Commentary on Pilarinos <i>et al</i>. (2020): Scientific realism and the study of coerced substance use treatment

A shift away from overly simplistic research is needed on whether compulsory and quasi-compulsory treatment ‘works’. More can be gained from attending to shifting motivations over time among all people entering treatment, and the mechanisms through which mandates to participate in treatment promote (and hinder) people's efforts at self-directed recovery. A wide range of strategies is used to encourage or compel people to enter substance use treatment. These range from quasi-compulsory arrangements (in which people are mandated to treatment through the legal system, child protection services or other external agency, but ultimately have the ‘choice’ of whether to comply) to forced or compulsory treatment orders. Countries vary in their use of these strategies, but all are based on the idea that the harms of substance use disorders can be mitigated by leveraging the coercive power of legal and other systems to promote recovery through treatment. A wealth of research has been dedicated to determining whether such strategies are effective, the bulk of which relies on simple group comparisons of people who have been ‘coerced’ and those who have not. Studies tend to find that people who are mandated to enter and participate in treatment have similar or better retention rates and comparable outcomes to those who are not mandated 1-4. This has been interpreted as evidence that coerced treatment ‘works’ 5. However, a closer look at the evidence base highlights gaps in our understanding. Systematic reviews have drawn attention to mixed findings on post-treatment outcomes of quasi-compulsory and compulsory treatment, including both positive and negative effects on substance use and criminal recidivism 6-8. There is also evidence that mandates to participate in treatment are associated with poorer therapeutic relationships, particularly in the context of low motivation 9, 10. With this mixed body of evidence it is difficult to draw conclusions to inform policymaking, system planning and clinical practice. Pilarinos et al. have added to this literature by reporting an absence of improvements in substance use outcomes among those who reported being coerced to treatment or those who attended voluntarily 11. Indeed, there were no differences between those who did and did not attend treatment. Acknowledging that information was not available on the duration or quality of services received, these findings nonetheless highlight the need for enhancing the existing systems of services and supports that are available to people who use drugs. The findings reported by Pilarinos et al. also speak to the need for research that goes beyond simple group comparisons of people who are and are not ‘coerced’, to more effectively take into account the complexity in people's motivations to enter treatment and their encounters with service systems over time. While comparing those who do and do not enter treatment under a formal mandate may seem like an intuitive way to evaluate coerced treatment, it obscures the reality of varying levels of perceived coercion and motivation among all people who enter treatment 12. With specific respect to quasi-compulsory arrangements, it has been well documented that mandates, perceived coercion and treatment motivation are not interchangeable constructs 9, 13-16. Many people who are mandated experience a coercive imposition, but not all. Others who are not formally mandated nonetheless perceive coercion to participate in treatment and vary in their levels of motivation. Statistically, this within-group heterogeneity in how people respond to legal and other mandates to enter treatment would lead exactly to the types of mixed findings that we see in the literature. There is much more to be gained by research that attends to within-group heterogeneity in motivation and how it shifts over time as people navigate their substance use and health and social service systems. This work could fruitfully explore the mechanisms through which formal mandates, interacting with people's own motivation and preferences for treatment, influence their experiences of service encounters and, in turn, their health over time. The expansion of (quasi-)compulsory treatment strategies has occurred in the absence of this kind of evidence on the mechanisms through which they exert their effects. Following a tradition of research and evaluation grounded in scientific realism 17, the key question is not whether formal treatment mandates work, but for whom they work and under what conditions, with a particular focus on how to avoid harms. This shift in the frame used to evaluate treatment is needed to promote positive service encounters so as not to hinder people's current and future engagement in services, or jeopardize their health and efforts for self-directed recovery. None.

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