The Role of

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The Role of Intent to Seek Treatment Among
Drug Users Legally Mandated to Treatment
V.A. Stanick, A. Laudet, K. Morgen National
Development and Research Institutes, Inc., J.
Carway - VIP Community Services, Inc. NYC, NY
B. Sands NYC Health Hospitals Corp./Woodhull
Hospital Center Funded by National Institutes
on Drug Abuse Grant R03 DA13432 Correspondence
stanick_at_ndri.org
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Since inception in 1989, treatment courts has
proliferated to 1,183 in2003, with many
additional courts in the planning phase.1The
criminal justice field has produced the
overwhelming majority of literature in the area
of court-referred treatment (philosophy, target
population, process, outcomes, etc.).
Demonstrated benefits that have supported the
expansion of the treatment court concept are also
those that have received the primary focus in
literature on this topic. They include21.
Reduction of criminal recidivism.2. Cost
savings from drug courts (relative to cost of
incarceration and crime-related costs to
communities).3.  Impact on treatment retention
of mandated clients. 
Background Treatment Courts
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Limitations of current research

• Criminal justice and addiction studies have
  widely divergent perspectives, interests, and
  objectives.
• Thus there is relatively little research on
  addiction-related outcomes and on treatment
  outcomes.
• Much of the relatively small body of work in this
  area has been criticized for focusing primarily
  on sociodemographic, rather than psychosocial
  characteristics of criminal justice subgroups in
  addiction treatment.3

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Outcome areas where research is needed

• Recovery-promoting cognitions
• Motivation
• Coping
• Recovery-promoting behaviors e.g., abstinence
  from DA, 12-step meeting attendance

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Prior Studies

• The few studies considering psychosocial
  domains among legally mandated participants have
  yielded mixed results.
• Of particular significance are findings regarding
  motivational variables (treatment motivation,
  readiness to change/stage of change),4 in
  subgroups with criminal justice involvement,
  ranging from none to mandated. Specifically
• Marshall Hser (2002) reported that legally
  mandated clients had LOWER LEVELS of 1) treatment
  readiness, 2) confidence inand 3) satisfaction
  withtreatment, than non-mandated peers.3
• In contrast, Gregoire Burke (2004) reported
  overall GREATER readiness to change in mandated
  clients entering treatment.4
• Neither of those studies reported post-treatment
  outcome data to assess the impact of legal
  coercion and its possible interaction with
  readiness/motivation, treatment goal-attainment,
  program completion rates, etc.

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Objective/Methods

• Objective To extend and clarify previous work
  regarding the role of recovery-related cognitions
  on outcomes among legally mandated clients in
  substance abuse treatment.
• Specifically, we examined
• The association between intent to seek
  treatment and recovery-promoting cognitions at
  baseline (BL) and
• The role of intent to seek treatment as a
  predictor of end of treatment (END) outcomes

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KEY CONCEPTS

• LEGAL STATUS (entire sample) involvement with
  the legal system at BL (YES?NO)
  ?IF INVOLVED
• LEGAL MANDATE Was your coming to drug treatment
  at this time required or recommended by the
  criminal justice system (judge, probation/parole,
  etc.)? YES/NO
• ? IF YES (mandated)
• 3. INTENT TO SEEK TREATMENT Do you think you
  would have come for drug treatment at this time
  if it had not been because of any legal pressure
  from the criminal justice authorities? (YES/NO)

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DOMAINS STUDIED

• LEGAL INVOLVEMENT/COERCION INTENT TO SEEK
  TREATMENT
• Baseline RECOVERY-PROMOTING COGNITION Readiness
  to change, commitment to abstinence, commitment
  to 12-step, avoidance of high risk drug
  situations and 12-step attendance
• END OF TREATMENT length of stay, treatment
  completion status, drug use and 12-step
  attendance.

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HYPOTHESES

• H1 Legally coerced and non-coerced groups do not
  differ in (BL) levels of RECOVERY-PROMOTING
  COGNITIONS or (END) treatment outcome measures
  (LENGTH OF STAY, TREATMENT COMPLETION, DRUG USE
  and 12-STEP ATTENDANCE).
• H2 Among legally mandated participants, those
  who INTENDED TO SEEK TREATMENT independently of
  adjudication, compared to those who did not will
  have significantly higher levels of (BL) RECOVERY
  PROMOTING COGNITIONS and better outcomes at END
  (i.e., LENGTH OF STAY, TREATMENT COMPLETION, DRUG
  USE and 12-STEP ATTENDANCE).

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STUDY DESCRIPTION

• Data collected in the context of a NIDA-funded
  investigation of predictors and effectiveness of
  12-step participation as an aftercare resource.
• Participants (total N 314) recruited from two
  large inner-city, publicly funded outpatient
  substance abuse treatment facilities within New
  York City.
• Data were gathered at admission to index
  treatment and treatment end (completion or
  drop-out).
• End of treatment interviews conducted with 221
  participants to date (78 of valid cohort in
  treatment lt30 days))
• Participation was voluntary and based on informed
  consent.
• Computer-assisted semi-structured interviews
  approximately 2.5 hours in duration, administered
  at each data collection point.
• Participants received 30 at each interview.

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DESCRIPTION OF SAMPLE (N 221)

• Male 58
• Age (mean) 39 years (range 19-60)
• African American 63
• Hispanic 35
• Education (mean) 10.6 years (range 3-16)
• Primary income
• Government assistance 75()
• Job (on or off the books) 6
• Other legitimate income 18
• Illegal sources 1
• Hepatitis C 22
• HIV 9
• Mental Health Problem (ever) 41
• Substance Use past yr. 82
• Substance Use past month 32
• First time in treatment 59

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PRIMARY PROBLEM SUBSTANCE _at_ BL
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MANDATED TO TREATMENT STATUS
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INTENT TO SEEK TREATMENT STATUS(Mandated
Subgroup Onlyn54)
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BASELINE Subgroup Comparisons
Measure Score Range Means Non-Mand vs. Mand (N157) (N54) Means Non-Mand vs. Mand (N157) (N54) Means Tx. Without Mandate? Yes vs. No (N21) (N33) Means Tx. Without Mandate? Yes vs. No (N21) (N33)
Addiction Severity (MINI) 0-14 8.23 5.61 5.43 5.73
Process of Change 10-60 42.88 41.31 47.95 37.09
Commit. to 12 Step 1-5 3.61 3.40 3.87 3.11
Commit. to Abstinence 1-5 4.10 3.96 4.35 3.71
Readiness to Change  0-48 32.07 29.93 29.93 28.88
12 Step Mtgs, Past Yr. 0-? 19.05 17.65 34.33 7.03
12 Step Mtgs, Past Mo.  0-? 5.31 3.35 7.24 0.88
12 Step Mtgs, Comm. 0-? 4.28 2.63 5.52 0.79
days abstinent at BL 0-? 315.20 898.30 1007.43 828.85
Age 18-60 40.22 35.90 39.61 33.54
Prior Tx. Episodes 0-? 4.82 3.89 5.81 2.67
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END OF TREATMENT COGNITIONSSubgroup Comparisons
Measure Score Range Means Non-Mand vs. Mand (N157) (N54) Means Non-Mand vs. Mand (N157) (N54) Means Tx. Without Mandate? Yes vs. No (N21) (N33) Means Tx. Without Mandate? Yes vs. No (N21) (N33)
Process of Change 10-60 43.97 42.89 47.14 40.18
Commit. to 12 Step 1-5 3.34 3.17 3.65 2.86
Commit. to Abstinence 1-5 3.90 3.76 3.99 3.62
Readiness to Change  0-48 28.10 27.04 27.38 26.82
12 Step Mtgs, Past Yr. 0-? 31.60 21.37 31.90 14.67
12 Step Mtgs, Past Mo.  0-? 4.75 4.54 5.95 3.64
12 Step Mtgs, Comm. 0-? 4.33 4.15 5.57 3.24
Length of stay in tx. (days) 30-? 147.45 147.30 157.90 140.55
Days Abstinent (_at_ discharge) 0-? 145.43 353.94 646.16 180.44
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END OF TREATMENT OUTCOMES Subgroup Comparisons
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Measure Measure Frequencies () Non-Mand vs. Mand Frequencies () Non-Mand vs. Mand Frequencies () Non-Mand vs. Mand Sig. Frequencies () Tx. Without Mandate? Yes vs. No Frequencies () Tx. Without Mandate? Yes vs. No Sig.
Used D/A since Baseline _at_ Discharge? NO NO 38.9 38.0 .910 57.9 25.8 .023
Used D/A since Baseline _at_ Discharge? YES YES 61.1 62.0 .910 42.1 74.2 .023
Did you leave the program because you graduated? NO NO 59.9 63.0 .687 42.9 75.8 .015
Did you leave the program because you graduated? YES YES 40.1 37.0 .687 57.1 24.2 .015
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BASELINE FINDINGS SUMMARY

• Comparisons of NON-MANDATED and MANDATED groups
  found
• Age NON-MANDATED OLDER THAN MANDATED
• Dependence severity - MANDATED LESS SEVERELY
  DEPENDENT than NON-MANDATED
• Readiness to Change (NON-MANDATED gtMANDATED)
• days abstinent from drugs/alcohol at baseline
  (MANDATED reporting longer abstinence than
  NON-MANDATED)
• Comparisons of mandated subgroups defined by
  INTENT (vs. NO INTENT) to seek treatment
  regardless of court mandate found
• Age INTENT group OLDER than NO INTENT.
• Commitment to 12 Step INTENT group gt NO INTENT
• Commitment to Abstinence INTENT gt NO INTENT
• Frequency of 12 Step Meeting Attendance INTENT gt
  NO INTENT (all measures past year, past month
• Process of Change INTENT gt NO INTENT
• 12-Step attendance community-based meeting
  locations INTENT gt NO INTENT.

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END OF TREATMENT FINDINGS SUMMARY

• Comparisons of NON-MANDATED and MANDATED groups
  indicated
• NO DIFFERENCES in reported drug use since
  baseline, length of treatment stay, rate of
  program graduation (vs. early drop-out), nor in
  commitment to abstinence/12 Step, Readiness to
  Change at discharge, or Process of Change.
• The single comparison yielding significant
  results was that of total number of days
  abstinent (mandatedgtnon-mandated).
•  
• Comparisons of mandated subgroups defined by
  INTENT (vs. NO INTENT) to seek treatment
  regardless of court mandate found
• Process of Change and Commitment to 12 Step
  INTENT gt NO INTENT
• Reported drug/alcohol use since baseline NO
  INTENT gt INTENT
• Rate of program graduation (vs. early drop-out)
  INTENT group left tx. due to graduation at a
  higher rate than NO INTENT.

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HYPOTHESES/CONCLUSIONS H1

• (H1)Legally coerced and non-coerced clients do
  not differ in (BL) levels of RECOVERY-COGNITIONS
  or END OF TREATMENT outcome measures
•  BASELINE Readiness to Change results
  (NON-MANDATED gt MANDATED) did not support this
  hypothesis.
• DISCHARGE results generally supported the
  hypothesis.

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HYPOTHESES/CONCLUSIONS H2
H2 Among legally coerced participants, the
subgroup WITH INTENT TO SEEK TREATMENT
independently of adjudication, will demonstrate
significantly higher levels of recovery promoting
cognitions _at_ BL and and better outcomes_at_ DIS.

• BASELINE results strongly supported the
  hypothesis, EXCEPT in the case of readiness to
  change
• DISCHARGE results supported to the
  hypothesismost strongly evident in the
  strikingly greater rates of graduation,
  abstinence during treatment, and Commitment to 12
  Step in the INTENT group.

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CONCLUSIONS

• Legally-mandated clients may
• Be younger on average, and have less severe
  substance dependence but otherwise appear OVERALL
  on initial assessment to be essentially similar
  to their non-mandated peers in treatment, AND
• in general have potential equal to those who are
  self-referred, for favorable treatment outcomes
  (program completion, integration into 12 Step
  support systems, maintenance of abstinence from
  drugs/alcohol, etc.) In fact with few exceptions
  the two groups did not differ substantially from
  one another.
• HOWEVER, when only the subgroup of
  legally-mandated clients was examined, accounting
  for whether or not treatment would have been
  considered an option independent of the coercive
  force of legal authority a different picture
  emerges . . .

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CONCLUSIONS (contnd)

• A distinct difference appeared in the legally
  mandated group at baseline, between those who had
  INTENT to seek treatment regardless of mandate,
  and those who had NO INTENT independent of the
  mandate.
• Those with INTENT had more favorable prognostic
  signs than those with NO INTENT.
• The NO INTENT group was younger than the INTENT
  group, with fewer prior treatment episodes.
• FURTHER That division extended to crucial
  treatment outcomes, with significantly greater
  attainment of important achievement markers by
  the group with INTENT (e.g., program graduation,
  drug/alcohol abstinence, sustained commitment to
  12 Step) that might well impact on longer-term
  behavior.

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IMPLICATIONS/RECOMMENDATIONS

1. Intent to seek treatment may be an important
   factor to consider in assessment of potential
   candidates for legally-mandated treatment.
2. Treatment providers serving legally mandated
   clients might benefit from attending to this
   factor when designing intervention strategies,
   and should explore the possibility of providing
   specialized services for the group whose lack of
   intrinsic intent to enter treatment, relatively
   young age and lack of treatment experience may
   prove to be challenges to the standard array of
   techniques.
3. Behavioral scientists studying addiction might
   consider intent to seek treatment in coerced
   participants as a variable that may mediate or
   interact with other effects (e.g., motivation,
   measures of treatment outcome, etc.).
4. Future, larger scale, systematic studies are
   recommended to assess the utility of the concept
   of intent to seek treatment as a prognostic
   and/or modulating variable in the population of
   legally-mandated clients in treatment.

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REFERENCES

• American University Drug Court Clearinghouse and
  Technical Assistance Project, 2003.
• National Drug Court Institute. Drug Court
  Facts. Drug courts A national phenomenon.
• Marshall, G.N. and Hser, Y-I. (2002)
  Characteristics of criminal justice and
  noncriminal justice clients receiving treatment
  for substance abuse. Addictive Behaviors (27),
  179-192.
• Gregoire, T.K. and Burke, A.C. (2004) The
  relationship of legal coercion to readiness to
  change among adults with alcohol and other drug
  problems. Journal of Substance Abuse Treatment
  (26), 337-343.
• INSTRUMENTS
• Sheehan, D.V. Lecrubier, Y. Mini International
  Neuropsychiatric Interview. University of South
  FloridaTampa, 2002.
• Prochaska JO, Velicer WF, DiClemente CC, Fava
  J. (1988) Measuring processes of change
  Applications to the cessation of smoking.
  Journal of Consulting and Clinical Psychology,
  56 520-528.
• Morgenstern, J. McCrady, B.S. Cognitive
  processes and changes in disease-model treatment.
  In McCrady, B.S. and Miller, W.R. (Eds.)
  Research on Alcoholics Anonymous Opportunities
  and Alternatives, New Brunswick, NJ Rutgers
  Center of Alcohol Studies, 1993, pp. 154-164.
• Budd, R.J. Rollnick, S. (1996) The structure of
  the Readiness to Change Questionnaire A test of
  Prochaska DiClementes transtheoretical model.
  British Journal of Health Psychology 1 365-376.
• Rollnick, S., Heather, N., Gold, R., Hall, W.
  et al, (1992) Development of a short 'readiness
  to change' questionnaire for use in brief,
  opportunistic interventions among excessive
  drinkers. British Journal of Addiction 87(5)
  743-54, 1992.