decided to co-fund a PhD with Lancaster University to examine the new criminal justice interventions in the UK . A year on, the project has become focused on the subjective experiences of drug users within the criminal justice system (CJS) in England . It aims to examine the various routes that they take through assessment, ‘punishment’ and treatment and their changing perspectives throughout this process. This paper outlines some of my initial thoughts and as results begin to emerge I will be working with Lifeline and Lancaster University to release the findings.

Recent changes in legislation detailed in the Drugs Act 2005 have lead to the introduction of new measures within the criminal justice system which target users of illegal substances. The Drug Interventions Programme has been extended and new measures introduced primarily (but not exclusively) in areas designated as ‘intensive’ relating to the levels of drug-related crime. In particular, the introduction of ‘test on arrest’ (TOA) has replaced its predecessor ‘test on charge’ (TOC) and is ensuring that a new and wider range of drug users are initiated into specially designed systems. All those who test positive (and do not contest the result) must attend a ‘required assessment’ (RA). This deals with issues around past and present drug use and is intended to identify appropriate future options for addressing drug use. Failure to attend the RA (which is not necessarily held at the time of arrest) constitutes a criminal offence. This has lead to the possibility of an individual being charged with failing to comply with the RA whilst the original arrest charges may not be pursued. This serves to criminalise not drug users per se, but rather those who fail to accept assessment or treatment.

The outcomes of the RA may be used in court to determine terms for bail or sentencing. A new option is available to courts called Restriction on Bail (RoB), which attaches a requirement to comply with drug treatment to other bail conditions. Refusal to consent to the addition of such conditions may lead to refusal of bail and infringement of the conditions constitutes a breach. Other options open to the courts on sentencing include Drug Rehabilitation Requirements (DRR) which attaches drug treatment and testing requirements to a Community Sentence, Custody Minus and Custody Plus which include treatment conditions as a requirement on release or as an alternative to custody.

There has been extensive government literature on the new legislation and corresponding legal and treatment routes. There has also been a wide range of studies on the varying components of successful treatment regimes both within and without of the Criminal Justice System (CJS). However despite the emphasis on linking new policies to the evidence-base, there have been some clear omissions. Of these, I will argue that three topics that have been largely ignored, are highly relevant. These are interlinked but can be roughly delineated as follows: firstly, client perceptions of coercion throughout the treatment process; secondly, the views and voices of those involved, primarily the drug users themselves but also staff and volunteers delivering services; and thirdly, evaluations of the processes of ‘coerced’ treatment and specifically of individual services.

In the first place a relevant issue that has been the subject of considerable study is the effect of ‘coerced’ treatment. ‘Coerced’ treatment is usually understood to be that which has been undertaken via the criminal justice system, in which the participant has limited or no choice as to whether they attend. It has been commonly assumed in research that treatment as an alternative to prison or as part of a sentence can be assumed to be coercive . However it is by no means clear that there is a direct relationship between a criminal justice referral into treatment and the client’s experience of ‘coercion’. Recent studies have demonstrated that not all those who have entered treatment via the CJS perceive themselves to have been any more ‘coerced’ than ‘voluntary’ patients (Wild et al , 1998). Other studies have shown that even those who do perceive legal coercion may rate other coercive factors, such as family pressure, as more relevant. It has thus been emphasised that the experience of coercion should not be confused with the source of referral (Marlowe et al , 1996).

These studies demonstrate the importance of specifically examining client attitudes to coercion within the CJS rather than assuming all DIP treatment is coercive. Indeed ‘perceived’ coercion, remains an under-studied concept. Yet the possibility that not all CJS clients perceive ‘coercion’ within the DIP treatment process is critical to our understanding of the role of ‘coercion’ within drug treatment and, indeed to whether it is a relevant concept within the treatment process at all.

As well as conceptualising coercion as something that is experienced by clients rather than something that is applied by professionals, it should be recognised that coercion is a process (Prendergast et al, 2002). In the ‘models of care’ climate in which treatment is understood in terms of pathways, it must be acknowledged that clients will experience coercion differently throughout their criminal justice/treatment episode. It is difficult to objectively measure the extent to which the ‘coercive’ element is relevant throughout each stage. In particular this will vary according to the client, their level of drug use and the nature of the offence/s committed. It is therefore inadequate to categorise all treatment originating in the CJS as coercive without also investigating the changing perceptions of those involved.

This study therefore aims to examine client perceptions of coercive treatment, and of the coercive element specifically, over a period of time. It will aim to trace their progress through the treatment process from their own perspective and will examine issues such as their perceived motivation for treatment. In addition, the impact of the current treatment will be gauged through details of drug using practices and in comparison with previous treatment episodes. This study will not aim, however, to provide a conclusive answers about the effects of coercion but will instead seek to unravel the relationship between pressure applied and pressure perceived and internalised. Thus it will seek to provide insight into the process of ‘coercion’ within drug treatment.

The second factor that this study will aim to address is the relative silence of drug users within the CJS treatment literature. The views of clients, practitioners and the public are largely missing from the debate on coerced treatment (Wild, 2006). Policies derived from criminal justice initiatives, seek to address behaviour but without consulting those involved. Yet the central role of ethnographic and other in-depth qualitative research in emphasising participant perspectives and thus ensuring the success of interventions has been widely acknowledged. Drug users themselves have a privileged understanding their own impressions and reactions that is critical to shaping useful interventions. It is essential that research tries to uncover drug using discourses and attitudes in order to make interventions relevant to those they are targeting.

There is also, I would argue, a political dimension to this second aim of re-inserting drug users into the coerced treatment debate. Users of illegal drugs are in an under-privileged position, in which their daily lives are subject to rules often dictated by other people (who are usually not extensive users of illegal drugs). Within coerced treatment specifically, their own decision-making power is restricted and they become subject to the authority of the CJS and practitioners within it. Even if have positive relationships with their drugs workers, within coerced treatment the user remains always in a more vulnerable position (indeed, it could be argued this is true within all treatment). There is, I believe, inherent value in redressing the balance of power by re-instating the voices of drug users to a relevant position within the debate.

The concept of representing marginalised groups has not been uncontroversial. It could be seen as unethical to represent people who have not specifically requested representation. Furthermore, as this project is largely self designed and will be interpreted, written up and used according to my own judgments, it may well make statements and have outcomes neither foreseen nor desired by its participants. Nonetheless, it has also been pointed out that it could be seen to be equally unethical, not to attempt to redress such an imbalance (Gillies and Alldred, 2002).

This study will be explicit about its intentions and will not claim to be representative either of drug users either individually or as a group. Rather it will content itself with placing their discourse at the centre of the research project and will acknowledge that this can never be anything other than my story of their lives ( Griffin , 1996).

The third feature that has frequently been overlooked is process evaluations of coerced treatment. It has been demonstrated that there is a huge variation in the application of legally mandated treatment over time and place (Anglin, 1988; Stevens et al, 2005). This is likely to be the case even in areas that theoretically have similar programmes. The evaluation of Drug Treatment and Testing Orders demonstrated how variations in the application of the orders lead to vastly different outcomes (Turnbull, 2000). Studies of the different components of treatment have pointed to the centrality of issues such as rapport with staff and amount of different services offered which again point to the importance of individual features of different services (Joe et al , 1999; Simpson et al, 1997). Clearly, then the exact nature of service delivery will affect outcomes. Yet process evaluations have proved rare (Wild, 2006). Unless it is clear what services clients are receiving, it must surely be impossible to attribute its outcomes to any one feature.

This study will therefore seek to thoroughly describe the treatment process in the localities selected both in terms of how they are intended to be set up and also in terms of what users actually receive. This should contextualise the experiences that the users describe. There is a strong ethical case to be made for ensuring that thorough process evaluations are carried out of coerced treatment. Whilst a small group of authors might have ethical questions about the morality of coercing users into treatment (e.g. Wild, 2006), surely more would accept that it is ethically reprehensible to coerce users into substandard treatment. It is thus essential to establish exactly what form of ‘treatment’ is being commissioned and what form is being received in order to gain an accurate understanding of the new system.

This study will therefore aim to add a new perspective to the understanding of treatment within the CJS. It will examine not treatment intended or even provided but rather treatment received. It will aim to trace user journeys through this type of treatment, examining their own perspective and their own words. It will add value to existing literature by adding this missing dimension.

References

Anglin, M.D. (1988) ‘The Efficacy of Civil Commitment in Treating Narcotic Addiction’ in C.Leukefeld and F.Tims (eds) Compulsory treatment of drug abuse: research and clinical practice , NIDA Research Monograph 86, DHHS Publication Number ADM 89-1578, Washington, DC: US Government Press.

Gillies, V. and Alldred, P. (2002) ‘The ethics of intention: research as a political tool’ in M.Mauthner, M.Birth, J.Jessop and T.Miller (eds) Ethics in qualitative research, London : Sage.

Griffin , C. (1996) ‘See whose face it wears’ : difference, otherness and power’ in S.Wilkinson and CKitzinger Representing the other, London : Sage.

Joe, G.W., Simpson, D.D. and Broome, K.M. (1999) ‘Retention and patient engagement models for different treatment modalities in DATOS’ in Drug and Alcohol Dependence 57 pp 113-125.

Marlowe, D.B., Kirby, K.C., Bonieskie, L.M., Glass, D.J., Dodd, LD., Husband, S.D., Platt, J.J. and Festinger, D.S. (1996) ‘Assessment of coercive and noncoercive pressures to enter drug abuse treatment’, Drug and Alcohol Dependence 42 (2): 77-84.

Prendergast, M.L., Farabee, D., Cartier, J. and Henkin, S. (2002) ‘Involuntary treatment within a prison setting: Impact on psychosocial change during treatment,’ Criminal Justice and Behaviour 29 (1): 5-27.

Simpson, D.D., Joe, G.W., Broome, K.M., Hiller, M.L., Knight, K and Rowan-Szal, G.A. (1997) ‘Program diversity and treatment retention rates in the drug abuse treatment outcome study (DATOS)’ in D.D Simpson and S.J Curry (eds) Psychology of Addictive Behaviors: Special Issue: Drug Abuse Treatment Outcome Study(DATOS) 11 (4) pp 279-293.

Stevens, A., Berto, D., Heckmann, W., Kerschl, V., Oeuvray, K., Van Ooyan, M., Steffan, E., and Uchtenhagen, A. (2005) ‘Quasi-Compulsory Treatment of Drug Dependent Offenders: An International Literature Review’ in Substance Use and Misuse 40, pp 269-83

Turnbull, P., McSweeney, T., Webster, R., Edmunds, M. and Hough, M. (2000) Drug Treatment and Testing Orders: Final Evaluation Report. Great Britain Home Office, Research, Development and Statistics Directorate 2000.

Wild, T.C. (2006) ‘Social control and coercion in addiction treatment: towards evidence-based policy and practice’ in Addiction 101 (1) , pp 40-9.

Wild, T.C., Newton-Taylor, B., and Alletto, R. (1998) Perceived coercion among clients entering substance abuse treatment: structural and psychological determinants. Addictive Behaviors, 23 , pp 81-95

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