Involuntary treatment of substance abuse disorders--impediments to success.

Legal pressures currently account for between 40 and 70% of all referrals to community alcohol and drug treatment programs (Collins and Allison 1983; Dunham and Mauss 1982; Harford et al. 1976; Schnoll et al. 1980; Connecticut Alcohol and Drug Abuse Commission 1987). Changes in criminal statutes (Korcok 1986) and in commitment procedures for potentially dangerous patients (Bursten 1986; Herrington 1986) make it likely that even larger numbers of court-stipulated patients will enter treatment in the future. Although policies to divert drug or alcohol-dependent offenders from the criminal justice system into treatment are motivated by humane intentions as well as by practical considerations, in practice, involuntary treatment is problematic for all parties involved. Because many of the issues raised by court-stipulated treatment for alcohol or substance use disorders have been addressed only rarely and incompletely, this paper, on the basis of a review of enforced treatment in an outpatient alcohol and drug abuse treatment clinic, describes the problems encountered in enforced treatment, discusses the major impediments to successful coercive treatment, and proposes safeguards to preserve the integrity of involuntary treatment within the humanistic tradition of psychiatry. The focus of the paper is on involuntary treatment of alcohol-dependent patients or poly-drug users who deny problems related to substance use. Court-mandated, opiate-dependent patients differ from these patients in that they more often acknowledge problems related to addiction and withdrawal; consequently, they present different problems with regard to involuntary treatment. My hope is that by identifying some of the dilemmas faced by both clinicians and patients, some of the negative effects of coercive treatment may be avoided.