The impact of and interaction between motivation and coercion for drug misuse treatment seekers in England

    Research output: ThesisDoctoral Thesis


    Background: Referral from the Criminal Justice System (CJS) is a key, common route into drug misuse treatment. It is important to know whether, and how, it impinges on treatment outcome, particularly in relation to motivational states that may influence behaviour change.Aim: To assess the association between motivational state and level of treatment coercion, and the effects of these on treatment engagement and outcome, among a sample of drug misuse treatment seekers in England.Setting: Patients were sampled from 342 community and residential drug misuse treatment services within 94 (of 149) commissioning areas in England during 2006-07. All patients seeking drug misuse treatment at these services were eligible for inclusion.Methods: The Circumstances, Motivation, and Readiness scale provided measures of propensity for treatment including specific sub-scores for circumstances, motivation and readiness for treatment. The degree of referral coercion was categorised according to the level of CJS involvement: CJS referral with a condition of attendance; voluntary CJS (no attendance condition); non-CJS. Predictors of propensity were examined using linear regression, with particular emphasis on level of coercion. The predictive nature of coercion and propensity in relation to treatment uptake and threshold points for duration of treatment retention was examined using logistic regression models. Cox proportional hazard models examined associations with linear measures of treatment duration. Analysis of treatment outcome focussed on changes in: the value of drugs used; severity of dependence score; and level of offending. Relationships between these measures and coercion and propensity were examined using quantile, linear and logistic regression models. These were further supported by longitudinal models, incorporating instrumental variables for continuous outcomes to account for potential time related confounding. Results: No negative association was observed between level of coercive referral and levels of motivation or readiness for treatment and conditional referral was positively associated with motivation at the point of treatment entry. Both readiness for treatment and coercion predicted treatment retention for three months, although previous treatment experience treatment and use of heroin were the most consistent predictors of retention. Increasing pre-treatment motivation predicted greater reduction in the value of drugs used but not changes in the level of offending. Neither propensity sub-scores nor coercive referral predicted change in dependence severity. However, coercion was associated with cessation of offending among opiate /crack users. Conclusions: Propensity and coercion have mutually exclusive effects on different aspects of behaviour change. Coercion can positively affect treatment retention but changes in drug taking behaviour are more strongly associated with level of intrinsic motivation. Assessment of propensity, including its motivational components, at treatment entry could inform treatment delivery but its importance should not overshadow that of other factors, which may exert more important effects. Coercive CJS referral is not detrimental to treatment success and may have particular benefits for specific populations, but the cost effectiveness of diversionary schemes should be considered.
    Original languageEnglish
    Awarding Institution
    • University of Manchester
    Publication statusPublished - Dec 2013


    • Coercion, motivation, treatment, outcomes


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