It is an age-old question in medical and substance use disorder (SUD) treatment circles: Does a patient have to WANT treatment, that is, want to get better, for treatment to work? Conversely, if someone does not want to change their behavior, can treatment still be effective?
This question can apply to countless medical issues — from heart disease to diabetes to mental illness to SUD — and opinions are widespread on whether you can coerce someone into getting well. But the science and outcomes for people coerced into care are clear: motivation and a desire to change at the time of entering treatment are not essential for positive outcomes or success.
Available research on outcomes for individuals legally coerced into SUD treatment shows that they do just as well, if not better, than those who begin treatment of their own free will. One study found that coerced patients in a SUD treatment program were significantly more likely to remain in treatment (either inpatient or outpatient) than the self-referred (or “voluntary”) patients. Post-treatment follow-up of coerced patients indicated marked improvements in alcohol and drug use issues, employment, medical, family, and psychiatric problems. These levels of improvement were comparable to those seen with the self-referred patients, and sometimes better.
Some people are mandated to enter treatment by the legal system which can provide “external motivation,” while voluntary clients are typically believed to be intrinsically motivated. But this isn’t always the case. Other motivators exist. For example, people can be mandated into treatment by a governing board or they will lose their license to work such as with physicians, nurses, lawyers, and other professionals. Others may find their way to treatment through an intervention coordinated by professionals with urging and support from family or friends. For young adults, there exists a type of “mommy mandate” wherein an individual’s parents refuse to pay for college, allow the use of a car, or even allow the person to live at home if they refuse treatment. This is most certainly experienced as a form of coercion.
In fact, many individuals in treatment report levels of perceived coercion comparable to those truly forced into treatment. Tellingly, one study found that there was no difference in patient engagement, satisfaction, and functioning between the groups characterized by the MacArthur perceived coercion scale as (1) coerced voluntary, (2) uncoerced voluntary, and (3) involuntary groups in treatment.
Another study found that legally coerced patients were more likely than noncoerced patients to report abstaining from alcohol and other drugs, and more likely to demonstrate reduced addiction severity at follow-up. Importantly, readiness to change at admission showed no relationship to treatment outcomes. Further, a study on the relationship of legal coercion to readiness to change among adults with alcohol and other SUD problems found that legal coercion was actually associated with greater readiness to change.
The evidence shows that most individuals do not need to want to get well at the onset of treatment for treatment to work. A person can completely resist the idea that they need help at all. But if this person can be convinced to go to treatment, and while in treatment, can see that they have a problem and can benefit from recovery, they can succeed. Whether they arrive with perceived coercion from family, of their own volition, or because a judge or employer orders it, evidence-based substance use disorder treatment can be effective.
The reason for this is that one of the top predictors of success in treatment is the “dose” of treatment received. We don’t often think of “dose” in regard to SUD treatment, but it’s easier to understand in relation to other illnesses. Someone with diabetes who needs insulin will not be able to control their disease without an adequate dose. Likewise, someone struggling with hypertension will not have effective treatment with just 10% of the medication they need. For diabetes and hypertension, treatment may not work if the person only puts forth 25% effort to making changes in sugar intake, diet, or level of exercise. The same is true for SUD; the “dose” of treatment for SUD must be adequate to be effective. There is no one-size-fits-all dose for every person with diabetes, hypertension, or SUD, but we can all agree that an insufficient dose is ineffective. In the case of SUD, when someone is coerced into treatment, they typically can’t leave or stop treatment before an adequate “dose” of (time in) treatment, and as a result, they get the right dose.
Some have argued that treatment will never work for someone who does not want it, no matter how much treatment they get. SUD treatment professionals and interventionists have refuted this. Someone does not have to want treatment for it to work, but they do have to want recovery after treatment ends, and that’s a treatment team’s job. Long-term success is dependent on the treatment being able to move the person from the stage of not wanting treatment to seeing the benefits of treatment and embracing recovery. This is accomplished by delivering quality care by a skilled treatment team.
Ultimately, the belief that a person has to want it for it to work has been blown away by the research. Perhaps this will help eliminate the dangerous notions of “detaching with love” or the belief that any type of support is enabling. Waiting for someone to ask or be ready for treatment can be life-threatening.
The importance of seeking care for someone who is struggling with a substance use disorder right now cannot be understated, even if it requires some coercion. The effects of the COVID-19 pandemic have brought about increases in SUD and mental health issues, and the number of individuals who have lost their lives to overdose is the highest we have ever seen. Financial hardships and uncertainty have increased feelings of depression and anxiety, factors that can often contribute to using drugs or alcohol to avoid uncomfortable feelings. Additionally, families forced to spend more time with one another may discover that a loved one is now drinking heavily or is struggling with drug use.
The message is simple: do not wait for someone you love to realize they need treatment or for them to hit that elusive rock bottom. Get help now, before it is too late.