1.0Introduction - Edge Hill University



Exploring Dimensions of Coercion across Treatment Programmes for Heroin Users: A Mixed Method StudySteven Lee JonesAugust 2016A thesis submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy, Edge Hill UniversityDeclaration This thesis is entirely my own work and has not been submitted, in full, or part, for the award of a higher degree at any other educational institution. Sections of the thesis have already been published, presented at conference, and details are listed below:Conference contributions refereedJones, S. (2014) The Care and Treatment of Offenders in the UK. Paper presented at KR Government University Hospital, Mysore, India. January 2014.Murphy, P.N., Mohammed, F, Wareing, M., Cotton, A., McNeil, J., Irving, P., Jones, S., Sharples, L., Monk, R., and Elton, P.(2014) High mortality rates in opiate using prisoners immediately post-discharge: could opioid antagonist treatment save lives? The British Psychological Society Psychobiology Section Annual Scientific Meeting held 3rd-5th September 2014.Jones, S., Murphy, P. N., Kirby, J. and Jack. B. (2014) The relationship between prescribed methadone treatment and psychological preparedness for opiate withdrawal. The British Psychological Society Psychobiology Section Annual Scientific Meeting held 3rd-5th September 2014. AcknowledgementsProfessor Philip Murphy (Director of Studies) Professor Barbara Jack (Supervision team)Dr Julie Kirby (Supervisor team) Kathryn Drury for all her line management support and encouragementTABLE OF CONTENTSDeclarationiTable of ContentsiiList of TablesviList of FiguresviiList of AppendicesviiAbstractviiiCONTENTS TOC \h \z \t "Heading 1,2,Heading 2,3,Heading 3,4,Title,1" Chapter One: Substance Misuse Literature Review PAGEREF _Toc458234122 \h 11.0Introduction PAGEREF _Toc458234123 \h 11.1Introduction to Substance Misuse PAGEREF _Toc458234124 \h 11.2Background to Heroin Use PAGEREF _Toc458234125 \h 21.2.1Prevalence of Heroin Addiction Treatment PAGEREF _Toc458234126 \h 31.2.2Different Treatment Experiences PAGEREF _Toc458234127 \h 71.3Heroin Drug Treatment Interventions PAGEREF _Toc458234128 \h 81.3.1Introduction to Methadone Modality PAGEREF _Toc458234129 \h 81.4Contexts of Heroin Treatment PAGEREF _Toc458234130 \h 101.4.1The Treatment Contexts for this Study PAGEREF _Toc458234131 \h 101.4.2Prison Drug Treatment Context PAGEREF _Toc458234132 \h 101.4.3Drug Rehabilitation Requirement Context PAGEREF _Toc458234133 \h 121.4.4Inpatient Context Drug Treatment PAGEREF _Toc458234134 \h 131.4.5Outpatient Context Drug Treatment PAGEREF _Toc458234135 \h 141.5Summary PAGEREF _Toc458234136 \h 151.6The Present Study PAGEREF _Toc458234137 \h 15Chapter Two: Literature Review: Processes and Outcomes in Specific Treatment Contexts PAGEREF _Toc458234138 \h 162.0Introduction PAGEREF _Toc458234139 \h 162.1Method PAGEREF _Toc458234140 \h 162.1.1Identification of Databases and Search Terms PAGEREF _Toc458234141 \h 162.1.2Inclusion and Exclusion Criteria PAGEREF _Toc458234142 \h 172.2Results PAGEREF _Toc458234143 \h 172.2.1Overview PAGEREF _Toc458234144 \h 172.2.2Treatment Entry from Criminal Justice Settings PAGEREF _Toc458234145 \h 182.2.3Separating Voluntary from Compulsory Treatment PAGEREF _Toc458234146 \h 202.2.4Treatment Relapse and Effectiveness in the Community PAGEREF _Toc458234147 \h 212.2.5Treatment Retention, Attrition and Outcomes PAGEREF _Toc458234148 \h 222.3Motivation, Coercion and Outcomes PAGEREF _Toc458234149 \h 252.3.1Internal and External Factors for Treatment PAGEREF _Toc458234150 \h 292.3.2Family Support and Treatment Outcomes PAGEREF _Toc458234151 \h 302.4Mental Health Coercive Treatment Literature PAGEREF _Toc458234152 \h 312.4.1Introduction PAGEREF _Toc458234153 \h 312.4.2Coercion Studies in Mental Health Populations PAGEREF _Toc458234154 \h 322.4.3MacArthur Coercion Studies PAGEREF _Toc458234155 \h 332.4.4The Oxford Community Treatment Order Evaluation Trial (OCTET) Study PAGEREF _Toc458234156 \h 342.5Co-morbidity and Heroin Treatment Retention PAGEREF _Toc458234157 \h 362.6Criminal Justice Drug Treatment Options PAGEREF _Toc458234158 \h 372.7Discussion PAGEREF _Toc458234159 \h 38Chapter Three: Method PAGEREF _Toc458234160 \h 613.1Identification of Research Question PAGEREF _Toc458234161 \h 613.1.1Introduction PAGEREF _Toc458234162 \h 613.1.2Conceptual Underpinning: Set and Setting PAGEREF _Toc458234163 \h 623.2Operationalising of the Study at T1 PAGEREF _Toc458234164 \h 633.2.1Treatment Contexts PAGEREF _Toc458234165 \h 633.2.2Utilisation of Mixed Methodology PAGEREF _Toc458234166 \h 643.2.3Participant Recruitment Procedures PAGEREF _Toc458234167 \h 653.3Qualitative Methodology PAGEREF _Toc458234168 \h 673.3.1Qualitative Data: Interview Guide and Procedure PAGEREF _Toc458234169 \h 683.3.2Qualitative Data: Analytic Strategy PAGEREF _Toc458234170 \h 693.4Quantitative: Method PAGEREF _Toc458234171 \h 713.4.1Quantitative Data: Design and Measures PAGEREF _Toc458234172 \h 713.4.2Quantitative Data: Procedure PAGEREF _Toc458234173 \h 753.4.3Quantitative Data: Analytic Strategy PAGEREF _Toc458234174 \h 753.5Operationalising the Study (T2) PAGEREF _Toc458234175 \h 763.5.1Re-establishing Contact with Participants PAGEREF _Toc458234176 \h 763.5.2Measures Administered PAGEREF _Toc458234177 \h 773.6Ethical Considerations PAGEREF _Toc458234178 \h 78Chapter Four: Results for Pre Treatment Measures PAGEREF _Toc458234179 \h 814.1Introduction PAGEREF _Toc458234180 \h 814.2Method PAGEREF _Toc458234181 \h 824.2.1Design and Participants PAGEREF _Toc458234182 \h 824.3Results PAGEREF _Toc458234183 \h 824.3.1Sample PAGEREF _Toc458234184 \h 824.3.2Heroin Lifetime Use PAGEREF _Toc458234185 \h 824.3.3Participant Relationship Stability PAGEREF _Toc458234186 \h 834.3.4Employment PAGEREF _Toc458234187 \h 834.3.5Education PAGEREF _Toc458234188 \h 844.3.6Self-reported crime PAGEREF _Toc458234189 \h 854.4Time Served in Prison PAGEREF _Toc458234190 \h 864.4.1Heroin Route of Administration PAGEREF _Toc458234191 \h 864.4.2Methadone PAGEREF _Toc458234192 \h 874.4.3Other Drugs Used PAGEREF _Toc458234193 \h 874.4.4Mental Health Service Contacts PAGEREF _Toc458234194 \h 884.5Interim Discussion PAGEREF _Toc458234195 \h 88Chapter Five: Qualitative Data Findings PAGEREF _Toc458234196 \h 905.1Introduction PAGEREF _Toc458234197 \h 905.2 Motivation PAGEREF _Toc458234198 \h 905.2.1Normality and stability PAGEREF _Toc458234199 \h 905.2.2Physical and Mental Health PAGEREF _Toc458234200 \h 925.2.3Financial PAGEREF _Toc458234201 \h 945.3Family Coercion PAGEREF _Toc458234202 \h 955.3.1Shame PAGEREF _Toc458234203 \h 955.3.2Being Clean PAGEREF _Toc458234204 \h 995.3.3Loss PAGEREF _Toc458234205 \h 1015.4Deviant Cases PAGEREF _Toc458234206 \h 1035.5Summary PAGEREF _Toc458234207 \h 104Chapter Six: Pre-treatment Psychometric Measure Results PAGEREF _Toc458234208 \h 1056.1Introduction PAGEREF _Toc458234209 \h 1056.2Method PAGEREF _Toc458234210 \h 1066.2.1Design and Participants PAGEREF _Toc458234211 \h 1066.2.2Psychological Measures PAGEREF _Toc458234212 \h 1066.3Results PAGEREF _Toc458234213 \h 1066.3.1Attributions for Responsibility Regarding Cessation of Using Heroin PAGEREF _Toc458234214 \h 1066.3.2Confidence Scale and Self-efficacy (DTCQ) Scores PAGEREF _Toc458234215 \h 1076.3.3SOCRATES Scales PAGEREF _Toc458234216 \h 1086.3.4Depression, Anxiety, and Stress Scores PAGEREF _Toc458234217 \h 1096.4Interim Discussion PAGEREF _Toc458234218 \h 109Chapter Seven: Results for Heroin Use or Abstinence at T2 PAGEREF _Toc458234219 \h 1117.1Introduction PAGEREF _Toc458234220 \h 1117.2Method PAGEREF _Toc458234221 \h 1127.2.1Design and Participants PAGEREF _Toc458234222 \h 1127.2.2Measures PAGEREF _Toc458234223 \h 1127.3Results PAGEREF _Toc458234224 \h 1127.3.1Availability for follow up PAGEREF _Toc458234225 \h 1127.3.2Heroin use at follow up by group PAGEREF _Toc458234226 \h 1137.4T2 Heroin use or not by T1 demographic and drug misuse variables PAGEREF _Toc458234227 \h 1137.4.1T2 Heroin use or not by T1 preparedness for Treatment and Drug Misuse Variables PAGEREF _Toc458234228 \h 1147.5Interim Discussion PAGEREF _Toc458234229 \h 115Chapter Eight: Psychological Changes PAGEREF _Toc458234230 \h 1178.1Introduction PAGEREF _Toc458234231 \h 1178.2Method PAGEREF _Toc458234232 \h 1178.2.1Design and Participants PAGEREF _Toc458234233 \h 1178.2.2Measures PAGEREF _Toc458234234 \h 1188.3Results PAGEREF _Toc458234235 \h 1188.3.1Changes in SOCRATES Scale Scores across Groups at T2 PAGEREF _Toc458234236 \h 1188.3.2Changes in DASS-21 Scales following Treatment PAGEREF _Toc458234237 \h 1188.3.3Changes in DTCQ Self-efficacy and Confidence Scale Scores following Treatment PAGEREF _Toc458234238 \h 1198.3.4Changes in Attribution Scales at T2 PAGEREF _Toc458234239 \h 1208.3.5Correlations between T1 and T2 scores across groups PAGEREF _Toc458234240 \h 1208.4Interim Discussion PAGEREF _Toc458234241 \h 121Chapter Nine: Discussion PAGEREF _Toc458234242 \h 1239.1Introduction PAGEREF _Toc458234243 \h 1239.2Coercion Experienced in Treatment PAGEREF _Toc458234244 \h 1249.3Psychometric measures PAGEREF _Toc458234245 \h 1279.4Conclusion PAGEREF _Toc458234246 \h 131Chapter Ten: Methodological Considerations, Limitations and Treatment Journey PAGEREF _Toc458234247 \h 13310.1Introduction PAGEREF _Toc458234248 \h 13310.2Methodological Strengths and Weakness PAGEREF _Toc458234249 \h 13310.2.1Participant Considerations for Psychological Measures PAGEREF _Toc458234250 \h 13310.2.2Participant Attrition PAGEREF _Toc458234251 \h 13310.2.3Failure to Recruit PAGEREF _Toc458234252 \h 13410.3Design Limitations PAGEREF _Toc458234253 \h 13510.3.1History PAGEREF _Toc458234254 \h 13610.3.2Maturation and Selection PAGEREF _Toc458234255 \h 13710.3.3Testing and Instrumentation PAGEREF _Toc458234256 \h 13710.3.4Mortality PAGEREF _Toc458234257 \h 13810.4Methodological Weaknesses PAGEREF _Toc458234258 \h 13810.4.1External Validity PAGEREF _Toc458234259 \h 13810.4.2Population and Ecological Validity PAGEREF _Toc458234260 \h 13910.4.3Qualitative Rigour PAGEREF _Toc458234261 \h 13910.4.4Trustworthiness of the Findings PAGEREF _Toc458234262 \h 14210.4.5Mixed Method Limitations PAGEREF _Toc458234263 \h 14210.4.6Reflexivity PAGEREF _Toc458234264 \h 14310.5Summary PAGEREF _Toc458234265 \h 143Chapter Eleven: Contribution to Knowledge, Recommendations and Conclusion PAGEREF _Toc458234266 \h 14511.1Introduction PAGEREF _Toc458234267 \h 14511.2Contributions to Knowledge PAGEREF _Toc458234268 \h 14511.3Originality PAGEREF _Toc458234269 \h 14611.4Recommendations for Clinical Practice PAGEREF _Toc458234270 \h 14711.5Recommendation for Research PAGEREF _Toc458234271 \h 14911.6Conclusion PAGEREF _Toc458234272 \h 150References PAGEREF _Toc458234273 \h 151LIST OF TABLESTable 1: Summary of study origin from the literature search detailed for Europe to highlight the increasing interest and growth in the UK17Table 2: Literature Review Table and Summary41Table 3: Summary of relationship stability across participant group83Table 4: Summary of relationship status within the groups at T183Table 5: Summary of group employment rates84Table 6: Summary of participant self-reported past employment84Table 7: Summary of the total number of self-reported offences across the groups85Table 8: Summary of self-reported mean time in prison served in months86Table 9: Summary of self-reported preferred route of taking heroin86Table 10: Summary of current methadone use and lifetime use at T187Table 11: Mean attribution scores by Group at T1107Table 12: Treatment confidence and self- efficacy108Table 13: The means and standard deviations for the SOCRATES scales108Table 14: The means and SD scores for each of the three groups109Table 15: Follow up: Possible or Not113Table 16: Heroin used or not at follow up by group113Table 17: Means and (SD) for scores on T1 demographic and drug misuse variables broken down by T2 heroin use or not 114Table 18: Means and (SD) for T1 Preparedness for treatment scales and heroin use or not at T2114Table 19: Means and (SD) for T1 attribution scale scores broken down by T2 heroin use or not115Table 20: Mean difference (SD) scores for the SOCRATES scales between T1 and T2118Table 21 DASS 21 broken down by group at T2119Table 22: Changes in DTCQ8 and confidence scale scores at T2 broken down by group119Table 23: Changes in attribution scale ratings following treatment120Table 24: Summary of Main Study Findings123Table 25: Design limitations summary136Table 26: Summary of Research External Validity138Table 27: The assessment of the study using the COREQ tool140LIST OF FIGURESFigure 1: UK heroin trends from the Crime Survey of England and Wales (CSEW)4Figure 2: Age related trends in Class A drug use against other drug use group percentages5Figure 3: Study modalities and contexts9Figure 4: Psychological set and setting with all qualitative variables63Figure 5: Measures administered on the participant groups77Figure 6: Themes – sub-themes identified from the data90LIST OF APPENDICESAPPENDIX A: Individual Qualitative Interview208APPENDIX B: Consent Form (Version 4)209APPENDIX C: Research Participant Information Sheet (Version 4)210APPENDIX D: National Research Ethics Board Approval Letter213APPENDIX E: Addiction Severity Index 5216APPENDIX F: Attribution of Treatment Responsibility Scale222APPENDIX G: DTCQ 8223APPENDIX H: DASS 21224APPENDIX I: Confidence Scale for Treatment225APPENDIX J: NHS Trust Research and Ethics Approval226APPENDIX K: SOCRATES 8D228ABSTRACTBackgroundDespite considerable political, social and empirical interest in drug treatment programmes the factors that assist heroin withdrawal remain elusive. Legal coercion is frequently used to provide leverage for drug users to enter treatment, however what programmes are most effective for heroin users and in what circumstances remains unclear. AimTo explore dimensions of coercion from the perspective of participants on heroin withdrawal programmes across a range of treatment contexts. Method A mixed methodology approach was adopted using semi structured qualitative interviews and psychometric measures of preparedness for treatment (e.g. SOCRATES) with heroin addicts in treatment in criminal justice and non-criminal justice settings (prison, inpatient, probation and outpatient programmes in the north west of England). An opportunistic sampling approach was used and 72 participants were recruited for data collection at treatment entry, with six month follow up data being obtained from 48 participants. Qualitative data utilised thematic analysis, whilst appropriate parametric and nonparametric procedures were employed with the quantitative data. Research ethics approval was obtained from the relevant university and NHS committees. ResultsThe probation treatment group did not recruit any participants. For the remaining groups the influence of formal and informal coercion was examined on treatment retention and completion rates. The smallest benefits for treatment effectiveness were found in the outpatient treatment group who were the least formally coerced. Confidence and self-efficacy scales demonstrated relationships to greater treatment effectiveness. The study suggests that informal coercion perceived by participants from their family with self-motivation may have more influence than formal criminal justice system coercion. Discussion and ConclusionThe risk of attrition from all the groups presents challenges to researchers and treatment teams. The psychometric measures including treatment confidence and self-efficacy could be used by clinical staff to monitor for early signs of treatment attrition when those scores reduce during treatment The qualitative data suggested that self-motivation for change and family generated pressures seemed to underpin more positive changes in drug habits, suggesting that drug treatment programmes should consider family pressures/influences and individual construal’s of coercion, that are perhaps as important in terms of treatment retention as criminal justice sanctioned approaches. What is known?Legal coercion is widely used to pressure individual drug users into treatment that would not have otherwise commenced treatment at that stage (Perron and Bright, 2008). Legal coercion involves court imposed sanctions that are enforceable by further punishments. Legal coercion can involve probation drug outpatient treatment orders or prison treatment, but both require consent for that treatment from the participant (Hough et al, 2003; Miller and Flaherty, 2000). Outpatient treatment for heroin treatment was established to reduce viral transmission to high risk drug users and the mainstay of treatment was the heroin substitute methadone. On one hand coercion to enter treatment is important politically to reduce crime figures and enforce treatment on drug related offenders who would not have otherwise chosen to do so (Anglin et al, 1988). On the other hand, coercive approaches are not very well understood with poor completion and retention rates (Klag et al, 2005). Treatment for heroin addiction may require a range of approaches and treatment settings, but this is not assisted by the confusion within the literature regarding the effectiveness of coercion. Some advocate that the desire to enter treatment must originate from the individual (Polcin, 2006). However, others suggest that coercion can help those who may not have done so, to access heroin treatment resources (Anglin, 1989). What this study addsEssentially legal coercion is only one form of pressure that operates on individuals to enter drug treatment programmes and other constructs must be considered to select the right person for the right programme. Individual participants felt supported at the same time as being pressured, and construed that pressure as constructive. Social coercion operated across the groups irrespective of treatment being court sanctioned or not, and voluntary outpatients, for example, may be considered coerced from their family members. This study suggests that treatment confidence, attributional correlates, family involvement and self-efficacy, all operate at an individual level and improve treatment effectiveness when present coerced or otherwise. The inpatient and prison groups had improved outcomes for heroin treatment effectiveness, but the outpatient group in terms of heroin reduction or abstinence did not. The prison and inpatient treatment groups do benefit from treatment, but that prison incarceration must be opportunistic and not a mainstay of heroin addiction treatment. Investigating the group differences between the outpatient and inpatient group provides an opportunity to explore group differences. Irrespective of which contexts participants are treated, attrition rates are typically high and the mechanisms that lead to attrition in this study would have benefitted from data on those who left the study, to compare against those remaining (Jacobson, 2004). Structure of studyChapter one begins by setting out the background aims and objectives, and describes how the study has assembled the evidence gathered. The chapter also explores drug treatment contexts and modalities. Chapter two provides the literature and explores the nature and extent of coercive drug treatments across the study treatment settings. Literature from significant mental illness coercion studies is considered. Chapter three considers the study mixed method approach to investigate the phenomenon to highlight the challenges investigating coercion and the influence of coercion upon individual drug users. A range of data measures administered and findings commence in chapter four; that include demographics, substance use history, criminal behaviour and treatment differences between participants across three treatment contexts. Chapter five reports participant qualitative data and results. Chapter six considers the range of factors at treatment entry that contextualises participants in programme treatment settings. Chapters seven and eight provide the remaining quantitative results that report on outcomes between treatment entry interviews and follow up. Discussion of findings from the study are set out in chapter nine. Chapter Ten examines study methodological considerations and limitations. Chapter eleven concludes with original contributions to knowledge, implications for practice and policy and recommendations for further research. Key Words: Heroin, Coercion, Drug Treatment Pressure, Mixed Method.Chapter One: Substance Misuse Literature Review1.0IntroductionThe following literature section is divided into two chapters. Chapter one examines treatment contexts for heroin addiction. Chapter two reviews the clinical and empirical literature specific to the processes and outcomes for heroin addiction. Coercion is not a single well defined entity but coercive programmes may share some characteristics for those included. Coercion is not very well defined within the literature and many terms are often used interchangeably (Farabee et al, 1998). Coercive approaches towards heroin drug treatment may include a range of pressures to enter compulsory treatment programmes (Anglin and Hser, 1991; Young and Belenko, 2002; Seddon, 2007). Coercion within the present study is explained as those compelled into heroin treatment via court orders or those imprisoned through the criminal justice system. This chapter explores the complexities of substance misuse in four treatment contexts that include prison, inpatient, drug rehabilitation orders and outpatient settings. One treatment modality that incorporated prescribed methadone is concentrated upon although others will be considered in the present chapter.1.1Introduction to Substance MisuseThe terms substance misuse and addiction are used interchangeably with almost no clear distinction between them (Farabee et al, 1998; West, 2001). A common theme is the impaired control a person has over their individual behaviour. Individuals, who recognise the behaviour is harming them or those who they care about, find they are unable to stop engaging in the behaviour and may then be deemed drug dependent or addicted (Rounsaville and Klebber, 1985; Cottler, 1993; Heather, 1998). From a medical standpoint addiction is primarily conceptualised as a long term disease that is characterised by impaired control over the use of a psychoactive substance/s. There is a large quantity of literature on the origins for addiction that cannot be examined here; the focus of the present study is to investigate the coercive processes that compel those addicted to heroin into methadone drug treatment programmes (McAuliffe and Gordon, 1980; Borysenko and Borysenko, 1995; Khantzian et al, 1990; Thombs, 1994; Vaillant, 1995). Clinically the manifestations occur along biological, psychological, social and spiritual dimensions (Canadian Society for Addiction Medicine (CSAM), 2012). An example of spiritual dimensions is those that pursue spiritual emptiness to offer meaning to the person addicted (Miller and Kurtz, 1994). Addiction results from a complex interplay between genetics, neurobiology, and environment (Koob and LeMoal, 2008). The medical perspective upon addiction identifies it as a chronic relapsing brain disease, compulsive drug seeking and use, despite the presence of harmful consequences (Amato et al, 2005; Gossop, 2006; National Institute for Health and Care Excellence (NICE), 2007; National Prescribing Centre (NPC), 2008; National Institute of Drug Abuse (NIDA), 2013).The behaviour of drug misuse causes a wide range of individual problems that make it challenging for any one approach or intervention to address (Tiffany and Carter, 1998; Keene, 2010; NHS, 2013). When considering the immediate and wider harms, the debate cannot be confined solely to the individual, but must consider the impact on the family, society and the local community (Parssinen and Kerner, 1980; Sedgwick, 1994; Sullivan et al, 2008; NIDA, 2009; National Treatment Agency for Substance Misuse (NTA), 2012). Those addicted who enter treatment services across treatment contexts are likely to have been using heroin for at least eight years before treatment entry (NTA, 2013). The longer the person has used heroin, the wider the range of problems experienced and the greater the number of co-existing conditions, with more limited social support, all make treatment more challenging (Gossop et al, 1998; Hiller et al, 1998; Health Education England (HEE), 2013). Those heavily addicted to heroin are often in poor health and have low self-esteem before coming into treatment, with low self-belief in their ability to complete a drug treatment programme (NTA, 2012). 1.2Background to Heroin UseOpiates are the collective label for alkaloids that are derivatives of the opium poppy. The collective term opioid is often used interchangeably with opiates, but the term opioid should only be used with synthetic opiate drugs (Prus, 2014). The term opiate and opioid will be used throughout this work. Opiates from a pharmacological perspective mimic the effects of naturally produced endorphins and act as agonists throughout the human physiological receptor sites, examples include: heroin, morphine and methadone. Antagonists at these receptor sites such as naltrexone, displace agonists, blocking the opiate effect (Schuh et al, 1999). Antagonists are used in treatment programmes but are not covered in detail in this work (see Adi et al, 2007). Heroin is an opiate agonist with significant analgesic properties and useful medically for severe pain relief (NTA, 2009; NIDA, 2009). The action of heroin works by reducing the excitability of neurons and producing a feeling of euphoria (NPC, 2008; NIDA, 2009). Opiates and narcotic analgesics such as heroin and methadone help decrease sensitivity to pain, discomfort, and anxiety whether physical or psychological (Berridge and Edwards, 1981; Wheatley et al, 2005; NTA, 2007). Heroin is often described as the most addictive of the commonly abused drugs (Taylor et al, 2012; NTA, 2012). Some societal populations are more likely than others to become dependent on drugs, especially if they have difficulty in dealing with pain (physical or emotional), stress, uncertainty, loneliness, frustration and boredom (Gossop, 2000a; RSA, 2007; NTA, 2012). 1.2.1Prevalence of Heroin Addiction Treatment Prevalence studies estimate that 350,000 people in the UK abuse heroin, with a total drug using population of 1.2 million (NTA, 2012). National UK literature suggests that 2.6% of adults aged 16 to 59 have taken a Class A drug in 2012, which is approaching 850,000 people (NTA, 2012). In 2013 there was an estimated 298,752 heroin users in England between the ages of 15-64, whereas in 2009 the figure was higher at 306,150 (National Drug Treatment and Monitoring Service (NDTMS), 2014)). Heroin is a leading cause of death in 15 to 34 year olds in the UK especially when used in combination with cocaine; death rates have quadrupled (NTA, 2012). Drug-related overdose deaths among UK drug users are among the highest in Europe and include suicide, accidents and physical complications through drug misuse (DH, 2007). In England 29,855 drug users successfully completed drug treatment programmes in 2012 (NTA, 2012). This trend was up from 27,969 the previous year and almost 2.5 times the level they were in 2005 of 11,208 (NTA, 2012). The data reveals that nearly one third of heroin users on drug treatment programmes in the last seven years successfully completed their treatment and did not relapse, which compares favourably to international drug recovery rates (NICE, 2007; NTA, 2012). The north west of England had the highest UK heroin prevalence rates nationally in the 35-64 age range which is much greater than any other region at 9.58 per 1,000 people (Hay et al, 2011; Health and Social Care Information Centre (HSCIC), 2013). The Crime Survey of England and Wales (CSEW) provides evidence-based patterns of heroin use within the UK, see Figure 1.Figure 1: UK heroin trends from the Crime Survey of England and Wales (CSEW) Permission obtained (Home Office, 2012:6) (,000) Figure 1 illustrates criminogenic factors associated with heroin addiction. The price per gram has decreased whilst the purity per gram by weight has increased from 2010-12 (CSEW, 2012). Drug related deaths are also declining as street level purity declines due to being cut with adulterants to increase profit (CSEW, 2012). Evidence indicates that older injecting heroin users have higher levels of morbidity than their younger drug using counterparts (NICE, 2007; NTA 2008, Home Office 2012). Heroin causes significantly more individual harms than other drugs physically, psychologically, and socially reflected in morbidity and mortality rates (Smith, 2002; Taylor et al, 2013). Empirical evidence does not adequately consider groups such as those living in prisons for example, who tend to have higher problematic drug use and are hard to access (Wild, 2006; McKeganey, 2007; NTA, 2012). Addiction to Class A drugs typically affects more males than females (NDTMS, 2014). Figure 2: Age related trends in Class A drug use against other drug use group percentages. Permission obtained (Home Office, 2013; 9). The trend for Class A drug use remaining constant may suggest that current drug policy is already effective in limiting heavy end drug use (Garland, 1985; Rose, 1999; Reuters and Stevens, 2007; Hay et al, 2007; Reuters and Stevens, 2007; Independent Expert Working Group, 2007; UK Drug Policy Commission (UKDPC), 2012; Drug Policy Alliance, 2013). However, there are a minority of heroin users who develop dependent patterns of drug use that cause large amounts of harm through their offending, incarceration and family tensions (Johnson et al, 1985; Shaxon, 2005; Marmot, 2006; RSA, 2007; Hunter, 2009; Drug Scope, 2013). The Crime Survey of England and Wales (CSEW, 2013) reports that 2.6% of adults aged 16 to 59 had taken Class A drugs in 2012/13. The long-term trend is noted between 1996-2013 in relation to Class A and drug use as a whole; which until 2012 had been relatively stable from 1996 (2.7%) and 2012/13 (2.6%) surveys (DH, 2005; Home Office, 2013). Although numbers for patients within a service is a way of reporting drug treatment uptake, they do not indicate drug reduction, abstinence, or harm reduction performance (Young, 2002a; Singleton et al, 2006). The median age for opiate only use participants who first enter treatment services averages 38.0 years, and three quarters entering treatment were male (NDTMS, 2014). Gender specific programme statistics reflect prevalent use of opiates and crack cocaine in males (74%) with females accounting for 26% in treatment (Health and Social Care Information Centre, HSCIC 2014). Distribution figures for 2013/14 show that the largest number of drug users in treatment is for heroin, combined with crack cocaine. During this survey (n=193,098) primary heroin drug users in treatment totalled 91,560 (47%) of all those on programmes (NDTMS, 2014). Higher levels of problem severity experienced by drug users have been associated with volunteering for treatment programmes, and studies that explored treatment dynamic predictors have found individuals with higher motivation more likely to enter treatment (Rounsaville and Klebber, 1985; Simpson et al, 1997; Boyle et al, 2000; NTA, 2010). Figures for all drug service referrals in England (n=200,000) suggest the most common route into drug treatment was self- referral 44% (n= 88,000) with referrals from the criminal justice system (n=54,000) accounting for 27% (NDTMS, 2014). Individuals treated for heroin addiction are the hardest to treat, more likely to relapse, and have the poorest longer term health outcomes across all other drug of misuse (NDTMS, 2014).Attrition rates in the UK suggest that 43% (n= 68,201) do not re-present to services suggesting they may have already received what they needed to overcome their addiction before exiting (NDTMS, 2013). Some practitioners have argued that drug programme drop-out typically indicates relapse, but an equal proportion of those in treatment walk away once it has met their treatment needs (Niven, and Stewart, 2005; Prendergast et al, 2006; Pelisier et al, 2007; NDTMS, 2013). Nonetheless, irrespective of treatment context, around half of those who leave treatment prematurely will relapse and use drugs again a short time after treatment exit (Gossop et al, 2001; Braden et al, 2011). The challenges are in retaining participants in treatment, early detection for treatment attrition, and by exploring coercion in those who relapse sooner (NDTMS, 2013).There are associated high levels of mortality and morbidity suffered by drug users as they leave prison and the implications should be considered when formulating and evaluating treatment practices (Polkinghorne et al, 1996; Reed and Lyne, 1997; Gossop et al, 1998; Shaw, 2002; Lewandowski and Hill, 2009). Between 33% and 50% of new persons received into prison are problem drug users, equivalent to around 45,000 prisoners in England and Wales (UKDPC, 2008). In the week immediately following release, former prisoners were forty times more likely to die from their drug use than a member of the general population (Singleton et al, 2003; Farrell and Marsden, 2005; HSCIC, 2013). Therefore not treating those addicted to substances in criminal justice contexts would be a missed opportunity for improved treatment retention and completion rates (Mathews, 2004; NTA, 2014). 1.2.2Different Treatment ExperiencesA range of intervention options are available which represent differing modalities within addiction treatment (Prendergast et al, 2002; Gossop, 2006; Stevens et al, 2006; McSweeney et al, 2008), including non-medical perspectives. For example psychosocial perspectives acknowledge that the issues arising are much broader than one theory alone can address for heroin addiction (Durrant and Thakker, 2003; McSweeney et al, 2008; NDTMS, 2014). Essentially, an exclusive focus on an individual neurobiological or a medical addictive model may preclude important additional layers of understanding concerning for example, the roles of individual or joint human actions, the socially relevant processes of addiction, and the role of gender (Graham et al, 2008). Psychosocial perspectives could offer avenues for further investigation beyond the medical model, due to the putative failure of the latter to address psychosocial concerns (McSweeney et al, 2008). Other treatment modalities exist that include acupuncture, massage, and numerous alternative medication approaches. For the present study a focus upon medical interventions was adopted, particularly on methadone, due to its predominance throughout clinical practice and research in the UK. There is evidence that supports the effectiveness of methadone treatment programmes in a range of contexts (Gossop, 2006; NTA, 2012; NDTMS, 2014). Some commentators have argued that substance abuse should not be considered as a one dimensional disease, and that it cannot be divorced from its social, psychological, cultural, political, legal and environmental contexts (Heim et al, 2014). Patients with addiction problems often present with comorbid psychological problems, the treatment of these problems alone will not effectively treat substance dependence (Gourlay et al, 2005; Steven et al, 2005; McSweeney et al, 2008). Therefore persons addicted may require extensive treatment interventions in all life areas, specifically those persons who have a form of mental illness and substance dependence (Alterman et al, 1993; Magura et al, 1993; Bellin et al, 1999; Daley et al, 2004; Kaya et al, 2004; Neale et al, 2005). Heroin addiction is disproportionately found among the poor, unemployed, the homeless and young people who have been in care (Jayakody et al, 2000; Steven et al, 2005; Home Office, 2012). Addiction to heroin is the focus of this study whilst acknowledging that poly drug use (including alcohol) is increasingly encountered in the UK (Hunt et al, 1986; Gottheil et al, 1993; Strain et al, 1994; Kassebaum and Chandler, 1994; NTA, 2012). Despite the heavy emphasis on medical aspects of treatment, addiction is not considered to fit within a physical diseases category due to the lack of clear physiological pathology (Stein, 1985; DuPont, 1993; Seddon, 2007). A central component within the medical model is diagnosis and the Diagnostic and Statistical Manual of Disorders (5) or DSM-5 supports that requirement (American Psychiatric Association (APA), 2012). DSM-5 proposes a diagnosis of substance dependence if three or more of the following are presenting in the individual over a twelve month period.Tolerance – diminished effect with use of the same amount, or increased amount used to achieve intoxicationWithdrawal – characteristic withdrawal syndrome for the substance, or the same or closely related substance is taken to relieve or avoid withdrawal symptomsThe substance was taken in larger amounts or for a longer period than was intendedThere is a persistent desire or unsuccessful attempts to cut downA great deal of time is spent in activities to procure the substanceImportant activities are given up or reduced because of the substanceThe substance use is continued despite knowledge of having a physical or psychological problem caused by, or exacerbated by, the substance use.(APA, 2012)An alternative approach to DSM-5 (APA, 2012) may be to focus upon measurement of the degree of distress addicts experience, in order to identify and utilise interventions aimed at symptom control and reduction, rather than to formulate a clinical diagnosis (Moncrieff, 2007). Which treatment approach works best in drug programmes is not easily identifiable in the literature (West, 2001; Spanagel and Heilig, 2005). In some cases the individual drug user will achieve recovery for a substantial period of time, and perhaps even permanently, without any professional interventions, with the support of family and friends (Parssinen and Kerner, 1980; Simpson and Sells, 1990; NTA, 2006; NIDA, 2009; NHS, 2013). 1.3Heroin Drug Treatment Interventions1.3.1Introduction to Methadone ModalityThis study had a modality specific focus on prescribed methadone medication; within the treatment contexts of prison, inpatient, probation and outpatient programmes (see figure 3 below). The UK Home Office drug strategy emphasises the importance of drug treatment completion and exit (Home Office, 2008; NDTMS, 2008). The meaning of drug treatment within this study includes maintaining and reducing substitute prescribing regimes that encompasses drug cessation and abstinence approaches (DH, 2010; Ramo et al, 2010). Opioids are the gold standard for chronic pain management and are widely available for clinical use. Opioids are also used in the treatment of heroin addiction and methadone is the most widely used (Inturrisi, 2002; NTA, 2012). Methadone and buprenorphine are synthetic opioids used to treat heroin addiction and used to reduce cravings and withdrawal phenomenon. Methadone has been used for many years to treat addiction to opiates, whilst buprenorphine has been used comparatively recently (Gossop et al, 2003; NICE, 2007; Royal College of General Practitioners, 2011; Nincovi? and Roy, 2013). The synthetic opiate agonist methadone is the recommended first line medication for heroin addiction (Gossop et al, 1998; Ghodse et al, 2002; Farrell et al, 2002; Butler, 2002; Dolan et al, 2005; Nice, 2007; National Prescribing Centre, 2008; NTA, 2012). The biological basis for methadone prescribing is to inhibit neural activity by blocking/replacing the excitatory effects experienced after taking heroin (Inturrisi, 2002; Nincovi? and Roy, 2013). 1713230305325Methadone (Modality)00Methadone (Modality)Figure 3: Study modalities and contexts192214521418553046095214185510502902144395150304514605001874520113728523888701137285143637029654524364952965451497965120396040697152141855 2779975332105Maintenance00Maintenance819371322580Detoxification00Detoxification31842211943102436495143897104457514257021153191618Drug Rehabilitation Requirement (DRR)00Drug Rehabilitation Requirement (DRR)357380726366Outpatients (Contexts)00Outpatients (Contexts)263494626670Inpatients00Inpatients141519522860Prison00PrisonAs indicated in figure 3 above, although individual drug users may commence on one treatment modality and one context, movement is possible throughout the course of treatment between the contexts. This movement can involve an initial community court order for example, but failure to comply with that order can result in imprisonment (Gossop et al, 2002; NTA, 2012). Methadone treatment programmes commonly have two main aims; first to stabilise the chaotic lifestyle, and then move the person towards abstinence (McCarthy and Borders, 1985; Nolimal and Crowley, 1990; NTA, 2006; NTA, 2012). Methadone contributes to reducing mortality rates, illicit drug use, and criminal activity (Caplehorn et al, 1994; Gossop et al, 2002; Dolan et al, 2003). Methadone treatment aims to promote stability by maintaining a patient on a fixed dose, or reducing the amount over time which varies between individual patients. Lastly, an abstinence based approach may follow reduction and maintenance regimes. The fundamental objective for all three treatment aspects is to reduce harm caused through heroin use, reduce dependency and improve stability (Tomkins et al 2007; German, 2009; NTA, 2012). 1.4Contexts of Heroin Treatment1.4.1The Treatment Contexts for this StudyFour treatment contexts were considered in this study and these contexts accommodate more than 90% of all those receiving drug misuse treatment within the UK (Waldorf et al, 1991; Hough, 1996; Gossop et al, 1998; Seddon, 2000; Seivewright, 2000; Stewart et al, 2000; Reith, 2004; NICE, 2012; NTA, 2014). It should be noted that difficulties arose in the course of the study with the court imposed Drug Rehabilitation Requirement (DRR) context which led to a modification of study which is described later. It should also be noted that there are a number of treatment modalities that can be employed for substance misuse populations across these contexts. Individuals who are mandated by the courts onto a DRR (further discussion on DRR below) can receive their treatment subject to the conditions of the order, but may also receive periods of voluntary inpatient treatment. However, the consequences of not cooperating with treatment order staff may result in a return to court for resentencing on the original offence for breaching the DRR. Prisoners cannot be subject to DRR but are subject to mandatory drug testing as requested by prison staff, and a positive test for drugs would result in a loss of privileges and influence release dates from prison. 1.4.2Prison Drug Treatment ContextMethadone treatment in a prison context can be divided into two groups, those who are drug using offenders and those who are offending drug users (Best et al, 2008; Public Health England, 2014). Therefore, for some, offending is directly linked to drug acquisition and for others that offending and drugs coexist and do not drive offending directly. Between a half and two thirds of prisoners are identified as being problem drug users and therefore at the severe end of the drug dependency spectrum (Cassidy et al, 1999; DH, 2005; NTA, 2012). There are on average about 135,000 prisoners incarcerated each year, and a slightly smaller number released, with about 50% serving sentences of less than six months (DH, 2005; Williamson, 2007; Ministry of Justice, 2009; HM Prison Service, 2009; Public Health England, 2014). Male prisoner occupancy rates for 2015 were 81,900 and evidence little change for rates in 2014 which was slightly lower at 81,982 (Ministry of Justice, 2015). Once in prison some evidence indicates that up to 76% of individuals reported some illicit drug use at some time during their sentence (Edgar and O’ Donnell, 1998). Continued heroin use may be exacerbated by prison, with a lack of social support, isolation, boredom, and a desire to escape the prison regime through drug use if only for a few hours (Hunt et al, 1986; Leenerts, 2003; Wheatley et al, 2005; Steven et al, 2006a). Similarly on admission to prison, 25% of prisoners report wanting treatment for substance misuse and to engage with drug treatment (Brooke et al, 1998; Niven and Stewart, 2005; Leenerts, 2003; DH, 2006; Tomkins et al, 2007; HSCIC, 2013). As already noted drug misuse in prisons is prevalent and individual drug use can be attributed to a range of psychological, pharmacological, social, psychiatric, and economic reasons (Waldorf, 1983; Biernacki, 1986; Gossop et al, 2003; Marmot, 2006; Home Office, 2007; Tompkins et al, 2007; DH, 2010). Demographic data suggests that prisoners are more likely to have been in local authority care as a child, with 60% unemployed, and are more likely to be released to no fixed abode (Niven and Olagundoye, 2002; DH, 2006; Ministry of Justice, 2012; Public Health England, 2014). Participants on prison treatment programmes generally have longer offending histories with serious levels of substance misuse and higher levels of treatment drop out compared with those with shorter treatment histories (Lines, 2005; Hepburn, 2005; Stewart, 2009; Ministry of Justice, 2012; NTA, 2013). There are significant studies of treatment entry and retention within prison settings with the majority focusing on offending on release, but often do not offer clear explanations for treatment drop out (Hepburn, 2005; Best et al, 2008; Stewart, 2009; Home Office, 2012). Studies investigating treatment success have encountered little consistency in the characteristics of predictive treatment effectiveness (Hser et al, 1998; Hiller et al, 1999; DeLeon, 2000; Pellisier, 2004).1.4.3Drug Rehabilitation Requirement ContextThe DRR is a criminal justice mandated order that requires an individual to cooperate with the Probation Service (National Offender Management Service, NOMS) in an outpatient context. Contextually this is likely to involve collaboration with NHS outpatient services for methadone prescribing purposes. The DRR was first raised in the Criminal Justice Act of 1991 that linked compulsory drug treatment and punishment in the UK criminal justice system for those over the age of 16 (Home Office, 1991; 2001; 2003; Powell et al, 2007). A prerequisite for a DRR is that the individual has to consent to the order being made, but a choice between custody and community treatment arguably may not be a real choice (Freiberg, 2000). The DRR is a sentence that allows an intervention to be individually tailored with progress rewarded and poor progression challenged (Wilson, 2014). Therefore, a DRR has the potential to respond to differing levels of problematic drug use throughout the order as dynamics change over time (Ministry of Justice, 2011; Wilson, 2014). The DRR order involves constructing a treatment package that includes treatment with medication such as methadone and two mandatory drug tests per week. The programme also offers structured day care, between 8-15 hours per week (Wilson, 2014). There is always the possibility of movement between contexts following a DRR being imposed, for example residential treatment on an inpatient basis. The length of DRR orders vary from 6-36 months depending upon the seriousness of the offence (Home Office, 2003). Once made subject to a DRR, individuals must attend all appointments offered, as failure to attend two appointments without a reasonable explanation will result in a return to court for resentencing (McSweeney et al, 2008). These DRR conditions form a compulsory framework for individual compliance, or legal sanctions are faced which are coercive in nature. A DRR order is not an option within prison contexts or on release from prison. Offences linked to substance use for DRR entry are generally acquisitive crimes, most notably theft and domestic burglary, with drug possession offences accounting for only 5% of DRRs (Field, 1992; DuPont and Baumgartner, 1995; Belenko and Peugh, 1998; Campbell and Best, 2007). Drug outcome studies suggest that while many drug-dependent offenders fail to complete DRRs those participants who are retained and complete the programmes report statistically significant reductions in illicit drug use (Seddon, 2007; Powell et al, 2011; Home Office, 2012). Additionally, there is evidence to suggest that those coerced into community based treatment via DRR arrangements report larger reductions in illicit drug use and offending behaviours than voluntary patients entering the same services, but with no significant differences in retention rates and other outcomes (McSweeney et al, 2008). 1.4.4Inpatient Context Drug TreatmentDetoxification (detox) from heroin in any context involves the elimination of the use and effects of opiate used. The duration of detoxification varies within treatment regimens and contexts but is generally between two and twelve weeks (Keen et al, 2000; NTA, 2005; Best et al, 2006; National Prescribing Centre (NPC), 2008). Between 2-4% of referrals to drug treatment teams (up to 4,000 people) are for inpatient detox programmes of the 200,000 patients in contact with drug services in the UK (NTA, 2014). Some evidence suggests that three quarters who exit programmes prematurely use heroin again, usually in the first week following treatment unit departure (Chutuape et al, 2001; Gossop, 2002; Campbell and Best, 2007; Bermen et al, 2008; Home Office, 2012). For the present study participants received medical detox from heroin as an inpatient for up to 28 days in duration. This is an important definition as whilst the inpatient context combines medication with therapy the duration of intervention is time limited. The study acknowledges, for example, that therapeutic communities may continue to provide residential structured programmes following an inpatient unit discharge to consolidate drug free living for six to twelve months.Inpatient drug treatment programmes work best with emotional support obtained from family, friends, professionals, and welfare agencies, especially in the weeks following discharge (NICE, 2007; NTA, 2007; Alliance, 2008). The smallest treatment group across all contexts were the inpatients (n=4,461). However, inpatient treatment participants are also the most effective group in terms of drug cessation following programme exit (McSweeney et al, 2008; NDTMS, 2013). Social support within inpatient treatment contexts can have negative and positive effects on completion rates depending on the type of the support provided (Lewandowski and Hill, 2009). Overall, participants do better in drug treatment when they are socially connected, have close friends, and higher social conformity than those who drop out from treatment (Hubbard et al, 1997; Gossop et al, 1999; Lang and Belenko, 2000; Ghodse et al, 2002). 1.4.5Outpatient Context Drug Treatment Outpatient drug treatment services attract a wide range of individuals wanting treatment for their addiction (NTA, 2012). Outpatient drug treatment is primarily a service provided by a community drugs service and aims to reduce heroin use, provide methadone, and reduce viral transmission harms to the individual. Outpatient support involves meeting up with a drug service key worker and the prescribing doctor to monitor drug use, methadone dosage and general wellbeing of the patient (Nolimal and Crowley, 1990; NTA, 2009). In a community setting only a small minority of heroin users will come into contact with formal drug treatment services (NICE, 2007; NTA, 2012). Most of those who make contact with services are dealt with through primary healthcare teams and drug treatment clinics (Marshall et al, 2000). Annual figures from the 200,000 persons treated in England (NDTMS, 2013) suggest that the outpatient group are the largest group of all the treatment contexts (n=176,820). Outpatient drug treatment requires a residential address, and for the drug user to adhere to the rules of prescribing, or their methadone supply could be suspended (Amato et al, 2005). Reduction regimens of medication are measured against symptoms reported and amount of illicit heroin taken, with the aim of reducing withdrawal symptoms and therefore the need for illicit drugs (Keen, 1999; Campbell and Best, 2007; DH, 2010). Improvements in social functioning and favourable outpatient treatment outcomes are lacking from the evidence base (Stevens et al, 2006; Digiusto et al, 2006; Hunt, 2007). Irrespective of the treatment context, individual motivations differ and services should aim for individualised treatments to engage participants in whatever context (DeLeon et al, 2000; Chutuape et al, 2001). Many heroin users experience more than one treatment context, with over half in outpatient treatment programmes also having been in prison at some stage (Meulenbeek, 2000; NTA, 2012). Outpatient, prison, and inpatient drug treatments services often struggle to provide an approach that has proved effective for each individual heroin user (NTA, 2009). Research studies have shown more favourable treatment outcomes that focus on individual needs and choices in preference to prescribed regimes (Inciardi et al, 1993; Roebuck et al, 2003; Gossop et al, 2007; NTA, 2009). Drug treatment programmes should be considered as a part of an overall journey and should not viewed as a finite stage (European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), 1997). 1.5Summary Literature has been presented from four treatment contexts and one treatment modality. Background statistics have been considered that highlight the scale of the populations. The modality of methadone prescribed medication treatment applied to the four study contexts, and that movement between the study settings can occur. Evidence from the contexts is offered on heroin use generally before moving into the study coercion specific literature that follows. The aim is to establish what works within heroin addiction treatment regimens for those addicted and the different contexts they reside in. 1.6The Present StudyThere is a broad study aim to investigate what works within heroin treatment programmes, how coercion differs between the contexts and specifically, how individual participants experience coercion in different contexts. What characteristics predict favourable or unfavourable treatment outcomes for individuals, and if they are associated with coercive approaches. The main objective of the present study is to measure a range of participant variables across four treatment contexts and gather coercion data. Different types of pressures including legal coercion (formal) and social coercion (informal) are investigated over the participant groups (Collins and Allison, 1983; Klag et al, 2005). Even though participants by definition in non-criminal justice groups (inpatient and outpatients) may not be legally coerced, the power of informal social coercion, from friends and family for instance, may be an equally important consideration. The use of a mixed methods (quantitative and qualitative) approach to study such interactions is detailed in chapter three. The quantitative measures allow some important participant psychological variables to be examined alongside the qualitative exploration for treatment pressures. The qualitative elements allows for coercion to be explored and operationalised. The coercion literature (reviewed in chapter two) from national and international perspectives on the effectiveness of coercive treatment approaches will be reviewed. Chapter two contextualises the literature specific to contexts and categories investigated, including treatment motivation, pressures, attributions, change stage, mood, confidence, and self-efficacy for drug addiction treatment. The literature regarding coercion to accept treatment from mental health populations is considered due to the close affinity to substance misuse populations. Chapter Two: Literature Review: Processes and Outcomes in Specific Treatment Contexts2.0IntroductionChapter two considers coercive treatment literature from substance misuse and mental illness populations. Coercion studies undertaken on mental illness populations have direct relevance to this study by the similarity of mechanisms used to engage unwilling participants in treatment (Lidz et al, 1998; Monahan et al, 2005; Burns et al, 2011). Throughout this study attention will be given to demographic and some psychological variables that emanate from the literature to provide a baseline of who the participants are. Examination of the psychological variables provides context to inform coercion data gathered qualitatively to gain a perspective of participant coercion experiences. Investigation into coercion is generally important because of the continued interest from international and UK drug agencies in coercive forms of treatment (Home Office, 1991; 2001; 2003; Powell et al, 2007; DH, 2010; NTA, 2012). Irrespective of treatment aims and processes, the overriding aim becomes engaging a person in treatment that they may not want at that time in their life. Coercion is what people other than the drug user utilise in order to propel them into treatment contexts, and it is the internal and external participant influences that this present study aims to capture. 2.1Method2.1.1Identification of Databases and Search TermsDatabases were initially searched from their inception to 23rd August 2015 via NHS Evidence (evidence.nhs.uk). These databases were Medline (1950- ), Embase (1980- ), Cinahl (1981- ), PsycInfo (1981- 2014), HMIC and The Cochrane Library comprising of The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, The Cochrane Controlled Trials Register, NHS Economic Evaluation Database, and Health Technology Assessments from 1993 to June 2015. The literature search summary table is sub divided by the key search terms concluding the present chapter (see table 2). The initial search terms were: coercion and heroin, substance abuse, client characteristics, and pressures for treatment. These preliminary terms were further refined to include participant characteristics, coercion, mental illness, treatment motivation, pressures, leverage, treatment retention and readiness for change. Synonyms, related terms, relevant thesaurus terms unique to each database and advanced search operators (for example, adjacency) were also utilised. 2.1.2Inclusion and Exclusion CriteriaStudies that specifically considered coercion and all countries were included. Literature that matched search parameters was further examined for scientific rigour and through hand searching. Systematic reviews were included and original studies to ensure specific matches to coercion within treatment programmes. Journals and monographs were included from prison, inpatients, outpatients, and probation drug treatment contexts. Only English language papers were included due to no available resources for translation services. 2.2Results2.2.1OverviewThis section is structured around themes generated from the literature review. A review of empirical literature for the present study was completed and included largely quantitative studies (56). The remaining studies (6) were qualitative or mixed method (see table 1). The total of 62 scientific peer reviewed studies are summarised in tabulated format at the conclusion of the present chapter (see table 2). The literature related to mental illness coercion studies was confined to three rigorous studies from the USA and UK (Lidz et al, 1998; Monahan et al, 2005; Burns et al, 2011). The relatively small numbers of mixed method studies influenced the present study design. The national origin of studies included is summarised in table 1. Table 1: Summary of study origin from the literature search detailed for Europe to highlight the increasing interest and growth in the UKCountry of StudyNumbers includedUSA41Europe 16(11-UK; 2-Sweden; 1-Netherlands, 2-Europe wide).Australia3Canada22.2.2Treatment Entry from Criminal Justice SettingsLiterature from the US, Australia and UK proposes that compulsory criminal justice treatment programmes are equivalent in relation to treatment retention and outcomes to their voluntary counterparts (Klingemann and Hunt, 1998; Barton, 1999; Porter et al, 1999; Gossop et al, 2001; Marlowe, 2003). A paucity of studies has focused on coercion from heterogeneous groups of heroin users. Some evidence suggests a myriad of factors converging to direct the person into drug treatment that may provide a decision tipping point, although these combinations present challenges to capture (Polcin and Weisner, 1999; Gossop et al, 2001; Marlowe, 2003). Informal mandates by friends and family occur more frequently than the formal (legal) mandates which contributed to their treatment admission, with more than one referral pressure commonly experienced (Polcin and Weisner, 1999). A US study examined participant drug treatment seeking pressures at treatment referral (Hser et al, 1998). The participant groups consisted of one criminal justice mandated; one involved in the criminal justice system who were not legally mandated and finally those who had no current contact with the criminal justice system. The strongest group to place pressure via an ultimatum to enter drug treatment was family members followed by the criminal justice system. At six-month follow-up 171 (62%) had entered treatment after the initial data had indicated that there was pressure to enter treatment. The study findings indicated that treatment entry and treatment refusal for participants did not differ in terms of age, gender, type of drug used, or years of use. Participant characteristics at baseline that predicted subsequent treatment entry included legal pressure, lower levels of psychological distress, stable mood state, family problems and prior successful treatment experience. The study found that non mandated/voluntary participants shared a lot of similarities, in their treatment related beliefs; with the court mandated group especially in their motivation for treatment. The study concluded that legal coercion (external pressure) was effective in promoting treatment entry but also that internal barriers to treatment were important, for example not recognising a problem and low treatment motivation level. However, participants with more severe addiction problems seemed less likely to enter treatment, suggesting that higher levels of psychological distress and family problems may actually undermine motivation. Heroin users with more severe problems were simply less likely to respond positively to pressure (Hser et al, 1998). The right pressure combinations perceived by the individual appears to be crucial, with too much or too little reducing the chances of treatment entry (Sinha, 2001; Wild et al, 2006; Campbell et al, 2007; Best et al, 2008). However, this must be balanced against the individual’s perceived level of support (physically, emotionally, and socially) as over a sustained period erosion of vital supportive networks occurs (Simpson and Sells, 1990; Lovejoy et al, 1995; Barton, 1999; Porter et al, 1999; Seivewright, 2000; Gossop et al, 2001; Polcin and Beattie, 2007). The literature presents inconsistencies regarding the effectiveness of coercion in drug treatment, but is generally more favourable in terms of more positive treatment outcomes. Gaps exist in the literature regarding specific treatment entry pressures heroin users encounter from their families, irrespective of criminal justice sanctioned treatment or not (Leshner,1997; Lamb et al,1998; Goodman et al, 2011). There is paucity in the literature for studies that takes account of both criminal justice and family initiated coercion to allow comparison (Kelly et al, 2005; Stevens et al, 2006). The study of treatment contexts and abstinence opportunities provide perspectives on the effectiveness of heroin treatment. However, the findings present inconsistencies in that coercion can again be inferred by referral source.Coercion literature presents many challenges arising from the diversity of effects reported, and findings must be incorporated into practice in a way that is meaningful to staff and participants (Marlowe, 2003). What is emerging is that a range of drug treatment interventions should be available and tailored to the individual’s circumstances. For example, a structured coercive order may be used to initiate an intervention, but this may not be universally beneficial (Pelletier et al, 1997; Wild et al, 1998; Makkai, 2002). Legal coercion and readiness to change was examined between consecutive admissions from five public funded outpatient treatment programmes in the US (n=295) focusing on legal coercion from internal and external sources (Gregoire and Burke, 2004). Participants entering treatment due to legal coercion were three times more likely to have engaged in recovery orientated behaviour in the month preceding admission. Consequently, entering treatment prepared to benefit from it as a result of legal coercion could contribute to positive treatment outcomes, alongside motivation and readiness to change (McLellan et al, 1994; Gossop et al, 2001; Carey et al, 2002; Gregoire and Burke, 2004; Oliver et al, 2010; Orford et al, 2010). Readiness for treatment is generally higher among substance abusers with more severe substance abuse problems. A positive relationship exists between heroin use and problem severity indicators by the recognition factor in the Stages of Change Readiness and Treatment Scale (SOCRATES found in a large sample (n=1,672) (Miller and Tonigan, 1996). This suggests that higher scores on the Addiction Severity Index were positive predictors of higher levels of Problem Recognition, Desire for Help, and Treatment Readiness on SOCRATES (Boyle et al, 2000; Rapp et al, 2003). There are other factors that have also been associated with treatment readiness that include frequency and severity of drug use, but these have not been consistently reported (Carney and Kivlahan, 1995; Hubbard et al, 2003). A common phenomenon in treatment was lack of participant motivation as defined behaviourally, and typically treatment is approached with some degree of ambivalence (Di Clemete et al, 1999). Participants’ social networks can play a significant role in precipitating a treatment experience that can engage them with treatment (Marlowe et al, 1996). Drug treatment participants who have greater perceptions of family support are more likely to have an extensive history of drug abuse treatment, combined with a greater desire to seek help in coping and more positive views of methadone treatment (Schwartz et al, 2011). Legal coercion has associations with a greater readiness to change, suggesting that treatment retention resulting from coercion may reflect underlying change present among those coerced into treatment (Allan, 1987). However, a heightened readiness to change from coercive means may result in a self-selection process that is often related to those who are more motivated in drug treatment (Brizer et al, 1990; McMurran, 2006; Best et al, 2008).2.2.3Separating Voluntary from Compulsory TreatmentThe use of the word coercion is often used interchangeably with other terms representing leverage, pressure, and duress (DeLeon, 1988; Anglin and Hser, 1990a; Gregoire and Burke, 2004; Clag et al, 2005; Szmukler and Appelbaum, 2008). Judicial requirements are not sufficiently differentiated, for example, from family based persuasion. Distinctions must be made using the term coercion more accurately that can then be aligned to specific programmes (Collins and Allinson, 1983; Ryan et al, 1995; Mellor and Stevens Negus, 1996: Hall, 1997; Szmukler and Appelbaum, 2008). Separating voluntary from compulsory treatment within studies that investigate a wide range of participant groups and treatment approaches was problematic due to definition ambiguity. Additionally, some authors are not sufficiently explicit about the compulsory nature of the treatment programmes they are investigating. Some US national studies have examined treatment outcomes from a range of contexts that are often solely confined to criminal justice populations (Gossop et al, 2001; Marshall and Hser, 2002; Wild, 2006; Polcin and Beattie, 2007). 2.2.4Treatment Relapse and Effectiveness in the CommunityThe Drug Abuse Treatment Outcome Study (DATOS) examined the effectiveness of drug treatment (n=2,966) on participants (Joe et al, 1999). Participants were recruited from outpatient methadone clinics, long term residential programmes, outpatient drug free programmes and short term inpatient programmes. Somewhat contradictory in the US study, 39.8% (1,180) of participants would have entered treatment without criminal justice mandates which calls the recruitment strategy and findings into question. This is at odds with some later studies which suggest the degree of coercion is important, and not solely that they had been legally referred into treatment that was not considered in the study (Mackain and Lecci, 2010). The subsequent DATOS provided an increased sample of 10,010 US participants (Anglin et al, 1997). However, the DATOS sample was uncharacteristic of criminal justice populations in the UK that have reported higher drug use severity levels than the DATOS study (Gossop et al, 2006). One large US study examined pre-treatment factors and changes matched against post treatment outcomes with one and five year follow up (n=1,095). The study found favourable results for those who received judicial mandated treatment entry (Kelly et al, 2005). However, criminal justice referrals were less severe drug users at entry, with coerced treatment being more effective for them as voluntary entrants with comparable drug use experiences (Kelly et al, 2005). Nonetheless, judicial coercion appears to predict an initially stronger treatment response measured by methadone and heroin use reduction, although this effect diminishes over time. It should be noted that the reverse is usually the case with UK studies and populations, as more severe heroin users are imprisoned or placed on a DRR (Gossop et al, 2007; NDTMS, 2013). It might be that the treatment response is reversed in UK studies considering that judicial mandates are used differently. Consequently, this could limit the extent of study generalisation between the US and UK. However, this does present some evidence to support the present study between participant design from criminal and non-criminal justice populations. A paucity in the evidence remains about how court mandated participants fare longer term against those who enter drug treatment on a voluntary basis beyond six months. It would seem reasonable to investigate pre-treatment characteristics, satisfaction, perceptions and changes over a period of years with six monthly contacts. Motivation to change and treatment seeking could be represented by behavioural motivation/self-efficacy scales (Miller et al, 1999) by focusing upon individual persistent characteristics towards change. Investigating behavioural change by including motivation and self-efficacy scales for example may provide some cognitive/ affective basis or future research (Murphy and Bentall, 1997). Studying the cognitive affective basis for readiness for change might provide a profitable approach for increasing our understanding of the relationship between aspects of coercion and performance of change behaviours. It is desirable to retain the representative nature of participant groups often changed through attrition rates. Consequently, those who leave treatment prematurely could provide valuable reasons and characteristics to contrast against those remaining in treatment; this is problematic across many research studies to varying degrees and is examined in the next section (Joe et al, 1999). 2.2.5Treatment Retention, Attrition and OutcomesTreatment retention is a critical outcome measure and is consistently one of the best predictors of longer term addiction treatment success (Simpson et al, 1997; Young and Belenko, 2002). The longer a person is retained in treatment, the greater the likelihood there is of longer term treatment success that is consistently found within the literature (Anglin and Hser, 1990; Fletcher et al, 1997; McLellan et al, 2000; Best et al, 2001; Makkai, 2002). Retention in methadone treatment programmes also promotes longer term drug abstinence and is a key target for sustained treatment success (Oppenheimer, 1994; Keen et al, 2000; Young and Belenko, 2002; Strang et al, 2003; Godfrey et al, 2004; Nutt et al, 2007; Gossop, 2007). However, comparatively few studies have addressed the impact that treatment programmes have on individual participant outcomes between criminal justice and non-criminal justice populations. This could be considered a gap in the literature. The literature supports the findings that those legally coerced have greater engagement in rehabilitation, improved retention rates, reduced treatment drop out, and better readiness to change (Gainey et al, 1993; Marlowe et al, 2001; Burke and Gregoire, 2007; Perron and Bright, 2008; Daughters et al, 2008). However, some studies have found little significant differences in treatment outcomes and retention rates between coerced and non-coerced populations (Brecht and Anglin, 1993; Grichting et al, 2002). Firm conclusions and findings are made more difficult as some studies report positive and negative effects that are based on small sample sizes, single sites, with methodological and definition problems (Klag et al, 2005).A US study compared three groups (n=330) mandated to the same treatment programme (Marlowe et al, 1996). The study found that participant perceptions of treatment entry pressure varied considerably and could be attributed to different practices in terms of how information was presented and experienced (Marlowe et al, 1996). Treatment retention was experienced as three times greater for participants from the most coerced group, providing some evidence that highly structured and coerced treatment programmes do retain drug users (Young and Belenko, 2002; Young, 2002; Jacobson, 2004; Coviello et al, 2013). Treatment retention is increasingly important with poor retention rates strongly associated with reinstatement of heroin irrespective of treatment context (Brizer et al, 1990; Hutchinson et al, 2000; Tucker and Ritter, 2000; McKegany et al, 2004; Marlatt and Donovan, 2005). Therefore, findings that contribute to increasing treatment entry and retention rates are worthy of continued investigation. Participant attrition at follow-up is expected when drug treatment involves criminal justice populations and is often reported above 30% of original samples (Gossop et al, 1997). Some studies report much higher treatment attrition in criminal justice populations, approaching 70% within the first three months, rising to 90% up to twelve months (Taxman, 1999; Marlowe, 2002). However, attrition rates are not solely confined to criminal justice populations but towards participants generally receiving treatment for heroin addiction (Stark, 1992; Backmund et al, 2001; McCarthy et al, 2005). Therefore, components that decrease inpatient treatment attrition warrant attention, including co-morbid psychiatric histories and mood state, which are up to four times more prevalent in patients lost to treatment than treatment completers (Martin et al, 1988; Hser et al, 1999a; Maglione and Boyle, 1999; Lang and Belenko, 2000; Backmund et al, 2001; McCarthy et al, 2005). The evidence for treatment entry and retention combined suggests that first attempts are rarely successful, and only a few patients achieve abstinence and remain prone to relapse within the first year (Simpson et al, 1997; Ghodse, 2002; Marshall and Hser, 2002; Zhang et al, 2003; Day, 2005; Lefforge et al, 2007). Non completion rates for US inpatient drug programmes, including legally and non-legally mandated patients, vary between 25-50%, suggesting premature treatment departure is problematic (Joe et al, 1995; Perron and Bright, 2008). The Drug Outcome Research in Scotland (DORIS) project recruited from 33 treatment units including five prisons (n=1,007) across Scotland (McKegany et al, 2006). A specific strength of the DORIS project was that whilst recruiting across treatment contexts the study recognised lower participant inpatient treatment numbers and over recruited to address this shortfall. This over recruitment provided a better comparison to be made across the contexts with sufficient participant numbers secured to raise study reliability. There were 147 refusals at first interview with a total of 860 participants interviewed with participation in relation to total referrals of 87.7%. A longitudinal design allowed for follow up at 33 months and achieved a follow up rate of 668 (70%) of the 860 participants even after excluding 38 deaths within the study period (McKegany et al, 2006). This attrition effect could leave findings that are increasingly unrepresentative of the original sample. Heroin users who completed inpatient programmes were more likely than non-completers to be drug free and have better outcomes in other areas providing some background context (Miller and Flaherty, 2000; McKegany et al, 2006; Best et al, 2006). Studies do not offer a consensus regarding the effectiveness of sanctioned pressure or examine the degree of pressure which is important in treatment retention and heroin use reduction (Simpson and Curry, 1997; Brecht and Anglin, 1997; Hiller et al, 1998; Joe et al, 1999; Benyon et al, 2006). A US study investigated whether offenders mandated to community-based outpatient treatment had better completion rates compared to those who entered treatment voluntarily (Coviello et al, 2013). The study participants (n=160) were under various levels of criminal justice community monitoring on an intensive weekly outpatient therapy and problem solving programme. The court-ordered offenders were ten times more likely to complete treatment compared to those who entered treatment voluntarily, and suggests structured treatment for offenders on a DRR could benefit from this approach to increase compliance (Coviello et al, 2013). Additionally, improved outpatient treatment outcomes were associated with being over 35 years old, having a better education, regular contact with a counsellor, being on probation, a history of imprisonment, and future plans for participating in treatment (Godfrey et al, 2004; Nutt et al, 2007; Gossop, 2007). One US study of three treatment contexts investigated short-term inpatient, long-term inpatient, and outpatient treatment groups (n =1,181). By administering treatment intake questionnaires a participant group was identified (Perron and Bright, 2008). The influence of legal coercion on retention rates was examined using a survey methodology from the three public sector drug treatment programmes. Legal coercion was found to reduce attrition risk across all three treatment groups. But the greatest effect was found in participants in short-term inpatient treatment and smallest within the outpatient context. A study design flaw was not collecting reasons for participant treatment attrition, which should be considered for future endeavours, and is arguably as important as those who remain in studies. Establishing a better understanding behind the reasons for treatment exit was proposed (Wild et al, 2006).Treatment conditions must be carefully considered when using coercion to involve individuals in treatment (Taylor et al, 2013). The effectiveness of coercion can be limited to certain groups, in this case short-term inpatient drug treatment, with less effectiveness reported in the outpatient treatment group (Porter et al, 1999; Gossop et al, 2001). Perron and Bright (2008) demonstrated that legal coercion could reduce attrition rates, but rates are somewhat influenced by treatment contexts. 2.3Motivation, Coercion and OutcomesInternal, also referred to as intrinsic and external or extrinsic motivation to enter and remain in treatment is used interchangeably within the literature. It is important to clarify the terms to establish what is meant within the present study context. The real challenge is in distinguishing to what extent family based coercion has on intrinsic value to any one individual. Additionally, external change drivers may impact upon the internal allocation of pressure to enter treatment and vice versa. Perhaps the best position within studies is to acknowledge and accurately define these pressures and set out whether they are internal, external, or derived from both. It is important to establish this coercion allocation in order that it can be better considered and the right study measures adopted. The study will use internal and external descriptors in preference to the terms intrinsic or extrinsic. Some strong predictors of treatment success are problem severity and motivation to change, suggesting those addicted to heroin with low severity and higher motivation have much shorter drug careers by comparison (Simpson and Sells, 1990; Hser et al, 2001; Wolfe et al, 2013). The Drug Treatment Outcomes Research Study (DTORS) reported on a sample of drug users from the UK criminal justice system (Donmall et al, 2012). DTORS was a mixed method study (n=1,796) of treatment seeking participants. Participants were recruited from outpatient and inpatient treatment environments and followed up at 12 months. DTORS participants were predominantly male and longer term drug users (Donmall et al, 2012). The study supports the motivational correlates of social pressure as benefiting those who seek treatment (Farabee et al, 1998; Joe et al, 1999; Maglione et al, 2000; Campbell et al, 2007; Best et al, 2008). From a cognitive-behavioural perspective, self-efficacy and confidence for treatment could contextually increase participant resistance to use heroin (Connors et al, 1996; Larimer et al, 1999). It is interesting that the use of heroin after cessation increases the probability of continued use and reduces abstinence-violation effects through reduced self-efficacy for abstention. Initial taxonomy of relapse situations features both intrapersonal reasons for relapse (for example, negative emotional states, testing personal control, urges and temptations) and interpersonal factors of relapse (for example, interpersonal conflict, and social pressure) (Marlatt and Gordon, 1980). This early study found that 58% (n = 41) of substance dependent participants (N = 70) initially returned to substance use in intrapersonal contexts, particularly when 26 participants experienced a negative mood state (37%). Mood state is often reported as an important indicator for drug treatment effectiveness with some studies reporting depression prevalence rates between 50-85% (Grillo et al, 1995; Abrantes et al, 2004). This is especially important as some evidence suggests those with co morbid mental health problems, such as low mood or anxiety, are more likely to relapse and experience poorer treatment outcomes against those who do not have comorbid mental health issues (Grella, et al, 2001; Tate et al, 2004; Tomlinson et al, 2004). Although evidence suggests that the extent to which motivation to pursue treatment is internalised can be independent of the variables driving treatment entry, those who display both high internal and external motivation have the best attendance and treatment retention rates, whilst the opposite occurred for those who had low internalised motivation regardless of the degree of external motivation (Ryan et al, 1995; Farabee et al, 1998; Joe et al, 1999; Maglione et al, 2000; Wild et al, 2006). One US study examined perceptions of social pressure of both sexes seeking substance abuse treatment (n=300). Participants rated the extent to which treatment was being sought because of coercive social pressures (external) and guilt about continued substance abuse (Wild et al, 2006). External treatment motivation was defined by legal referral, social family and peer pressures to enter treatment, and was inversely related to problem severity. In contrast, the referral source (criminal justice mandated), legal history, and social network pressures did not predict any of the six engagement measures at the time treatment was sought (Wild et al, 2006). The referral source does necessarily make the study coercive, except for solely legal mandated studies. Nonetheless, other pressure combinations at entry and throughout treatment must be taken into account within study designs (Stewart et al, 2000; Rush and Wild, 2003; Klag et al, 2005). Socio-family support is an essential stabilising force when attempting to combat addictive behaviour throughout treatment stages (Granfield and Cloud, 1996; Marlow et al, 1996; Lawental et al, 1996; Best et al, 2006). One UK study found that legal coercion had negative consequences for heroin misuse treatment with poorer treatment outcomes (Benyon et al, 2006). In the UK study (n=26,415) attrition was significantly higher for those coerced into treatment via the criminal justice system, which contradicts findings from US studies in (see section 2.2.5) (Benyon et al, 2006). The study focused on the outcomes of being discharged drug free and also the reasons behind treatment drop out. The study concluded that more participants drop out of criminal justice treatment than other treatment groups, suggesting coercion had a negative role to play in treatment drop out with fewer discharged drug free (Benyon et al, 2006). Whilst the study accepts that if coercive measures are employed then individual treatment flexibility is required, but coerced criminal justice participants who are not internally committed are less likely to succeed (Benyon et al, 2006). Participants entering US treatment services through non-criminal justice routes (n=77) reported fewer reductions in heroin use compared to those mandated into treatment (Wolfe et al, 2013). Motivation and therapeutic alliance played a significant role in their treatment programmes with similar reductions in heroin use (Anglin et al, 1998; Neale et al, 2005; Wolfe et al, 2013). Criminal justice coerced participants had retention and outcome rates as good as those who entered treatment voluntarily (Anglin and Waugh, 1992; Hubbard et al, Young and Belenko, 2002; Wild et al, 2002; Day et al, 2004; Kelly et al, 2005). Participants entering outpatient drug treatment through criminal justice referral routes had treatment needs similar to those of their voluntary counterparts, although they lacked the internal motivation to readily commit themselves to the treatment process (Wild et al, 2002). This lack of internal motivation towards change has been associated with low treatment retention and poorer outcomes (Inciardi et al, 1988; Satel, 1999; Norland et al, 2003). However, motivational subtypes have been examined at treatment entry, with a distinction being made between internalised and external motivational elements (Satel, 2000). Consequently, some studies suggest that measuring or taking motivation into account for treatment readiness has more predictive value for treatment success (Marlowe et al, 2001; Wild et al, 2006). Motivation for treatment is frequently used interchangeably with treatment readiness when decisions to enter treatment are considered (Rapp, 2007). Treatment motivation or readiness for drug treatment includes an individual’s personal considerations, commitments, and intent that may encourage certain behaviours (Cunningham et al, 1993). Elements of treatment readiness have been examined among drug misuse populations in treatment and found to comprise well-defined components, which include problem recognition and a desire for help (Simpson and Joe, 1993). Completing drug treatment is associated with initial motivation prior to entry onto programmes (Egg, 1993; Brecht et al, 1993; Carroll, 1997; Miller et al, 1999). Nonetheless, a motivated and coerced client may do better than an unmotivated volunteer into treatment (Miller, 2000; Ayling and Grabosky, 2006). A randomised control trial conducted within the Australian prison system examined drug treatment against a control group. A total of 593 eligible prisoners for treatment entered the study. The follow up period of five months provided data (n=129 in treatment group and n=124 control group) which found that heroin use was significantly lower in the treatment group than in the control group. The study argues that serious consideration should be given for methadone prescribing within prison drug treatment (Dolan et al, 2003). There are also commonalities in institutional context drug use, not solely confined to prisons, as drug treatment units have similar group characteristics for continued drug use and relapse to prison populations (Anglin et al., 1998; Dolan et al, 2003; Neale et al, 2005; Adinoff, 2010). A residential coerced into treatment group (n=529) and an outpatient non coerced group (n=623) were investigated for motivational constructs including self-efficacy and treatment attributions in Canada (Unbanoski and Wild, 2012). Some studies have argued that neither insight nor internal motivation has to be present to treat substance misusing clients on court drug testing orders, justified by reference to retention rates in programmes over 70% (Satel, 2000; Parker et al, 2002; Hucklesby et al, 2005; Conner et al, 2009).Research into the effectiveness of DRRs has examined whether or not the DRR could act as a catalyst in readiness for drug treatment when the right circumstances are presented (Bennett, 1998; Garland, 2001). One study of DRR participants found larger reductions at twelve weeks in illicit drug use than non-criminal justice volunteers entering the same services, but there was little difference in retention rates, reported as 74% and 76% respectively (Hough et al, 2003; Skodbo et al, 2007; Best et al, 2008). Nevertheless, little is known about the role coercion follows when influencing participant motivation to change (Graham, 2002; Valliant, 2003; Gregoire and Burke, 2004; Orford, 2007). There are benefits for addicts who remain in treatment due to the potential threat of further sentencing, although retaining individuals in treatment programmes is problematic (Anglin and Hser, 1990a; Collison, 1994; Hough, 1996). The issues of coercion and treatment readiness and motivation are central to clinical understanding when attempting to define the effects of treatment with problematic drug use (Peters and Greenbaum, 1996). Motivation to change may not always be necessary as some participants will not be motivated to change when they are coerced, although they are less likely to engage and succeed in treatment (McSweeney et al, 2008; Oliver et al, 2010). Coercion presents choice, although sometimes these choices can be limited (Mark, 1988; Marlowe et al, 1996). There are those who leave treatment prematurely and require closer investigation to explain this effect, as changes seem to occur irrespective of entry and programme type (Norland et al, 2003; Day et al, 2004). Motivation at treatment entry, treatment retention, readiness to change, coercion into treatment by internal and external pressures are worthy endeavours that should attract more empirical attention (Wild et al, 2002; Stevens et al, 2005; Sullivan et al, 2008). However, little consensus about the intermediate, long-term, and cost effectiveness of legal coercion has been reached (Farabee et al, 1998; Polcin, 2001; Klag et al, 2005; Marlowe et al, 2003). There is mixed evidence from a conceptual level in the UK and a lack of focus towards identifying reliable sub-types of motivation more generally (defined by subjective perception of coercion and treatment motivation) within mandated treatment populations (Wild et al, 2002; Klag et al, 2005; Petticrew and Roberts, 2006). Consequently, it is difficult to establish whether these numerous sub-types require a range of specific treatment interventions. Gaps within studies exist due to examining one sub-type in limited settings. 2.3.1Internal and External Factors for Treatment Entry into drug treatment with legal mandates (formal) and pressure in the form of threats and ultimatums from friends and family (informal) upon the individual drug user is more likely than not in the UK (Rush and Wild, 2003; Gregoire and Burke, 2004). Reasons cited for relapse are equally diverse, and include depression, anxiety, adverse life events, marital conflict and social pressure (Belenko, 1998; Miller and Flaherty, 2000; Pinfold et al, 2001). A follow up study of patients discharged from residential drug treatment from 23 UK residential programmes (n=242) linked abstinence or lapse back into drug use specifically to reduced levels of cognitive function which could be associated with continued drug use and low mood (Gossop et al, 2002). It remains unclear from the literature how social factors, particularly pressure from families and the legal system, impact on outpatient treatment effectiveness (McKegany et al, 2004). Combinations of internal and external factors are not very well explored in coercion studies that investigate the objective sources of social pressure from legally mandated referrals. Few studies have examined the impact of participant perception of coercion from combined legally and non-legally mandated sources (Campbell et al, 2007; Best et al, 2008). Substance abusers entering treatment as a result of formal coercion have been found to be three times more likely to engage in recovery oriented behaviour following treatment entry (Gregoire and Burke, 2004). Similar conclusions have been found in that higher readiness for change was positively associated with legal coercion (Blanchard et al, 2003). 2.3.2Family Support and Treatment OutcomesInteresting parallels exist within criminal justice populations and those who have sanctions in other domains placed upon them, for example from close family members. In a US five year follow up study of admissions across 18 outpatient methadone treatment programmes (n=432) attributions from the participant perspective were investigated upon their long term recovery (Flynn, 2003). Participants were divided into two groups of recovering and non-recovering drug users based upon self-report and biological measures of opioid use or not. The findings suggest that the 28% (121) who were in recovery at five years reported that primarily they had relied upon personal motivation, treatment retention, spirituality, having a supportive family and job opportunities. Specifically, great value was attributed to the support of family and friends who indicated the importance of making stronger efforts to develop social supportive networks when promoting drug free social functioning, especially in those who do not have strong networks (Best et al, 2006). Effective strategies and approaches in the review favour the use of therapeutic communities and interventions modelled on the mandatory approach in combination with methadone therapy (Farabee et al, 1998; Young and Bleneko, 2002). Research has not effectively captured the world the client moves within outside of treatment environments and these encounters may provide additional insights for treatment settings (Patoine, 2012). Developing the role of drug treatments that involve natural family support systems in the maintenance of change has been neglected, and should focus on the process of change above studying one approach over another (Orford, 2008). Emerging from this omission from the literature other psychological variables could be relevant, for example treatment confidence, self-efficacy, mood and attribution combinations. The present study has adopted quantitative psychometric measures in an attempt to capture some of these details, providing a foundation for who the participants are, informed by the qualitative data. This is important as substance misusing participants have consistently credited their family as being a major reason for them entering a drug treatment programme but are not often captured within study designs (Simpson and Sells, 1990; Miller et al, 1999; Hser et al, 2001; Lang and Blenko, 2001). 2.4Mental Health Coercive Treatment Literature2.4.1Introduction This sub section considers coercion studies undertaken upon mental illness populations and are confined to three major international studies (Monahan et al, 1995; Hoge et al, 1997; Burns et al, 2013). The main literature related to coercion in the treatment of mental illness populations emanated from the MacArthur Foundation studies (Monahan et al, 1995; Hoge et al, 1997). Severe depression is one of the major mental disorders investigated within the Oxford Community Treatment Order Evaluation Trial (OCTET) studies. Further insights have emerged from subsequent studies that have improved understanding of the prevalence of coercion within mental health populations informed by significant contributions from the MacArthur group (Monahan et al, 2005) and OCTET studies (Burns et al, 2013). The MacArthur Foundation coercion studies are directly relevant to the literature on non-legal coercion that have developed methods to study treatment pressures by examining the use of leverage to improve adherence to psychiatric community treatment (Hoge, 1997). The three studies from 1991 onward developed an approach to the assessment of being exposed to non-legal coercion using a set of standard questions (Monahan et al, 2005). Leverage to improve adherence to psychiatric treatment in the community is well documented and informs coercion literature irrespective of diagnosis or setting (Monahan et al, 2005). Coercive treatments from mental health populations could inform drug misuse populations regarding which aspects propel them into treatment (Lidz et al, 2000). Debate continues regarding leverage use within psychiatric and substance misuse populations which are critical to improve understanding of the nuances between the participant groups (Monahan et al, 2005). A number of researchers in the US and England have subsequently developed MacArthur instruments to study coercion in a wide range of treatment contexts. The most widely recognised UK coercion study was the OCTET which investigated patient compliance with psychiatric community treatment orders when compelled into programmes (Burns et al, 2013). Leverage or coercion is the influence exerted that reduces the voluntary nature of hospital admission (Gardner et al, 1993). 2.4.2Coercion Studies in Mental Health PopulationsInterest in leverage and coercion has grown following the MacArthur Foundation studies in the US (Gardner et al, 1993) and OCTET studies from the UK (Burns et al, 2013). There is an increasing body of literature that indicates mental health populations experience coercion to enter and remain in treatment from a variety of routes (Gardner et al, 1999; Cromby et al, 2013). Some participants may enter psychiatric treatment voluntarily or be compulsorily compelled into it (Bennett et al, 1993; Treffert, 1999). Others who enter psychiatric treatment may do so due to conditions of psychiatric treatment via a probation order or, for example, to save a relationship. All are individual reasons for treatment entry and highlight potential leverage combinations that may be operating. Churchill et al (2007) summarised 72 available studies finding that coercion evidence falls into three broad categories. Firstly many of the early studies were descriptions of practice and not controlled trials and therefore no firm conclusions could be drawn from them. The second group comprised case-control studies. These studies draw on existing administrative databases of patients on Community Treatment Orders (CTOs), but use them as their own controls or matched them with similar patients to compare admission rates after imposing a CTO. The third group were Randomised Controlled Trials (RCTs) clearly needed because of the limitations and conflicting results from earlier case-control and administrative studies. The MacArthur and OCTET studies provided a template to address imbalances from less robust scientific studies (Gardner et al, 1993; Burns et al 2013). The MacArthur studies will be addressed first and the OCTET study will follow. 2.4.3MacArthur Coercion StudiesThe MacArthur Foundation coercion studies tried to understand better the effects of coercion on mentally ill individuals when compelled into treatment (Monahan et al, 2005). They examined what effect coercion had on participant outcome efforts and investigated whether coercion helped or hindered treatment outcomes (Monahan et al, 1999). The MacArthur group studies for the first time refined the definition for coercion by using perceived levels of patient and family coercion (Treffert, 1999). This is interesting as studies then examined coercion from an individual perspective rather than merely associating it with legal commitment to an institution (Poythress et al, 2002). The studies collectively established that coercion could be experienced as an outpatient or inpatient irrespective of compulsory commitment or not under statutory mental health legislation for the more severe and enduring mental illnesses (Hoge et al, 1993). Three main MacArthur studies investigated the role of coercion within psychiatric treatment in the US. The first study of randomly selected patients (n=157) sought factors associated with the admission process experiences of coercion (Hoge et al, 1993). The same study investigated how hospital admission events may be differently perceived by others involved in that process (Hoge et al, 1993). A second study with a larger sample size of randomly selected adults (n=433) aimed to compare the perceptions of participants at treatment admission and following hospital discharge as an outpatient (Monahan et al, 1999). The third study was conducted in parallel with the first studies adopting the perceived coercion scale battery. The coercion battery of instruments examined a large number of variables including compliance with outpatient treatment in a sample of voluntary and compulsory admitted participants (n=1,136). The participant group was interviewed and assessed five times up to twelve months post discharge (Lidz, 1998). Among the key findings that emerged from the studies was that the legal status of compulsion alone is a blunt index of participant experience of coercion (Hoge et al, 1993). Participant accounts of their experiences of coercive treatment tended to be as factually complete as family clinician accounts (Monahan et al, 2005). Participant accounts at follow up about the need for admission did change over time with over half who initially denied the need for admission acknowledging it in retrospect. Significant treatment entry pressures applied to participants strongly affected the amount of perceived coercion and the use of threats engendered negative mood states; but persuasion and inducements were viewed more positively, for example access to family members, goods and money (Lidz et al, 1998). The amount of coercion experienced was found to be strongly related to participant beliefs about the justice of the process prior to being admitted (Lidz, 1998; Monahan et al, 2005). Specifically, if participants believed that others acted out of a genuine concern for them, treated them with respect and with a chance to tell their side of events then this was better received (Jones and Mason, 2002; Poythress et al, 2002). These in turn reduced levels of patient perceived coercion irrespective of voluntary or compulsory admissions to hospital (Lidz et al, 1997).The MacArthur studies have generated international debate and interest into coercive treatment by enhancing understanding and providing pressure insights irrespective of context or diagnosis. 2.4.4The Oxford Community Treatment Order Evaluation Trial (OCTET) StudyCommunity Treatment Orders (CTOs) were introduced in 2007 to reduce psychiatric hospital admissions rates for patients with more frequent Mental Health Act admissions for treatment. The OCTET was a clinical effectiveness study of whether CTOs reduce relapse and readmission rates in patients with psychosis (Burns et al, 2013). The OCTET was designed as a multi-site, single outcome study that aimed to isolate the effect of being on CTOs. In particularly the trial aimed to test the consequences and impact of CTOs when patients were discharged to community mental healthcare (Burns et al, 2013). For pragmatic reasons, to reduce excess variability in the data, the trial was confined to adults (over 18 years) within mainstream psychiatric services with a psychotic psychiatric diagnosis. Study participants had all been detained under Section 3 of the Mental Health Act (DH, 2008) and when considered suitable for discharge onto a CTO their names were forwarded for randomisation after inpatient discharge. The primary outcome measure for OCTET was the proportion of the total group readmitted over the 12 month period following inpatient discharge onto the CTO. All patients discharged were afforded similar levels of service, irrespective of study inclusion or not by the randomisation process. Secondary outcomes included time to readmission and duration of hospital inpatient stay. A pragmatic decision was taken to include NHS Trust patients who were within a day’s travel of Oxford. The trial over-recruited against the target sample (n=333) and obtained 100% of primary and secondary outcome data. There were no baseline differences across the two groups who all closely matched the descriptions of CTO patients in other studies (Dawson, 2005; Churchill et al, 2007). The OCTET findings reported there was no difference in the proportions readmitted, 36% (n=120) in both groups, nor in the time readmission. The total length of hospital stay was not significantly different (41.5 days) for CTO patients or Section 17 (approved whilst person detained under the Mental Health Act) leave patients (48 days). The study finding confirms earlier empirical evidence from two RCTs that CTOs do not achieve their stated purpose of reducing relapse and readmission (Killapsey et al, 2009). The OCTET study did have limitations as 20% (n=67) of patients did not get the treatment into which they were randomised. For example, 13 patients were never discharged from hospital and of the total group 35 patients never had the CTO imposed. Many of these violations reflect changes in clinical conditions during the consideration period prior to imposing a CTO. A sensitivity analysis was conducted excluding identified violations and there were still no significant differences in outcomes apart from the total length of hospital stay, which was shorter in CTO patients (P?= 0.035). A further limitation was for participant selection and potential for bias in the sampling process. Study participants were selected from a narrow range of groups but the clinical characteristics of those recruited do not provide much evidence that this was the case. Participants over the age of 65 and those from criminal justice forensic populations are excluded in the OCTET study, which does influence generalisations in those groups. This is unfortunate when examining coercion as they are the groups that often encounter sanctions imposed upon them. In addition forced community treatment does not seem to bestow reduction in hospital admission in the CTO groups either after 12 month follow-up. The MacArthur and OCTET studies raise different study limitations but collectively found that coercion is no more effective in psychiatric or substance misuse populations (Monahan et al, 2005; Burns et al, 2013). There is however the possibility that a sub-group of those on CTOs may benefit from enforced treatment, and perhaps those over the age of 65 - this warrants further attention. The OCTET study did raise concerns regarding continuity of care and treatment teams. Participants across the groups reported a lack of consistency in their care package with less than a quarter retaining the same consultant at 12 months follow up, with some reporting up to five changes of consultant, which is unacceptable for care continuity even before research influences are considered (Monahan et al, 2005; Burns et al, 2013). CTOs were introduced by the UK Government with no convincing evidence that they worked, and similarly with DRRs about their effectiveness. OCTET has however provided strong evidence that liberty is being curtailed without clear clinical benefit to justify it (Churchill et al, 2007). The OCTET study clarifies the need for more evidence into coercion for psychiatric treatment and one group included in the study also misused illicit drugs. There is the issue though that drug misusers are in violation of criminal law to start with, in a way which might not be the case with the psychiatric populations reviewed here.More trials are needed that consider coercion in other contexts and other treatment groups, but essentially address the limitations from the study regarding selection bias, forensic and older participant groups. Some have suggested that it is time to stop pursuing coercive interventions and government policy, and start refocusing efforts on restoring enduring and trusting relationships with patients (Churchill et al, 2007). 2.5Co-morbidity and Heroin Treatment RetentionCo morbid mental illness and substance misuse within drug populations presents challenges for treatment retention and increases the likelihood of treatment attrition (Lang and Belenko, 2000; Backmund et al, 2001; McCarthy et al, 2005). The Australian Treatment Outcome Study (ATOS) found post-treatment reductions in participant heroin use, use of other drugs, risk taking behaviour and crime, combined (n=615) with improved physical and mental health (Teeson, 1998). The 36 month sample completed at least one follow up interview during the period of the study (94.5%). Positive outcomes were associated with increased duration in maintenance and inpatient treatment which also correlated with fewer treatment episodes. However, time spent in detoxification was not associated with more positive outcomes. Major depression was also associated consistently with poorer outcomes across all groups. Consistently, national studies find that drug users remaining in treatment show reductions in heroin use and benefit in a broad range of other health areas in support of the UK DATOS findings (Gossop, 1998; Darke et al, 2007; Teeson et al, 2008). Although for more severely dependent heroin addicts, outpatient reduction regimes are associated with high drop-out rates with few patients actually achieving abstinence (Gossop et al, 2003; Darke et al, 2007). Relapse is a significant problem when treating heroin addiction as an out-patient whilst trying to avoid opiate withdrawal syndrome (Unnithan et al, 1992). Relapse was examined in a later Australian study for participants enrolled onto a treatment programme (n=104). Data was gathered via retrospective questionnaires to explore the role of family dysfunction, mood state, primary drug dependence, and other factors in relation to relapse. Findings reported the common reasons reported for relapse were mood state, followed by external pressure to use drugs, desire for a positive mood state and social family reasons (Young and Belenko, 2002; Hammerbacher and Lyvers, 2006). Reasons for relapse did not differ according to the primary drug of choice; it is possible that relapse factors are consistently similar across different types of drug dependency (Hammerbacher and Lyvers, 2006). Investigating relapse rates in the UK among 42 persons addicted to heroin and undergoing out-patient detoxification treatment found that 40% (17) had lapsed back into drug use within the first two weeks of the programme due to the influence of interpersonal factors and drug-related triggers (Unnithan et al, 1992). Most participants encountered a range of high-risk situations that included regularly meeting other drug users and being offered drugs, with an associated persistent negative mood state (Unnithan et al, 1992). However, participants were from one treatment clinic and the total number at treatment entry limits generalisation. A US study of participants (n=463) who entered treatment voluntarily, compared to those court mandated, found that individuals who were not court mandated had more severe addiction problems and higher rates of psychiatric disorders including depression and anxiety (Banducci et al, 2013). This raises the question of how the individual treatment needs of addicted patients should be addressed within established treatment programmes such as DRRs (Broome et al, 1999; Daley and Thase, 2000; Day et al, 2004). 2.6Criminal Justice Drug Treatment Options Behaviouristic views of motivation are adopted and are incentive driven with properties that energise behaviour and are proportional to the amount and quality of the reinforcer (Golin et al, 1981). However, all of these concepts point to characteristics that are divided into internal, external or combinations of both that operate upon individuals. External motivation is defined as incentives that can be related to the environment. Internal motivation is something that is experienced by an individual from within, such as motive states or drives, both of which can vary over time (Koob and LeMoal, 2008). Treatment readiness with coercion was applied to encourage individuals into drug treatment and could increase the likelihood of patients staying within inpatient treatment, compared to those under low levels of coercion (Hiller et al, 1998). Some evidence suggests that the longer a person stays in treatment, in this case beyond ninety days, the better the outcomes (Harkaway, 2001; Farabee et al, 1998; Backmund et al, 2001; Braden et al, 2001; DH, 2010). US evidence in support of UK data suggests criminal justice sanctioned patients tend to complete treatment at higher levels than their sole probation order counterparts (without a DRR), with a 60% completion rate in court ordered drug treatment and only 30% in straight probation drug treatment regimens (Nurco et al, 1991; Gossop et al, 1998; Keen et al, 2000; Belenko, 2001; Klag et al, 2005). On the other hand, there is some evidence to suggest court drug treatment orders are not effective (Miller and Shutt, 2001; Sechrest and Shicor, 2001). For example Howard and McCaughrin (1996) reported that relapse rates are high for clients, who do not live in environments that support recovery whilst undergoing treatment and that treatment gains can be undermined by the social context they live in. The study used two outcome variables of meeting the goals of treatment and failing to comply with the treatment plan. Those who had higher rates of court mandated clients reported less compliance with the treatment programmes than the lower court mandated population groups, but there was no difference in participants from either groups meeting their treatment goals. In summary, this study surveyed the mix of clients with regard to their being court mandated or not, and does provide some evidence in relation to one form of coercion being beneficial above others.2.7DiscussionThe evidence base discussed in this chapter largely emanates from the USA although interest in the question of coercion in addiction treatment is developing Europe wide, including the UK. The majority of studies reviewed above were undertaken between 2001 and 2014. Criminal justice sanctions for drug treatment should be considered as a catalyst, rather than an absolute requirement, for drug treatment programmes (Graham, 2002; Valliant, 2003; Gregoire and Burke, 2004; Orford, 2007). Studies that include outpatients as well as non-criminal justice sanctioned programmes that consider treatment entry outside of court mandating are clearly warranted (Lamb et al, 1998; Gossop, 2003; Marlowe, 2003). Recent developments in England and Wales targeting drug-using offenders have incorporated features of coerced treatment, in the wake of growing literature from the USA.There are gaps in the literature surrounding coercion and some studies accept that they are time and context dependent (Leukafeld and Tims, 1998; Lang and Bleneko, 2000; Marshall and Hser, 2002). Further gaps in the literature regarding reasons for participant attrition with strategies for pre-emptive interventions to prevent treatment drop out are being lost. Some mixed evidence exists that questions the benefit of coercion to retain participants in substance abuse treatment (Klag et al, 2005). Challenges to coercion literature have arisen from small, non-empirical, one context studies that have serious conceptual and methodological problems (Klag et al, 2005; Peron and Bright, 2008). Conceptually, accurately defining coercion and methodological clarity are important as they could improve generalisation and clinical applications toward treatment programmes (Perron and Bright, 2005). In addition to a clear definition of coercion in studies, consideration of a range of mechanisms operating upon individuals should be addressed within future studies on coercive approaches. For example these might include family pressures, context specific pressures, treatment readiness, mood related variables, and peer support. Existing research presents dichotomously in favour of the benefits of coercion or refuting coercive drug treatment as detrimental to the therapeutic treatment alliance (Barnard et al, 2009; Bell, 2010). There is some evidence that coercion can increase the chances of successful outcomes from court mandated clients from US studies, who tend to stay in treatment longer than those who enter treatment services on a voluntary basis (Anglin and Hser, 1990b; Harrison and Blackenheimer, 1998; Clag et al, 2005; Szmukler and Appelbaum, 2008; Taylor et al, 2013). But there is contradictory evidence from some UK studies that does not support coercion as a sole approach (Benyon et al, 2006). Patients with more severe problems at treatment entry are at greater risk of premature exit from treatment programmes and studies into the efficacy of criminal justice initiated treatment has yielded inconsistent results (Zanis et al, 1996; Klag et al, 2005). Depression has been frequently associated with measures of readiness, motivation for treatment seeking and change for treatment (Ryan et al, 1995). Higher levels of depression are reported to be positive predictors of treatment readiness and problem recognition (Newakeze et al, 2002). Yet despite the positive relationships identified between depression and improved treatment readiness for treatment entry, depression has also been found to be associated with poor treatment outcomes (Blanchard et al, 2003; Dodge and Sindelar, 2005). Compulsory or enforced treatment outside of hospital contexts has received international attention but remains underdeveloped. The OCTET study in the UK and MacArthur studies from the US have advanced the coercion debate but raised questions that require further investigation (Hoge et al, 1997; Lidz et al, 1998; Burns et al, 2011). Whilst some recent progress has been made regarding perceived coercion from participants, there is still little consensus on how to measure coercion or what real coercion entails (Lidz et al, 1997; Hoge et al, 1998; Churchill et al, 2007). Perhaps a starting point is that clinicians should consider that all patients experience some form of coercion and all should explore that perception (Poythress et al, 2002; Cromby et al, 2013). Future studies may conduct experimental interventions that examine patient experiences of coercion and what reduces intrinsic perceptions of coercion. Therefore, this may bring new understandings of coercion and inform government policy before it is enforced and not vice versa. Finally, the OCTET study is a bold finding, considering the limitations and biases acknowledged, that CTOs do not confer any benefit for coerced patients in terms of readmission within 12 months which is the outcome measure tested (Lidz et al, 2000). However, it is challenging to draw firm conclusions based on findings from different populations and thus makes generalisation difficult. The present study focused on the experiences of participant drug-related care and treatment, primarily within the UK criminal justice system and National Health Service (NHS). This is an important consideration, with many of the studies reviewed above being conducted in different national and socio-cultural contexts outside the UK. There has been some movement in the literature towards qualitative research attempting to give greater understanding and individual perspectives to assist in treatment advancements (Ford et al, 2003; McSweeney et al, 2008; Oliver et al, 2010). Despite the increasing body of literature that supports coercive treatment interventions for heroin users, many clinicians remain reluctant to utilise such treatments on their clients (Miller and Flaherty, 2000; Norland et al, 2003; Klag et al, 2005; Cromby et al, 2013). The use of mixed methodology, involving both quantitative and qualitative, in the present study indicates an intention to identify which participant characteristics and concerns may benefit (or not) from particular treatment contexts and programmes. Table 2: Literature Review Table and SummaryStudyStudy aimsPopulation/SettingMethodsOutcomesKey findingsKelly JF; Finney JW; Moos R (2005).USAWhether differences in mandated pre-treatment characteristics or during-treatment changes could help explain post treatment outcome similarities or differences2,095 adults Prospective study examined differences in pre-treatment characteristics, treatment perceptions and satisfaction, during-treatment changes. Follow up at 1- and 5-year outcomes. Among these three types of patients and tested for substance misuse disorders. Interview using, treatment perception, satisfaction measures and in treatment changes. Measured at 1 and 5 years post treatment. That judicial mandates can provide an opportunity for offenders with SUDs to access and benefit from needed treatment.Mandated patients had a less severe clinical profile at treatment intake, yet this did not account for their observed similar/better outcomes, which appeared because of the similar therapeutic gains made during treatment.Treatment perceptions and satisfaction were also comparable across groups.Marshall GN; Hser YI (2002)USAAimed to examine clients currently involved with the criminal justice system whose treatment was not legally mandated and clients who had no current criminal justice contactClients mandated to treatment from the criminal justice system (CJ-mandated; n = 124. clients currently involved with the criminal justice system but whose treatment was not legally mandated (CJ contact; n = 77), and clients who had no current CJ contact (no-CJ contact; n = 364)Compared socio-demographic and psychosocial characteristics including prior history of drug treatment and criminal justice system involvement, criminal behaviour, psychological and physical health status, and Treatment-related beliefs (e.g., motivation).Non-mandated clients currently in contact with the justice system had similarities to other voluntary clients as well as to clients mandated to receive treatment.Banducci, Anne N; Dahne, Jennifer; Magidson, Jessica F; Chen, Kevin; Daughters,Stacey B; Lejuez, C. W (2013).USAAims to investigate substance users who voluntarily (VO) elect to receive treatment and substance users who are court-mandated (CM) to receive treatment and to differentiate these individuals. Residential substance use treatment (463 participants).Compared socio-demographic and psychosocial characteristics including prior history of drug treatment and criminal justice system Involvement, criminal behaviour, psychological and physical health status, and treatment-related beliefs (motivation).Overall, VO individuals appeared to have more severe problems than their CMCounterparts which may suggest that they require more intensive or different types of treatment.VO individuals, as compared to CM individuals had significantly higher rates of psychiatric disorders (68.7% versus 55.2%, respectively), including mood disorders, major depressive disorder, generalised anxiety disorder, and borderline personality disorder. Additionally, they were significantly more likely to have alcohol dependence (43.0% versus 20.8%) and cocaine dependence(66.5% versus 48.9%).The three groups differed from one another in certain respects; non-mandated clients currently in contact with the justice system showed similarities to other voluntary clients as well as to clients mandated to receive treatment.The current study provides rates of specific DSM-IV AxisI and Axis II psychiatric and substance use disorders, comorbidities, childhood trauma, motivation, and other clinical and demographic characteristics as a function of referral status, among individuals in residential substance use treatmentSchwartz, R. P; Kelly, S.M; O'Grady, K.E; Mitchell, S G; Brown, B. S(2011)USATo understand the characteristics of individuals entering and failing to enter methadone treatment.(n = 351) from methadone treatment programs and from the streets from among Non-treatment seekers (n = 164). Participants were opioid-dependent adults were recruited from new admissions to one of six methadone treatment programs.Participants were administered the Addiction Severity Index, AIDS Risk Assessment, Community Assessment Inventory, Attitudes toward Methadone Scale, Motivation for Treatment Scale and a urine drug test.A series of logistic regression analyses were conducted to determine the best model to predict treatment entryInterviewed rating scales administered. Predictors of treatment entry included: being African-American, being on parole or probation, having lower rates of self-reported cocaine use and criminal activity, higher employment functioning, and greater perceptions of support from family and community for behavioural change.In-treatment participants were more likely to have a more extensive prior history of drug abuse treatment, combined with a greater desire to seek help in coping with their drug problem, and more positive view of methadone treatment.MOTIVATIONWolfe S; Kay-Lambkin F; Bowman J; Childs S.(2013)USATo examine the effect between coercion on engagement and treatment in relation to coercion, motivation, therapeutic alliance.77 clients recruited from community drug treatment centre. Examining the presenting characteristics of clients attending a community drug and alcohol counselling service in relation to coercion, motivation, therapeutic alliance and substance use, as well as the effect that these variables had on treatment outcomes. A phone assessment upon treatment entry and 15 weeks post-baseline.Coercion was not associated with substance use outcomes at 15 week follow up. However, due to a relatively small sample completing post-baseline assessments (n=33).Those entering the same treatment services through non-criminal justice routes also reported similar reductions and substance use upon presentation for treatment, although coercion did not.Results indicated that facets of motivation and therapeutic alliance played a significant role in client's treatment regimes. Coviello DM; Zanis DA; Wesnoski SA; Palman N; Gur A; Lynch KG; McKay JR.(2013)USAAim to assess whether offenders who are mandated to community-based outpatient treatment have better completion rates compared to those who enter treatment voluntarily160 research participants (substance abusers) who were under various levels of criminal justice supervision (CJS) in the community.The participants were enrolled on an intensive outpatient program. All received weekly therapy sessions using a cognitive problem solving framework. The court-ordered offenders were over 10 times more likely to complete treatment compared to those who entered treatment voluntarily (OR=10.9, CI=2.0-59.1, p=.006). These findings demonstrate that stipulated treatment for offenders may be an effective way to increase treatment compliance.45% completed the 6 month treatment program. Those who were mandated demonstrated less motivation at treatment entry, yet were more likely to complete treatment compared to those who were not court-ordered to treatment.Urbanoski KA; Wild TC. (2012).CanadaAimed to assess the construct validity of the Treatment Entry Questionnaire (TEQ), a brief scale derived from SDT to measure identified, introjected, and external treatment motivationTwo independent groups of clients entering residential and outpatient treatment (n = 529 and 623).Exploratory and confirmatory factor analyses supported a 9-item version of the scale, with 3 factors aligning with SDT motivational subtypes. .The TEQ-9 is a valid option for assessing self-determined motivation in clinical practice and evaluating coerced addiction treatmentSubscales showed high internal consistency and correlated as expected with social controls and perceived coercion at treatment entry.Conner BT; Longshore D; Anglin MD.(2009)USAAim to examine the role of internal motivation, external pressure, and dramatic relief.465 drug usersStructural equation modelling on data from all participants on entry to drug treatment. When external pressure and internal motivation are high, dramatic relief is also likely to be high. When dramatic relief is high, attitudes towards drug treatment are likely to be positive.Entering drug treatment indicated that internal motivation and external pressure significantly and positively predicted dramatic relief and that dramatic relief significantly predicted attitudes towards drug treatment: chi (2) = 142.20, df = 100, p < 0.01; Robust Comparative Fit Index =0.97. Hampton AS; Conner BT; Albert D; Anglin MD; Urada D; Longshore D.(2011)USATreatment expectations and motivation influences, and the effect on treatment retention.289 treatment admissions in CaliforniaWhile being legally coerced may lead to different pathways to treatment retention, for individuals who were not legally coerced, higher levels of hope may play an important role in determining treatment retention. Motivation mediates the relationship between hope and retention for participants in general. Although the differences in mediation between the legally coerced and the non-legally coerced were not significant, when examining the groups separately, there was a significant mediation of the relationship between hope and retention by motivation only for those individuals who were not legally coerced into treatment (p<.05).Zemore SE.(2012)USAResearch the association between stage of change and substance abuse treatment retention and whether social desirability response bias could help explain whyParticipants (N = 200) recruited from an outpatient programNumber of treatment groups attended was collected from program recordsCompleted the University of Rhode Island Change Assessment Scale (URICA), Treatment Readiness Tool (TREAT), Marlowe-Crowne Social Desirability Scale, and other measuresHigher social desirability was also an independent predictor of greater treatment attendance and was strongly associated with lower Addiction Severity Index alcohol, drug, and psychiatric severity. Results underline a critical problem in measuring motivation and problem severity that has been largely neglected.Neither the URICA nor the TREAT was related to attendance. However, higher social desirability was strongly associated with lower URICA (but not TREAT) total scores, and a moderately strong association emerged between higher URICA scores and greater treatment attendance when accounting for social desirabilityStevens A; Berto D; Frick U; Hunt N; Kerschl V; McSweeney T; Oeuvray K; Puppo I;Santa Maria A; Schaaf S; Trinkl B; Uchtenhagen A; Werdenich W.(2006).EuropeExplores the link between formal legal coercion, perceived pressure to be in treatment and motivationOf 845 people who entered treatment for drug dependence in five European countries, half of them in quasi-compulsory treatment and half 'voluntarily'.Using both quantitative and qualitative data Motivation is mutable and can be developed or diminished by the quality of support and services offered to drug-dependent offenders.Those who enter treatment under Quasi Compulsory Treatment (QCT) do perceive greater pressure to be in treatment, but that this does not necessarily lead to higher or lower motivation than 'volunteers'. Many drug-dependent offenders value QCT as an opportunity to get treatment.Longshore D; Teruya C. (2006).USAExamine the two aspects of treatment motivation - readiness and resistance - as distinct constructs and examined their predictive power1295 drug-using offenders referred to treatment while on probationMotivation measured with items reflecting high treatment readiness (e.g., perceived need for treatment and commitment to participate) and low treatment resistance (e.g., scepticism regarding treatment benefits).That readiness and resistance should both be assessed among clients entering treatment, especially when the referral is coercive. Intake and counselling protocols should address readiness and resistance separately.Readiness (but not resistance) predicted treatment retention during the 6-month period. Resistance (but not readiness) predicted drug use, especially among offenders for whom the treatment referral was coerciveRapp RC; Li L; Siegal HA; DeLiberty RN.(2003)USAUnderstanding the role of motivation in substance abusers' acceptance of treatment for improving treatment outcomes. Recruited from two treatment programs whose services are funded by a state managed care system n=263Addiction Severity Index and Texas Christian University Pressures for Treatment Scale administer. Motivation was not related to alcohol and drug use severity six months later. The severity associated with motivation at treatment entry was, for the most part, not related to clients' success six months later. Higher client motivation was significantly associated with higher drug severity scores. (R=.399, p<.001, and r=.580, P<.001, respectively). Self-referral to treatment was positively related to client motivation (r=.260, p<.001,) and involvement with the criminal Justice System was negatively related to motivation (r= -.90, p<.05). Neither the coercion that accompanies legal system involvement nor self-referral was significantly related to measured levels of motivationMarlowe DB; Merikle EP; Kirby KC; Festinger DS; McLellan AT.(2001).USAIf clients are motivated to change, then explore guidance on how to retain an unmotivated client in treatmentn=415 substance abuse clientsInterviewed substance abuse clients about their reasons for entering treatment and scored their responses along the dimensions of (a) negative versus positive treatment-entry pressures, (b) internal versus external sources of those pressures, and (c) the life domain from which the pressures emanatedInterviewsThese data support the discriminative and predictive utility of performing a multidimensional assessment of pressures to enter treatment.Exploratory cluster analysis yielded 5 types of clients characterised by different profiles of perceived treatment-entry pressures. Cluster membership was predictive of treatment outcomes, and the clusters differed by demographic variablesGoodman, I;Peterson-Badali, M; Henderson, J(2011).USA134 youths (83 males and 51 females) presenting to an outpatient substance abuse programCross sectional study, completed questionnaires regarding substance use history, mental health, social pressure to reduce use and enter treatment, and treatment motivationQuestionnaires Family pressure was related only to external treatment motivation when peer pressure was considered in the regression model. These results highlight the importance of emerging adult peers as motivators for treatment seeking youths. Age was positively related to identification of internal reasons for seeking treatment and negatively related to external coercive social pressures as a motivator for treatment. Peer pressure accounted for significant variance in Identified treatment motivation. Prendergast, M; Greenwell, L; Farabee, D; Hser, Y. (2009). USAThe effects of perceived coercion and motivation on treatment completion and subsequent re-arrest. 7,416 clients included from criminal justice treatment entry program. Perceived coercion was measured with the McArthur Perceived Coercion Scale; motivation was measured with the subscales of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) and Addiction Severity Index.Drug misuse rating measures Correlations between perceived coercion and motivation measures at treatment entry indicated that these are separate constructs. In logistic regression models, the Recognition subscale of the SOCRATES significantly predicted "any re-arrest," and Ambivalence and Taking Steps predicted "any drug arrest."At treatment entry, clients were more likely to believe that they had exercised their choice in entering treatment than that they had been coerced into treatment. Clients scored relatively low on Recognition and Ambivalence regarding their drug use but relatively high on Taking Steps to address their drug problemMcgrain, P. N. (2006). USAExamines the factors that enhance or impede therapeutic engagement (the involvement in and commitment to drug treatment) of inmates in a prison-based drug treatment programn=30 inmates at the State Correctional Institution interviewed in a therapeutic community in which they had participatedQualitative study impressions of the inmate were noted during each interview, and each inmate's treatment file was reviewed at three distinct points of the treatment process.Qualitative interview The unique characteristics of an inmate may have greater influence than program characteristics on the inmates' involvement and commitment to engage in the drug treatment program. Specifically, therapeutic engagement is shown to be a product of external coercion, including familial and legal factors; internal motivation and treatment readiness; and program factors, including group meetings, activities, work assignments, authority and structure.Wild, T. C; Cunningham, J. A; Ryan, R.M. (2006).USAInvestigate relationships between social pressures, coercion, and client engagement prior to the commencement of outpatient addiction treatment. Clients seeking substance abuse treatment (N=300; 221 males and 79 females).Clients seeking substance abuse treatment rated the extent to which treatment was being sought because of coercive social pleting the Social Pressure Index and a modified version of the MacArthur perceived coercion scale, the Treatment Entry Questionnaire (TEQ). Interviews to complete rating scales.Treatment motivation variables accounted for unique variance in these outcomes when added to each model (R2s=.06-.23, ps<.05). Specifically, identified treatment motivation predicted perceived benefits of reducing substance use, attempts to reduce drinking and drug use, as well as self (and therapist) ratings of interest in the upcoming treatment episode (s=.18-.31, ps<.05). Results suggest that the presence of legal referral and/or social network pressures to quit, cut down, and/or enter treatment does not affect client engagement at treatment entry.(external motivation; a=.89), guilt about continued substance abuse (introjected motivation; a= .84), or a personal choice and commitment to the goals of the program (identified motivation; a=.85)External treatment motivation was positively correlated with legal referral, social network pressures to enter treatment, and was inversely related to problem severity. In contrast, identified treatment motivation was positively correlated with self-referral and problem severity, and was inversely related to perceived coercion (ps<.05).PERCEIVED COERCION /EXPERIENCES OF COERCIONLarsson-Kronberg M; Ojehagen A; Berglund M. (2005).SwedenExamine court entry requirements for drug treatment orders. 74 subjects who were being assessed prior to the court's decision on involuntary careInterviewed 74 subjects who were being assessed prior to the court's decision on involuntary care (n=39), or with previous experience of assessment and involuntary care (n=35)Interviews data collectionPoints at the need for new instruments to be developed covering all aspects of the coercive process and in particular the period of investigation prior to the decision on involuntary care.The clients who did meet with a social worker, often described the conferences as more of a perfunctory nature with a lack of focus on the actual situation and aftercare planning.In spite of the law, 18% were not contacted by the social services while in coercive treatment. The assessment group more often reported having the opportunity to express their opinions to the social worker during the assessment period (55% vs. 21%, p<.05) and they were more positive towards the final decision (60% vs. 24%, p<.05).Mackain, S. J; Lecci, L. (2010).USATo examine potential differences in subjective perceptions of coercion between substance abuse professionals and clients in how they view events that trigger entry to treatment.74 substance abuse treatment outpatients and 75 certified substance abuse clinicians.Clinicians and outpatient drug users rated 15 treatment entry-related events based on the degree of choice an individual would have in entering treatment. InterviewClients' views of external coercive events appeared to be more uni-dimensional than for internal events, whereas clinicians perceived internal events as more cohesive relative to external events.Clients perceived internal sources of coercion as more coercive, whereas the clinicians perceived external items as more coercive. Discrepant perceptions of treatment entry triggers may impact the development of a working alliance and the use of motivational strategies intended to enhance readiness to change.Young, D. (2002).USAExamine different forms of legal pressure used to compel treatment participation and their effects on client outcomes.161 offenders mandated from different criminal justice sources to attend long-term residential treatment.Scores on an experimental perception of legal pressure measure co-varied predictably with the coercive strategies employed by the mandating sourcesProviding information to clients about conditions and contingencies of treatment participation and convincing them they will be enforced are effective coercive approaches. There was less support for other forms of coercion--tight monitoring and use of severe penalties for failure. Analyses showed these scores to be relatively powerful, independent predictors of retention.Melnick, G; Hawke, J; Wexler, H.K.(2004)USATo evaluate the growing number of prison-based substance abuse treatment programs from the perspective of the clients1,059 participants from 13 prison-based substance abuse treatment programsTested whether participants from prison-based substance abuse treatment programs could be grouped according to elevated, moderate, or low perceptions of the treatment environment and according to their perceptions of the program climate. Despite being coerced into treatment, the majority of participants were positive about their treatment experience.PRESSURESStorbjork, J.(2013)SwedenExplores how self-choice and treatment-entry pressures are associated with one-year treatment outcome (dependence symptoms, 0-6, 12 months) among alcohol and drug misusers(N = 1,210) representative of the addiction treatment system of StockholmInformal pressures (from family and friends), formal pressures (related to work, healthcare, social services, social allowances, child custody) and legal pressures (related to the police, criminal justice system, and compulsory treatment) were analysed.Interviewed when starting a new treatment episode and after one year Pressures were generally associated with poorer outcome. Alcohol misusers who had experienced threats regarding child custody did better in comparison with those not experiencing such pressure.Analyses indicated that self-choice and pressures are associated with outcome among alcohol misusers but not among drug misusers when controlling for background factors and severity. Self-choice (without pressures) correlated with a good outcome (a lower number of dependence criteria).Polcin, D. L; Beattie, M. (2007).USAAssess how pressure from different sources varies698 individuals entering residential or outpatient treatmentPressure was assessed by asking participants if others had suggested they enter treatment, including family, friends, and professionals within institutions. Additional assessments included the Addiction Severity Index and readiness to changeInterview and completion of addiction severity measures Being on parole or probation, not being employed full time, and having more severe legal problems predicted pressure from institutions. Most of the participants (73%) reported some type of pressure: 29% from personal relationships, 30% from institutions, and 14% from both. The remaining 27% reported no pressure to enter treatment.In addition, institutional pressure was associated with lower motivation at baseline, whereas relationship pressure was not related to motivation at all. Compared with participants receiving only relationship pressure, those receiving only institutional pressure had lower alcohol, drug, family, psychiatric, and medical severity. When controlling for problem severity, baseline pressure was not associated with 12-month outcomes. Correlates of pressure from institutions for individuals to enter treatment differ from those associated with pressure from personal relationships to enter treatment. QUASI-COMPULSORYSchaub, M; Stevens, A; Haug, S; B, Daniele; Hunt, Neil; Kerschl, Viktoria; McSweeney, T; Oeuvray, K; Puppo, I; Maria, Alberto S; Trinkl, B; Werdenich, W; Uchtenhagen, A.(2011)European Aimed to identify such predictors in Quasi Compulsory Treatment (QCT) and voluntary treatmentParticipants were treated in one of 65 institutions in 5 European countries.430 QCT and 415 voluntary treatment participants. Interviewed at intake on substance use, crimes committed, perceived pressure for treatment, self-efficacy.European Addiction Severity Index and Readiness-to-Change Questionnaire (RCQ)Predictors of substance abuse treatment retention are quite similar across both QCT and voluntary treatments. Perceived medical pressure is of higher relevance than the often-believed legal pressure for treatment retention in QCT.Higher perceived medical pressure resulted in higher treatment retention rates only for participants in QCT. There was a higher proportion of male participants in the QCT group (86.1%) than in the voluntary group (77.4%, p=.01, effect size w=0.11). Furthermore, the QCT and voluntary groups differed in terms of the number of years of school education, with a higher educational level in the voluntary group (10.1 years, QCT group 9.6 years, p=.01, d=0.21).A higher number of working days in the previous month was positively associated with treatment retention, while use of heroin, crack, and multiple drugs, psychiatric problems in the previous month, and lifetime depression were negatively associated with treatment retention. READINESS FOR CHANGEBurke AC; Gregoire TK. (2007).USAThe relationships of coerced care to post treatment substance use and addiction severity. 289 participants in five large outpatient programs. Prospective study of substance abuse treatment outcomes. The findings are based on analyses for the 141 (48.8 percent of the original sample) individuals who completed a six-month follow-up interview using the short form of the Addiction Severity Index. Controlling for two important factors: readiness to change and addiction severity at admission to treatment. InterviewLegally coerced participants were more likely than non- coerced participants to report abstaining from alcohol and other drugs in the 30 days before their follow-up interview. They were also more likely to demonstrate reduced addiction severity at follow-up. Readiness to change at admission showed no relation to treatment outcomes.Gregoire TK; Burke AC.(2004)USAExamined the relationship between legal coercion and Readiness to Change. 295 consecutive admissions to five publicly funded outpatient treatmentprogramsAddiction Severity Index and readiness to change scale. Persons entering treatment due to legal coercion were over three times more likely to have engaged in recovery-oriented behaviour in the month preceding admission.That legal coercion was associated with greater readiness to change after controlling for addiction severity, prior treatment history, and gender.Marlowe DB; Merikle EP; Kirby KC; Festinger DS; McLellan AT. (2001).USAInvestigate why a client may be motivated to change, and suggest how retain an unmotivated client in treatment.interviewed 415 substance abuse clientsExploratory cluster analysis yielded five types of clients characterised by different profiles of perceived treatment-entry pressures.Interviews Cluster membership was predictive of treatment outcomes, and the clusters differed by demographic variables. These data support the discriminative and predictive utility of performing a multidimensional assessment of pressures to enter treatment.To establish reasons for entering treatment and scored the responses along the dimensions of (a) negative versus positive treatment-entry pressures, (b) internal versus external sources of those pressures, and (c) the life domain from which the pressures emanated.RETENTION /COMPLETION/ ADHERENCE/ COMPLIANCE /ENGAGEMENTBeynon CM; Bellis MA; McVeigh .J. (2006). UK. To assess outcome trends in 'dropped out' and 'discharged drug free' (DDF) clients.n = 26,415.A longitudinal dataset of drug users (1997 to 2004/05) was used to identify people who dropped out of, and were DDF from, services for years 1998 to 2001/02, The proportion of individuals dropping out has increased from7.2% in 1998 to 9.6% in 2001/02 (P < 0.001). The proportion DDF has fallen from 5.8% to 3.5% (P < 0.001). Drop out was more likely in later years, by those of younger age and by CJ referrals. The proportion re-presenting to treatment in the following year increased from 27.8% in 1998 to 44.5% in 2001/02 (P < 0.001) for those DDF, and from 22.9% to 48.6% (P < 0.001) for those who dropped out. Older age and prior treatment experience predicted re-presentation. Outcome (drop out or DDF) did not predict re-presentation. Increasing numbers in treatment is associated with an increased proportion dropping out and an ever-smaller proportion DDF. Rates of drop out are significantly higher for those coerced into treatment via the CJ system. Rates of re-presentation are similar for those dropping out and those DDF.Evans E; Li L; Hser YI. (2009). USAExamine why court mandated offenders dropout of drug treatment and to compare their characteristics, treatment experiences, perceptions, and outcomes with treatment completers.542 drug treatment dropouts (59%) and 384 completers (41%) over 35 drug treatment sites.Self-reported and administrative data assessed for CJ drugs treatment Several factors predicting drug treatment dropout were identified. Both groups demonstrated improved functioning at one-year follow-up, but fewer dropouts had a successful outcome (34.5% vs. 59.1%) and their recidivism rate was significantly higher (62.9% vs. 28.9%) even after controlling for baseline differences.At treatment intake, dropouts had lengthier criminal histories, lower treatment motivation, and more were using drugs, especially heroin. Relatively fewer dropouts received residential treatment and their retention was much shorter. A similar proportion of dropouts received services as completers.Perron BE; Bright CL. (2008). USAThe influence of legal coercion on retention in substance abuse treatmentn=2,694 Three different treatment modalities Short-term residential (N = 756), long-term residential (N = 757), and outpatient (N = 1,181).Substance use severity was an index, Clinical severity measures included two substance use variables, four measures of psychiatric problems, two measures of service characteristics and a proxy measure of the importance of substance abuse treatment was included.National survey in public sector The greatest effect was among persons in short-term residential treatment. The smallest effect was observed in outpatient treatment. This study shows that legal coercion significantly reduces the risk of dropout in substance abuse treatment.Legal coercion was found to reduce the risk of dropout across all three treatment modalities. Outpatient treatment exhibited a relatively small effect, suggesting that it works better for some people than others.Shearer, R. A; Ogan, G. D. (2001).USAInvestigated retention for at least 90 days of treatment and what improved or reduced this effect. 1,163 subjectsThis study looked at retention for at least 90 days of treatment, and engagement, defined as completing four consecutive months of drug-free and sanction-less participation.The following predicted dropping out: younger, primary drug of heroin, prior misdemeanour conviction(s), and residence in a neighbourhood characterised by greater social isolationParticipation during the 30-day period immediately following program entry was as important as coercion. Warranting or failing to begin treatment within 30 days of formal entry strongly predicted dropping out. The level of legal coercion, measured by expected incarceration time in the event of program failure, strongly predicted both retention and engagement. StudyStudy aimsStudy Population/ SettingMethods OutcomesKey FindingsBurns, T., Rugk?sa .J, Molodynksi. A., Dawson. J., Yeeles. K.,Vazquez-Montes .M., et al (2013) UK (OCTET).Examine if Community Treatment Orders (CTO) for patients with psychosis provided treatment benefit or not. When discharged from hospital on CTOs would have a lower rate of readmission over 12 months than those discharged on the pre-existing Section 17 leave of absence? 336 patients included in outpatient psychiatric treatment in the UK.A randomised controlled trial, non-blinded, parallel-arm. At 12 months follow up, despite the length of initial compulsory outpatient treatment differed significantly between the two groups. The number of patients readmitted did not differ between groups and did not support compulsory treatment as any more effective than not being on a CTO.In well-coordinated mental health services the use of compulsory supervision does not reduce the rate of readmission of psychotic patients. The study found that no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients' libertyBrown, R.T., Allison, P.A., Nieto,J.(2010) USATo describe the relationship between the imposition of short term jail sanctions and substance abuse treatment drop out. Also to explore the impact of jail sanctions during drug court participation upon substance abuse treatment completion. Administrative information collected by the Dane County Wisconsin Drug Treatment Court from 1996–2004 on all 573 participants achieving a final disposition of treatment completion or failure during those program years.Derived from iterative cox proportional models of time to treatment failure created. Theoretical framework and specific statistical criteria from administrative data. An initial jail sanction for non-adherence may be more likely to foster treatment compliance in less refractory individuals (i.e. those not already acclimated or socialised to incarceration or other corrections interventions). More stringent supervisory conditions and individualised services may be required to reintegrate such offenders and promote longer-term public safety.Brecht, ML. Anglin, M.D., and Wang, J.C. (1993).USAWhether addicts reporting themselves coerced into drug abuse treatment by actions of the criminal justice system differed from voluntary admissions in their response to treatment.618 methadone maintenance clients admitted to programs in six southern California counties were categorised into high, moderate, and low legal coercion levelsData obtained from addiction career histories in a representative sample between four and six years after initial treatment. Standardised structured interview questionnaire. Dependent variables included criminal justice system contact, criminal activities, drug and alcohol involvement, and measures of social functioning. Few differences within any measured domain were found among the three groups. All groups were similar in showing substantial improvement in levels of narcotics use, criminal activities, and most other behaviours during treatment with some regression in these behaviours post treatment. Results support legal coercion as a valid motivation for treatment entry; those coerced into treatment respond in ways similar to voluntary admissions regardless of gender or ethnicity.Wild, T.C., Newton-Taylor, B., Alleto, R. (1998).CanadaPerceived coercion among clients entering substance abuse treatment: structural and psychological determinants.Clients (N = 300) entering substance abuse treatment.Assessed on structural variables (socio-demographic background, criminal history, current legal status, referral source), psychological variables (personal beliefs about substance abuse, perceived interpersonal pressures), alcohol/drug use, and perceived coercion.Mandated treatment status predicted perceived coercion; however, many mandated clients did not, and many self-referrals did, report being coerced into treatment. Psychological factors accounted for additional variance in perceived coercion, controlling for referral source. Substance dependence did not add to the predictability of perceived coercion beyond structural and psychological variables. These findings are inconsistent with the notion that coercion can be inferred from referral source. Joe, G., Simpson, D, D., and Broome, K. (1999).USA. Retention and patient engagement models of different treatment modalities in DATOS.1362 patients in long term rehabilitation , 866 in Outpatient drug free, and 981 in Outpatient methadone Treatment programsInterviewed for demographic detail and following treatment at one and three months, diagnosis measure and motivation measure. Structural equation models showed there were positive reciprocal effects between therapeutic involvement and session attribute in all three modalities, and these variables had direct positive effects on treatment retention. Motivation at intake was a strong determinant of therapeutic involvement. Other patient background factors were significantly related to retention, including pre-treatment depression, alcohol dependence, and legal pressure. DeLeon,G., Melnick,D., Kressel,D.,and Jainchill,N.(1994).USA Investigate the Circumstances, Motivation, Readiness, and Suitability (The CMRS Scales): Predicting Retention in Therapeutic Community Treatment.658 prisoners at one prison in the US. Randomly assigned to two groups, self-administered measurement for treatment motivation taken using Circumstance, Motivation and Readiness scale (CMR). The CMR scores over the entire sample of the study was a mean of 67.17%, indicating relatively high motivational level. The circumstances (pressure for treatment) showed a fairly normal distribution.Treatment motivation has a significant effect on treatment status with treatment status having a detrimental effect on relapse rates. Finding that initial motivational levels have a direct positive effect on treatment outcomes. Hser Y-I, Joshi V, Maglione M, Chou C-P, Anglin MD (2001). USA.Effects of program and patient characteristics on patient retention of drug treatment patients. The study sample included 26,047 patients entering drug treatment settings, from outpatient drug free (ODF), residential, and methadone maintenance (MM) programs. Patient data were based on admission and discharge records. Program data were collected from program directors via a mail survey.Threshold retention rates were generally low in all three modalities (18.1% for residential programs, 22.9% for ODF, and 13.6% for MM). An articulated programmatic focus and low caseload increased patient retention in residential programs. A lower level of group therapy focus increased patient retention in ODF programs. A low programmatic focus and a low percentage of recovering staff were associated with high retention rates among MM patients.Program practice and service provision played important roles in determining patient retention in treatment. Heardon, I. (2000).UKProblem Drug Use and Probation in London: an evaluation; inner London Probation Service.Evaluative study of 278 drug-misusing offenders and 15 main grade probation officers. All the offenders were supervised by the Inner London Probation Service and had been sentenced to either a probation or a combination orderInterviews.Results suggest large reductions in drug use and crime, especially for those whose probation order included a condition of treatment. There was also strong evidence of effective working partnerships between the probation service and the specialist drug services which helped bring these reductions about.Edmunds, M., Hough, M., Turnbull, J, P., May, T. (1999). UKExploring the effectiveness of Referring Offenders to Drug Services.Data came from a review of 2,078 referral/assessment records.322 interviews with drug-using offenders who had contact with criminal justice drug workers (CJDW).Detailed interviews with crucial professionals, and field notes made at management and worker meetings. No significant changes occurred in employment, housing, or personal relationships. Findings suggested that well-designed referral systems can break the cycle of parallel drug and crime careers. That arrest referral systems, probation referral systems, and work in prisons can identify drug abusers as they pass through the criminal justice system, refer them to treatment agencies, and produce consequent reductions in drug use and drug-related crime. Gossop, M., Marsden, J., and Stewart, D. (2001).UK Changes in substance use, health and criminal behaviour during the five years after intake1075 patients from 54 agencies and four treatment modalities. Inpatients, rehabilitation units, methadone maintenance and methadone reduction programmes. Data were collected by structured interviews at intake to treatment, one year, two years and at four–five years, combined with a severity of dependence scale and 0piate Treatment Index.Rates of abstinence from illicit drugs increased after treatment among patients from both residential and community (methadone) programmes. Reductions were found for frequency of use of heroin, non-prescribed methadone, benzodiazepines, injecting and sharing of injecting equipment. For most variables, reductions were evident at 1?year with outcomes remaining at about the 1?year level or with further reductions. Substantial reductions across a range of problem behaviours were found 4–5?years after patients were admitted to national treatment programmes delivered under day-to-day conditions. Despite differences between the United Kingdom and the United States in patient populations and in treatment programmes, there are many similarities between the two countries in outcomes from large-scale, multi-site studies.Oliver. P. Keen, J., Rowse, G., Ewins, E., Griffiths, L. Mathers, N. (2010).UKTo examine the association between treatment status and rates of judicial disposals over a five year period for heroin users under primary care and measure treatment dropout rates. 108 consecutive patients who were eligible and entered treatment. 90 were followed-up for the full five yearsCriminal conviction and caution rates and time spent in prison, derived from Police National Computer (PNC) criminal recordsThe overall reduction in the number of convictions and cautions expected for patients entering MMT in similar primary care settings is 10% for each 6 months retained in treatment. Patients in continuous treatment had the greatest reduction in judicial disposal rates, similar to those who were discharged for positive reasons (e.g. drug free). Patients who had more than one treatment episode over the observation period did no better than those who dropped out of treatment.Hammerbacher, M.,and Lyvers, M. (2006)Australia Factors associated with relapse among clients in Australian substance disorder treatment facilities. 104 clients enrolled in treatment programs for substance disordersRetrospective self‐report questionnaires to explore the roles of family dysfunction, mood states, and primary drug of dependence, demographic variables and various other factors in relation to relapse episodes.Consistent with previous studies, the most commonly cited reason for relapse was negative mood states, followed by external pressure to use, desire for positive mood states, and social/family problems. General family functioning retrospectively improved from time of last relapse to time of testing. Results are consistent with previous work and suggest that relapse factors are remarkably similar across different types of drug dependence.De Leon G, Melnick G, Thomas G, Kressel D,Wexler HK.(2000).USAMotivations for treatment in a therapeutic community2,372 consecutive admissions Scales developed to measure client perceptions across 4 domains. Circumstances (external pressures), Motivation (intrinsic pressure), readiness, and suitability for residential treatment (CMRS). Significant relationships were obtained between initial motivation (i.e., Circumstances, Motivation, Readiness [CMR] scores), retention, aftercare, and outcomes in a sample of substance abusers treated in a prison-based TC programYoung, D.and Belenko, S (2002) USAProgram Retention and Perceived Coercion in Three Models of Mandatory Drug TreatmentThree groups of clients (N = 330) mandated to the same long-term residential treatment facilities.Study participants were referred from two highly structured programs or from more conventional legal sources, such as probation or parole agentsClients varied substantially in their perceptions of legal pressure, and these perceptions generally corresponded to the programs' different coercive policies and practices. Retention analyses confirmed that the odds of staying in treatment for six months or more was nearly three times greater for clients in the most coercive program compared to clients in the third group. Results support the use of structured protocols for informing clients about legal contingencies of participation and how that participation will be monitored, and developing the capacity to enforce threatened consequences for failure.Dolan, K. A., Shearer, J., MacDonald, M., Mattick, R. P., Hall, W., Wodack, A.D. (2003).AustraliaA randomised control trial to determine whether methadone maintenance treatment versus wait list control reduced heroin use amongst prisoners. ?Of 593 eligible prisoners, 382 (64%) were randomised to MMT (n=191) or control (n=191). 129 treated and 124 control subjects were followed up at 5 months.?Interview and blood and hair analyses at five months follow up. Consideration should be given to the introduction of prison methadone programs particular where community based programs exist. Examine the impact of treatment for heroin dependence on drug use over three years: findings of the Australian Treatment Outcome Study (ATOS).615 heroin users enrolled in the Australian Treatment Outcome Study.The proportion who reported using heroin in the preceding month continued to decrease significantly from baseline to 24-month follow-up (99% versus 35%), with this rate remaining stable to 36-month follow-up. The reduction in heroin use was accompanied by reductions in other drug use. There were also substantial reductions in risk-taking, crime, and improvements in general physical and mental health. Positive outcomes were associated with more time in maintenance therapies and residential rehabilitation and fewer treatment episodes. Time spent in detoxification was not associated with positive outcomes. Major depression was also associated consistently with poorer outcome.Dawe, S., Griffiths, P., Gossop, M., and Strang, J. (1991).UKCompares the responses of opiate addicts at a London drug treatment centre to two outpatient methadone-based detoxification programmes.82 participants for inclusion in the study, (n= 39) attended for the interview. 24 started a flexible withdrawal regime and 15 a fived withdrawal regime of methadone. Drug use interviews and clinic attendance self-reporting.There was no difference between groups in programme retention at 6 weeks though subjects who remained in treatment in the negotiable group tended to extend their detoxification period beyond this point. The overall response of subjects in both groups was unsatisfactory. Only 13% of the subjects initially allocated to detoxification or 28% of those who actually started detoxification completed treatment; urine screening showed that heroin abuse was a continuing problem during treatment. The implications of these results for detoxification and drug treatment services are discussed.Unnithan, S., Gossop, M., and Strang, J. (1992). UKFactors associated with relapse among opiate addicts in an outpatient detoxification programme.42 opiate addicts receiving out-patient detoxification pleted a self-report questionnaire about their social, psychological, and environmental circumstances in the week before interview, and were interviewed within the first two weeks.40% (17) had lapsed to illicit heroin abuse within the previous week. Interpersonal factors and drug-related cues were associated with lapse to opiate use. Most subjects encountered a range of high-risk situations, such as regularly meeting other drug users and being offered drugs, and persistent negative mood states.Meulenbeek, P. (2000).Netherlands. Addiction problems and methadone treatment397 heroin-addicted clients who applied to join a methadone programme. Each client was assessed during the intake phase according to the Revised Addiction Severity Index (ASI-R).?The results show that for a large group of the methadone clients (minimum of one third) there is an indication for treatment in the life areas of Employment, Drug Use, Legal Status, Social Functioning, and Psychological Functioning. D D Simpson, G W Joe, G A Rowan-Szal(1997)USADrug abuse treatment retention and process effects on follow-up outcomes.435 patients on methadone treatment. Self-rating form for psychological functioning and motivation for treatment. Desire for help and demographic data. Patients staying in treatment a year or longer were nearly five times more likely to have better outcomes. The length of treatment stay was predicted by higher patient motivation at intake and early program involvement. More comprehensive models of patient attributes, therapeutic process, and environmental influences are needed.Best, D, .Day, E., Homayoun, S., Lenton. H., Moverley. R. and Oppenshaw, M (2008). UKDo primary drug users fare better than primary offenders examining completion rates in a drug intervention programme (DIP)? 123 files were examined.A retrospective case-note method based on all files opened over a three-month window, examining outcomes three months after the last case was openedLess than 5% of cases were successfully completed, some form of positive outcome was reported in 14% of cases, 57% had negative outcomes (such as breaching the requirements of the order or failure to attend) and 29% were still open 6 months after the start of the programme. Negative outcomes were associated with more intensive criminal histories and lower levels of drug use in the month prior to intake to DIP. Lang, M. and Belenko, S (2000) USAPredicting retention in a residential drug treatment alternative to prison program.150 prisoners diverted from prison to residential drug treatment unit. Comprehensive interview, longitudinal study. Addiction severity index; Michigan Alcohol Scale; drug abuse screening questionnaire, ands self-rating form for motivation and psychological functioning. Those completing treatment had more social conformity and close friends, and less to encounter recent problems with significant others. They also commenced heroin at an older age than those who dropped out of treatment. Marlowe, D, B., Kirby, K, C., Binieskie, L. M., Glass, D, J., Dodds, L, D., and Husband, S, D (1996). USAAssessment of coercive and non-coercive pressures to enter drug abuse treatment260 consecutive admissions to outpatient service. Standardised interview. MPCS and CMRS measures. Among clients in outpatient treatment, 'coercion' is operative in multiple psychosocial domains, and that subjects perceive legal pressures as exerting substantially less influence over their decisions to enter treatment than informal psychosocial pressures.Monahan,J,. Redlich,A.,?Swanson, J., Robbins, P., Appelbaum,?P., Petrila,J., Steadman,?H.J., Swartz,?M., Angell,B, and McNiel, D.(2005) USA MacArthur Foundation studies from 1981 onwards. Measuring the Use of Leverage to Improve Adherence to Psychiatric Treatment in the Community. Aimed to determine the factors associated with patients' experience of coercion in their hospital admission. A sample of 157 randomly-selected adult patients admitted to a state hospital and a community hospital. This study relied only on patients' accounts of the hospital admission process. Then a second and more ambitious study, using a sample of randomly-selected adult patients from the same jurisdictions (n=433). This study compared the perceptions of patients at admission and later a month after discharge into the community. Third prospective study (n=1,136) patients.The same events may be differently perceived by others involved collectively over the three MacArthur studies. Legal status is only a blunt index of whether a patient experienced coercion in being admitted to a mental hospital. A significant minority of legally "voluntary" patients experience coercion and a significant minority of legally "involuntary" patients believe that they freely chose to be hospitalized. The kind of pressures that others apply to an individual to obtain his or her admission to a mental hospital strongly affect the amount of coercion that the individual experiences: the use of "negative" pressures, such as threats and force, engender feelings of coercion; the use of "positive" pressures, such as persuasion and inducements, do not. The amount of coercion a patient experiences in being admitted to a mental hospital is not related to his or her demographic characteristics. The amount of coercion experienced is strongly related to a patient's belief about the justice of the process by which he or she was admitted. That is, a patient's beliefs that others acted out of genuine concern, treated the patient respectfully and in good faith, and afforded the patient a chance to tell his or her side of the story, are associated with low levels of experienced coercion. Chapter Three: Method3.1Identification of Research Question The overall research question for this study is stated as follows“How does the participant construal of pressure influence their entry, retention, and completion of drug treatment programmes?” The following objectives to meet the overall question are:How did the treatment contexts with regard to participants’ construal of coercion at Time One (T1) influence outcomes at Time Two (T2)?How did treatment groups differ at T1 with regard to demography, drug misuse history, treatment history, and relevant psychological variables that influenced participant status at T2?How treatment outcomes at T2 were related to drug misuse history, cost of drug use, and confidence in treatment at T1?Were the psychological variables influenced between T1 and T2?3.1.1Introduction Coercion, previously introduced in chapter two has been interpreted to explore potential relationships between participant treatment entry, retention and outcome. The study does not have a direct quantitative measure of treatment pressure but seeks to establish a synergy between the qualitative construal of coercion and the psychological measures. The aim of the study is to investigate any potential relationships between coercion and other variables that may influence participant decision making. The focus of the main research question is coercion construal and the variables related to its construal. Relevant psychological and the related variables were discussed from the literature in chapter two, such as stage of change, self-efficacy, attributions, mood, treatment readiness and confidence and will be explored further here (Young and Belenko, 2002; Gossop et al, 2006; Perron and Bright, 2008; McSweeney et al, 2008; Oliver et al, 2010 Donmall et al, 2012). In conducting this study, relevant psychological constructs were brought forward from the literature and operationalised in the form of a set of quantitative psychological measures with the intention of providing a context for the interpretation of coercion. Time One (T1) refers to initial data collection shortly after admission to treatment and Time Two (T2) refers to six month follow up interview. Programme entry at T1 and follow up at T2 was designed to allow for any predictive value of measures for outcome and also for change on these measures over time. Demographic variables and their drug treatment relevance are important to look at as stated in chapter 2, not just because some are raised in coercion and substance misuse studies, but they could have the potential to profile characteristics that ground the qualitative data (Wild et al, 2002; Stevens et al, 2005; Sullivan et al, 2008). The qualitative results regarding coercion are presented in chapter five. 3.1.2Conceptual Underpinning: Set and Setting The literature reviewed in chapter two has raised themes associated with treatment readiness and family influence for example, which may link to some of the quantitative data variables to be examined in the current study. Specifically these variables and their relationship to heroin treatment that are considered include participant self-efficacy, treatment confidence, mood, stage of change and treatment readiness. These variables form part of the overall body of work and seek to examine this relationship between construal of coercion and some evidence from the literature that might underpin it. In practical terms, the quantitative measures have emerged from the literature as having importance in heroin treatment and may better contextualise coercion. The concept of a psychological ‘set’ is introduced, representing a framework of predispositions to perceive and to respond, which forms a bridge to influences in the broader setting as may be shown, for example, by the perception of coercion within different treatment contexts, from family behaviours and from external sources. This draws upon the classic work of Zinberg (1984) who defined drug set as being the mindset related to both the nature of the drug user and their expectation of the effects of taking the drug. This may subsequently influence behavioural responses. Therefore, the variables measured constitute part of such a ‘set’ and are relevant to the consideration of coercion. The psychological ‘set’ captured the variables identified in the literature; these being self-efficacy, confidence, readiness, mood, stage of change. Perceptions from participants are examined that follow from the treatment contexts. Inter-group demographics, drug use, and psychological variables to themes and issues concerning coercion are also considered. Zinberg’s (1984) description of setting referred to the collection of environmental factors that surrounded the event of drug taking, which could be social, cultural or physical. Within this study the setting captures the context of drug use for each individual heroin user. Figure 4 represents influences which comprise the setting for treatment and which will influence the psychological set. The two directional arrows between the psychological set, treatment contexts and influences beyond treatment (a, b, c, d), therefore represent directions of influence which represent possibilities for behaviour changes.2587295285750Setting: Treatment contexts00Setting: Treatment contexts207492288925Psychological set: DTCQ, SOCRATES, DASS 21, ATOS, ASI, Treatment confidence scale. 00Psychological set: DTCQ, SOCRATES, DASS 21, ATOS, ASI, Treatment confidence scale. Figure 4: Psychological set and setting with all qualitative variables 1863725385775(b)00(b)186118553010(a)00(a)15963903777000158145536258500186339546990(c)00(c)2568245200025Setting: Influences beyond treatment00Setting: Influences beyond treatment158336033972500187165027940(d)00(d)157828030861000The construal of coercion at T1 is where pressures identified from the qualitative data can be particularly important in order to address the research question. Attention will be paid to the types of coercion which are inherent within these treatment contexts. Relationships and outcomes across contexts will be explored considering treatment pressures as shown by a range of demographic and psychological variables (Clag et al, 2005; Monahan et al, 2005; Szmukler and Appelbaum, 2008; Burns et al, 2011). Dimensions of coercion across identified treatment contexts are explored in an attempt to establish whether treatment sanctions are beneficial to treatment entry, retention, and if they impact on completion rates.3.2Operationalising of the Study at T13.2.1Treatment Contexts The present study did not assume the treatment contexts represented an ordinal measure of coercion. Whilst the treatment contexts contain some formal indicators of coercion they are qualitatively different. Operationalising coercion as a construct was intended across treatment contexts which differ. In order to operationalise coercion, four independent treatment groups were identified but it was only possible to collect data from three. The study initially had a four group design, but the probation DRR group is not represented from this stage in the methods chapter, as no participants could be recruited throughout the data collection phase. With no DRR group participants, and after consultation with the supervision team, statistician in the supervision team, and approval from National Research Ethics Service (NRES), total group numbers were raised from the original target of 18 to 24 (n=72). The lack of DRR participants will be considered in the concluding discussion and findings chapters. Three treatment contexts were included, The Kevin White Unit (a specialist drug inpatient treatment unit), HMP Liverpool (large remand and sentenced prison) and Rodney Street Drugs Dependency Clinic (outpatient drug treatment) all located in Liverpool. Liverpool prison is a Victorian prison with eight large wings accommodating up to 1,247 prisoners. Each cell accommodates two prisoners who can remain confined up to 20 hours per day. Study participants included were all from the main accommodation wings of the prison and representative of the general prison drug using population. The inpatient drug treatment facility has a regional and increasingly national catchment area. Inpatient participants remain voluntarily throughout their residential detoxification programme, which can last up to 28 days, before eventual discharge to community outpatient support. Participants may leave the programme at their request at any time. The inpatient treatment unit is a North West UK specialist centre and can discharge participants regionally or nationally. The outpatient treatment clinic provides methadone and community support for those primarily addicted to heroin. The clinic accommodates up to 500 patients and covers a large inner city area. The drug treatment team provides rapid access, treatment and support for people wanting to recover from drug misuse. The north west catchment area where this study was undertaken had significant problematic levels of heroin misuse and also the highest UK mortality rate from heroin use in 2012 (41.0 deaths per million of population) (Office for National Statistics, 2012). 3.2.2Utilisation of Mixed MethodologyThe rationale for drawing upon a mixed methodology was to consider what differences might be uncovered when one perspective is used to work with another (Martens, 2007; Biddle and Scafft, 2014). The overarching rationale for using mixed methods was about bringing in participants subjective perceptions of coercive influences that might not be captured through the use of standardised objective quantitative measures. Specifically, the study investigated what coercive factors are beneficial in reducing heroin use and whether these factors persevered at six months post treatment.The mixed method design aimed to enumerate and contextualise participant perspectives of drug treatment to more completely address the research questions that might not readily emerge from a solely quantitative design (Feinstein, 1985; Firestone, 1987; Greenhalgh and Taylor, 1997; Tripp-Reimer and Doebeling, 2004; Freshwater, 2007; O’Carhain et al, 2007; Tashakkori and Teddlie, 2010). Contextualising any pressure to enter treatment is suggested to be a potential strength and may provide a more focussed target for suggesting revisions to treatment protocols in the contexts studied. The use of mixed methods necessarily draws upon a broader collection of philosophical orientations to research (Parahoo, 1997; Koch and Harrington, 1998; Polit and Hungler, 1999; Polit and Beck, 2009). A distinguishing feature of the study was in the objective analysis of quantitative data complemented by the qualitative component to discover new meanings beyond that of solely statistical nature (Jack and Clarke, 1998; Walker, 2005; Polit and Beck, 2013). 3.2.3Participant Recruitment ProceduresDuring participant recruitment all groups were approached simultaneously and the increase in numbers posed no significant study procedural issues. Once the maximum number for prison participants was reached, inpatient and outpatient drug treatment group recruitment continued until 24 from each group had been interviewed. The recruitment procedure initial approach was by treatment programme staff who had attended a briefing session by the researcher regarding study inclusion/ exclusion criteria. A participant information sheet and consent form was issued to all who expressed an interest (see appendices B and C), and a researcher appointment time offered. Group membership was dependent on the moment in time selected for study inclusion that dictated in which group participants were accommodated. The first meeting with the researcher allowed study discussion and consent to be confirmed. The first research interview at T1 marked participant entry to the study, and follow up six months later (T2) their exit from the study after repeating the same quantitative measures from T1. Data collection commenced in early 2011 and was completed in early 2012.All participants seeking treatment in each of the three groups within a nine week sampling frame were eligible for inclusion and those contactable at follow up were interviewed (T2). All first T1 interviews occurred within treatment environments and all the measures were administered. The convenience sampling strategy selected the first participants who expressed a preference to be involved in the study on treatment entry and consented (Lynch, 1982, Clifford, 1997; Parahoo, 1997). The choice of time and location within treatment settings was limited to interview room and participant availability. In prison settings interviews were conducted during prison unlock times for two hours each morning, and the assistance of drug treatment staff was paramount in organising the movement of participants to interview. Without this level of liaison and organisation only one participant per day would have been interviewed due to the prison security requirements of four days’ notice for any professional visit. Inpatient and outpatient unit interviews were less problematic and often corresponded with appointment times for outpatients and between structured activities for inpatients. The sequence for research interviews occurred following the participant meeting their support worker and the methadone prescription being issued, primarily so as not to place any undue pressure on persons to undertake the interview. Eligibility criteria for study inclusion were males, aged 18 or over with a primary heroin drug preference within their first two weeks of treatment. Only participants attending inpatient, outpatient and prison drug treatment programmes were included. Those participants with mild to moderate mental health problems, typically managed in primary care settings, were eligible for inclusion. Participants with a diagnosed serious mental illness were excluded and those that were patients of specialist secondary care mental health services. Those participants with learning difficulties were excluded by treatment staff, or where serious physical or psychological concerns existed. Serious mental illness rates from general population studies into heroin addiction treatment have been problematic in separating the groups with consistency, even after diagnostic assessments had been undertaken at study commencement (Ross et al, 1988; Rounsaville et al, 1991). Drug misuse and mental health problems are not solely the domain of prisons with some outpatient population studies reporting up to 84% and drug treatment court populations between 20-40% (Lehman et al, 1994; Belenko, 2000; Weaver et al, 2003). Co-morbid drug use and mental illness is increasingly the norm rather than the exception, and a constant issue considered throughout the present study (Wolf et al, 1988; Helzer and Pryzbeck, 1988; Kessler et al, 1994). Co-morbidity in prison environments is widely acknowledged and some evidence suggests 90% of the prison population has a combined drug addiction and mental health problem (Home Office, 2007). The study accepts that the majority of participants will have a degree of co-morbidity (Home Office, 2007). The exclusion of participants with severe and enduring mental health problems was a design decision and leaves the possibility of revisiting this group for future study. The design considered males only as mixed gender studies have assumed males and females respond the same in treatment environments, although there is some evidence that suggests this may not be the case (Nelson-Zlupco et al, 1995; Peters et al, 1997; Langan and Pellisier, 2001). The sole male design acknowledges these gender differences within drug treatment and the way in which males and females respond differently irrespective of modality and context (Anglin et al, 1987; Anglin et al, 1997; Grella et al, 2003; Ashley et al, 2003). The study accommodated a descriptive design that enabled variables to be examined against each other. The groups were pre-formed with the outpatient group also providing some degree of control for inpatients, but the outpatient group was not strictly a control group as assignment was not randomised (Dinardo, 2008; Shadish et al, 2008; DeRue, 2012). The study accepts and argues that a true experimental design was not possible due to the environments participants were drawn from and also for the pragmatic design issues already identified (see section 3.1.2 above) (Cook and Campbell, 1979; Campbell, 1988). Pragmatism is a commonly used philosophical framework within mixed method investigation for social endeavour (Tashakkori and Teddlie, 2010; Creswell and Plano-Clark, 2011). 3.3Qualitative MethodologyPrevious studies investigating coercion have been largely quantitative, with few being mixed method or solely qualitative resulting in the participants view and experiences being underrepresented (refer to section 2.2.1). Previous international research into coercion has focussed on measuring and reporting treatment pressures (See section 2.2.3) and recognised treatment pressures exist but has not explored associations that differ between contexts and individual groups? which a qualitative study can offer (Holliday, 2007; Freshwater, 2007). The qualitative paradigm adopts an interpretivist approach that accepts there are multiple perspectives on reality that are tied to an individual’s situated context (Lincoln and Guba, 2000; Johnson and Onwuegbuzie, 2004), and promotes the use of the most appropriate methods to broaden understanding of each participant’s situated views and perspectives (Lynch, 1997). The research question aimed to explore subjective perceptions of coercive influences that are not yet understood from a real-life context. The fundamental rationale for the qualitative element of the methodology was to gain insight into participants’ subjective perceptions of coercive influences that cannot be captured through the use of standardised quantitative measures alone. The qualitative interview facilitated an exploration of each participant’s subjective perceptions of treatment pressure/ coercion from his own perspective in order to advance understanding beyond a solely statistical representation (Murphy, 1990; Smith et al, 1999).A central tenet of the data collection process was the deliberate positioning of the qualitative interview before the standardised quantitative measures for collecting quantitative data were used. Standardised quantitative data collection instruments may influence the thoughts of participants in terms of trying to anticipate what the interviewer was expecting them to say (Silverman, 2012). Beginning the study with open qualitative questions minimised the potential for structuring effects of quantitative collection instruments upon participant responses (Alasuutari, 1995) by permitting each participant’s subjective views on coercive influences to be gained prior to the quantitative measures being introduced. 3.3.1Qualitative Data: Interview Guide and Procedure The interview duration was constrained by time limits imposed upon the researcher from the treatment settings. A sole researcher must also consider the project being achievable within the given time frame of the study. There was a paramount methodological consideration to attain statistical power and gather sufficient data whilst establishing balance within the interview. The interview guide devised focused upon participant perspectives of pressure to enter treatment (Wexler and Fletcher, 2007). The interview design and line of questioning was considered as the correct operational measure for the concept being studied (Yin, 1994). The questions attempted to gather internal and external influences to establish if pressure was present and the origins of pressure, for example from family members or friends. The interview guide commenced with some general questions on treatment entry and all questions had sub-prompts to encourage responses. The remaining questions then homed in on treatment pressures and influences (see appendix A). For example “Do you feel that anything has influenced you to have treatment and where do you feel this influence comes from?” Further questions then explore sources of pressure and family attitudes before exploring any motivational correlates for treatment pressure, with associated participant feelings. The qualitative interview allowed for some probing of the issues and verbal reactions were considered during the interview (Kumar, 2014). It is the sensitive nature of the situation participants found themselves in, at times of heightened stress levels, which allowed for the sensitive questioning that might better explain complexities above other methods of investigation (O’Leary, 2014). 3.3.2Qualitative Data: Analytic Strategy A thematic analysis from 72 participant narrative interviews was undertaken following transcription of the interview data. The use of a qualitative software package to assist in computer analysis was not undertaken in preference to manual analysis. Interviews were transcribed verbatim with any identifying features removed to protect anonymity. Thematic analysis was considered in the present study as a foundation for the qualitative analytical approach (Holloway and Todres, 2003; Braun and Clarke, 2006). Theme ‘keyness’ was not established merely due to repeated mention, but that the theme captured something important to the research question (Clarke and Kitzinger, 2004). However, when themes are repeated this can contribute to theme strength being carried forward into theory construction (Miles and Huberman, 1984; Burr, 1995; Sandelowski, 2000; Coolican, 2014). The approach incorporated the individual participant’s perspective on how their lives have changed or how they might change (Smith et al, 2009; Hefferon and Gil-Rodriguez, 2011; Polit and Beck, 2013). All transcripts were read through by one researcher and checked against the digital interview audio recordings for accuracy. All utterances and colloquialisms were captured and detailed by the researcher. The data was subjected to reading and re-reading each transcript to ensure familiarisation was achieved, whilst being mindful of not jumping to conclusions (Riessman, 1993; Bird, 2005). The approach was not a linear process but one that required recursive movement that was not rushed (Ely et al, 1997; Yardley, 2000; Patton, 2002; Braun and Wilkinson, 2003). During the familiarisation stage any similarities or disparities were highlighted and brought forward as themes coded for further analysis (Boyatzis, 1998; Hefferon and Gil-Rodriguez, 2011). The analytical approach continued as these themes were redefined to ensure all data were included (Miles and Huberman, 1994). A theme captures something that is important that may have relevance to the research question, and on some level a partnered response raised as a code (Braun and Clarke, 2006). Coding was undertaken with sentences or parts of sentences counting as units for analysis that followed a five stage analytical framework (Huberman and Miles, 2002). Coding was carried out by one researcher to increase the trustworthiness of the data findings (Pope et al, 2000; Stemler, 2001; Charmaz, 2008; Denzin and Lincoln, 2011). The process aimed to reduce overt influence upon the data to portray an accurate interpretation of participant meaning from their lived perspectives (Mishler, 1986; Riessman, 1993; Bernard and Russell, 1994; Morgan, 1998). The list of themes was then developed to examine any emergent causality from the themes (Strauss and Corbin, 1998; Braun and Clarke, 2008).The first stage was to read through the transcribed data on more than one occasion to get a sense of the meaning behind the words and phrases (Walker, 1985; Seale, 1999; Crabtree and Miller, 1999; Yardley, 2000; Sandelowski and Barroso 2002; Wittink et al, 2006; Thomas, 2006; Koro-Ljunberg, 2008).Stage one involved handling the transcribed narrative and commenced with a full initial read assisting familiarisation (Boyatis, 1998; Tuckett, 2005). Coding at a more formal process level is identified in stage three below, but accepts that coding on some level occurred throughout the stages. The second stage explored connections relating to topics, which included domains related to time frames and events. Indexing of the data progressed to the formation of themes which involved elaboration with short text headings on the hard copy. Charting then occurred with the themes being placed out of the transcripts that allowed for them to be distilled further (Ritchie and Lewis, 2005). Essentially, stage three was at the very centre of the iterative process, promoting rigorous analysis that involved re-reading the data to establish coherent themes that were then grouped (Grady, 1998; Taylor-Powell and Renner, 2003; Creswell, 2012). The aim of this process was to assemble data in a meaningful and comprehensive fashion directly identifiable from the data (Charmaz, 1983; Jorgensen, 1989; Polit and Beck, 2013). Stage four sought to identify patterns and connections between the coded categories. The importance of these patterns and connections required careful and considered examination between the researcher and supervisors before the data was assembled around a theme (Morgan, 1998). This stage allowed for themes to be collapsed and brought together or a separate theme established. The aim of theme formation was that they cohere meaningfully with clear and identifiable distinctions made between them (Patton, 1990). Thematic formation also involved checking for any sub-themes within the main themes.Finally, stage five involved mapping and interpreting the data, forming defined associations between the themes to provide meaning and explanations (Barbour and Barbour, 2003; Whittink et al, 2006). This final stage involved attaching meaning and significance to the data, as a direct result of the analysis and tapping into their real meaning (Taylor-Powell and Renner, 2003; Kline, 2004). During the reduction phase detailed attention was given to attaching meaning which was not restricted to frequencies (Angen, 2000; Stemler, 2001; Graneheim and Lundman, 2004). This process was assisted by revisiting the codes and organising them into a coherent and internally consistent account (Braun and Clarke, 2006). Saturation indicated that everything had been obtained from the data relating to the concepts and the analysis was concluded (Lincoln and Guba, 1985; Sandelowski, 1993; Holloway and Wheeler, 2010). Promoting process rigour, reducing bias, and enhancing trustworthiness within the analysis was achieved by two study supervisors independently analysing coded transcripts. Subsequently, a meeting between all the parties enabled a consensus and agreement reached to support the conclusions drawn from the data (Guba, 1981; Miles and Huberman, 1994; Lincoln, 1995). 3.4Quantitative: Method 3.4.1Quantitative Data: Design and Measures The between-participants design enabled cross-group comparison measures for the environmentally restricted prison group, followed by the inpatient and outpatient group. This allowed for a range of quantitative measures (introduced later in this chapter) to investigate components of drug misuse treatment, that have emanated directly from the literature reviewed in chapter two (Beck, 1993; Creswell and Plano Clark, 2011; Kumar, 2014). The dependent variables were derived from the measures administered.The measures collected demographic details of all participants in addition to drug misuse and treatment histories. Before discussing the quantitative measures in more detail below, collectively they gathered data on addiction severity, mood state, motivation for treatment, self-efficacy, confidence for treatment, and attributions. All the quantitative data measures have proven validity for substance misuse empirical investigation. This is not true of the confidence scale, although it has been used before. The range of measures included considered international findings that have brought the measures together for the first time. Each of the measures are now summarised and inclusion justified.The Addiction Severity Index (ASI) is a widely used assessment instrument that indicates the range of problems associated with substance abuse, both at admission to treatment and at follow-up contacts (McLellan et al, 2006). The ASI version five (drugs) was used to collect demographic data and to assess the severity of pre-treatment entry drug use (McLellen et al, 1992). The ASI compiles scores in the domains of medical, legal, employment, alcohol, drug, family and social status (Meulenbeek, 2000). The ASI has the added benefit of investigating recent and lifetime substance misuse problems (see appendix E). The ASI has been consistently validated and shows reliability both in drug and alcohol populations (Alterman, 1994). Change motivation and the relationship to addiction severity further informed the inclusion of the measure (Ryan et al, 1999; Carpenter et al, 2002). All demographic data, which allowed for the individuals to be contextualised within the study before the variables were examined in greater detail, was gathered from the ASI. Evidence of employment status was examined over the groups in the light of the association between drug use, offending, and unemployment highlighted in previous research (Hermalin et al, 1990; Baron, and Hartnagel, 1997). Personal relationships were examined in terms of stability as evidence suggests that relationship stability is related to higher treatment completion and lower drug relapse rates (Fals-Stewart et al, 1999; Gossop et al, 2003; Chandler et al, 2009; NTA, 2009). In addition, heroin route of administration, prescribed methadone, and mental health service use were considered to provide data on any relationship they may have to treatment outcome (Murphy et al, 1989). The Stages of Change Readiness and Treatment Eagerness (SOCRATES) 8D was designed to measure the stage of change a person was experiencing and treatment eagerness, both of which have been proven as important characteristics for treatment success (Miller and Tonigan, 1996; Maisto, 1999). Mixed drug use groups have provided consistent validity and reliability for SOCRATES and supported applications to wider drug group populations (Turner 1999; Carey et al. 2002; Sinha et al. 2003). Due to the considerable variances across treatment contexts and participants SOCRATES was incorporated to capture treatment readiness for change (Maisto et al, 1999; Carey et al, 2002). Psychological challenges exist in the development and construction of drug change cycles and advances in measurement have been made to evaluate motivation to change (Prochaska and DiClemente, 1992). SOCRATES can be used as a good predictor of outcomes and incorporates both movement and motive by providing a better predictive outcome score than just solely abstinence would (Isenhart, 1997; Zullino et al, 2007). The 19-item scale scores form the domains of Recognition, Taking Steps, and Ambivalence (see appendix K). A high score in the recognition profile is a direct acknowledgement from the participant that they are experiencing significant problems in their drug taking, and have a desire to change that behaviour, for fear of resultant harms occurring if change does not occur. The SOCRATES is reliable for use in criminal justice settings and Chronbach's alpha internal consistency coefficients rated as good sensitivity with test-retest reliabilities also rating highly (Peters and Greenbaum, 1996; Miller and Tonigan, 1996).The Attribution for Treatment Outcome Scale (ATOS 1) was the measure used in this study (see appendix F). Attribution scales acknowledge that there are two possible ways in which people interpret their behaviour, either by internal or external attribution (Heider, 1958). An attribution approach attempts to construct a causal explanation for the substance abuser’s own behaviour that may in turn influence future behaviours, both of themselves and of others. Moreover, attribution may serve to promote the individual’s feelings of self-worth and control over the environment and therefore serves as a protective factor by reducing anxieties and further feelings of guilt (Storms and McCaul, 1976). External attribution (or situational attribution) occurs when social or environmental pressure is believed to be the cause of the behaviour. Therefore, in this study using illicit drugs or not, and how the participant constructs internal or external attributions, was examined (Rotter, 1975). Attribution ranges between ability (internal stable cause), effort (internal stable cause), task difficulty level (external stable cause), and just pure luck (external unstable cause) (Kelly, 1967; Weiner, 1980).Participant attribution was explored to investigate whether a lack of attribution or a strong external attribution of blame was a predictor or indicator of future relapse into substance misuse/offending (Gudjonsson and Singh, 1989). Amongst attribution literature there is an increasing body of evidence that proposes punishment programmes should recognise the attribution of addiction linked to crime in reducing recidivism (Belenko et al, 2004; Warner and Cramer, 2009). However, attribution factors that increase the likelihood of drug treatment success and associations with coercion are of interest. The Drug Treatment Confidence Questionnaire (DTCQ 8) for self-efficacy examined a person’s capacity to organise and execute courses of action that are required to manage future situations (Bandura, 1995; Sklar and Turner, 1999). Self-efficacy can be applied to drug taking in the context of drug use situations and is a key determinant for identifying potential drug relapse situations (Witkiewitz and Marlatt, 2004; Brown and Ramo, 2006). Moreover, from a psychological perspective the higher the confidence rating in the person’s ability to refrain from drug use when faced with a drug using situation, the higher the probability for successfully resisting drug use and urges to use (Hays and Ellickson, 2006; Ramo, 2010). Subsequently, improvements in refining the focus of self-efficacy whilst the client is in treatment can have a significant effect in predicting and reducing drug use, that also improves client coping skills over longer time periods (Litt et al, 2005). Self-efficacy operates on a cognitive level as a partial mediator for behaviour change and could be an essential component for predicting drug relapse (Solomon and Annis, 1990; Bandura, 1999; Litt et al, 2005). Evidence exists that being out of control for periods can improve overall self-efficacy and enhances opportunities for future control strategies being adopted (Carey and Carey, 1993; Decorte, 2001). However, mediators for self-efficacy in controlling substance misuse may vary somewhat from the mediators for self-efficacy in abstinence or even drug refusal (Dean et al, 2011; Tsai, 2011; Lintonen et al, 2011). Fundamentally, self-efficacy is an important determinant in treatment progression as a relationship exists between time to relapse and self-efficacy scores (Carbonari and Di Clemente, 2000). Therefore, the role of self-efficacy in predicting relapses, and the processes involved is valuable for clinical practice areas (Harkaway, 2001; Carpenter et al, 2002) (see appendix G). The Depression Anxiety Stress Scales (DASS 21) is a shortened, validated form of the longer version (DASS 42) (Lovibond and Lovibond, 1995). The measure is a 21 item scale that measures for depression, anxiety and stress experienced. The DASS 21 has good reliability within the sub scales and supports the psychometric properties of the scale (Antony et al, 1998; Crawford and Henry, 2003; Henry and Crawford, 2005). Additionally, DASS 21 has gained approval in the literature over the full version (DASS 42) in relation to validity (see appendix H). The Confidence for Treatment measure is a visual analogue scale that aims to gauge participant perceived pressure by placing a mark on a 10cm scale, with one being no pressure and ten being considerable pressure (see appendix I). The measure in the appendix includes the scoring scale; however numbering was not present on the participant sheet in order not to unduly influence self-rating (Van Der Bijl and Shortridge-Baggett, 2001). Participants placing scores on the scale enabled measurement in millimetres and were asked the standard question ‘On the scale, how confident are you that you will be drug free following your drug treatment, if one is low and ten is high for confidence?’ Challenges to the robustness of visual analogues suggest that those participants measured should be handled with caution in quantitative studies as the sole measure, in case of positive bias (Connors and Franklin, 2000). Nonetheless, capturing this perspective is valuable, irrespective of validity questions raised, as it is the perception of the participant at the time of measuring that is under investigation (Murphy et al, 2003). 3.4.2Quantitative Data: ProcedureQuantitative measures were administered over one interview at T1 and followed the qualitative interview that was intentional to build a relationship. First contact from the researcher was undertaken with written information and accompanying verbal face-to-face explanations due to the potential for not being fully informed to consent, for example due to literacy issues. Quantitative measures commenced with the Addiction Severity Index (ASI) which provided good demographic data before progressing into lifestyle and more personal drug use factors (McLellen et al, 1992). This was purposeful and considered both the length of the interview as well as the potential for exhausting participants’ good will by an overly arduous test battery. The interview length and timing was further constrained by family visits, for example for prison and inpatient participants through set visiting hours; the outpatient group did not have these constraints. Collectively the measures used could all be completed within an hour, and included the opportunity for questioning. The order of the quantitative measures administrated followed the order below (see figure 4).3.4.3Quantitative Data: Analytic Strategy The quantitative data was both stored and analysed solely on Statistical Package for the Social Science (SPSS) (Field, 2013; Pallant, 2013). Statistical tests for means and standard deviations were used on the dependent variables generated by the measures (Kleinman and Horton, 2012). Descriptive statistics were used to capture and summarise participants’ characteristics across the treatment groups. Statistical power calculations were conducted using the GPower database (Erdfelder and Faul, 1992). For four independent participant groups with power at 0.80 it was originally calculated that each group required a minimum of 21 participants for a conventional alpha level of P < .05 for large effect sizes (i.e. f = 0.40). However, when it became apparent that this study would have only three independent groups (Cohen, 1992), a revised A Priori calculation indicated that a minimum of 24 participants would be required within each group. The decision to raise group participant numbers when the four groups became three was taken due to no DRR being recruited whilst the other group interview numbers approached double figures. It is important to emphasise that 24 participants per group was the minimum sample size aimed for, and that it was intended to recruit as large a sample as possible to allow for attrition between T1 and T2, subject to the rate of T1 participant recruitment within the time frame for which ethical approval had been granted.The analysis used parametric ANOVA and Pearson’s correlations, with post hoc pairwise comparisons undertaken (Tabachnick and Fidell, 2012). Some quantitative data was further analysed using non parametric statistical analysis, for example, Mann Whitney U test (Corder and Foreman, 2009). Descriptive analysis was completed using frequency tables with measures of mean, median and mode. Standard deviation was utilised as a measure of spread. Deviations from normal distributions were examined through measures of skewness and kurtosis. If distributions did not differ significantly from normal, parametric tests were used if at least an interval level of measurement was yielded by the measure in question. Clinically validated scales were also used with some rating scale data and parametric analyses were generally employed for example, t tests. Where these conditions were not met, nonparametric tests were used (Tabachnick and Fidell, 2012). Homogeneity of variances was checked in the population groups and sample variances were not significantly different. To test the normality of distributions of dependent variables, skewness and kurtosis were tested (F max) (Tabachnick and Fidell, 2012). 3.5Operationalising the Study (T2)3.5.1Re-establishing Contact with ParticipantsInterviews at six months (T2) to administer follow up measures presented challenges due to participants constantly changing addresses. This regional mobility was an important factor for participant attrition due to them not being contactable at T2. The tracking process to secure T2 interviews involved combinations of written invitation letters, phone calls, and visits to pre-arranged locations agreed at first interview. 3.5.2Measures AdministeredQuantitative data was collected on psychometric scales to compare the independent variables between T1 and T2 (Kelly, 2010). The quantitative measures were all repeated in the same order as first administered at T1 throughout the six month follow up period. All measures were delivered by the same researcher face-to-face. The qualitative interview scripts from T1 were member checked for accuracy with participants at T2 but was not repeated (see figure 5).Figure 5: Measures administered on the participant groups 1524000153670Group APrison00Group APrison3009900153670Group BInpatients00Group BInpatients4572000153670Group COutpatients00Group COutpatients342900028575004961255285750018529302857500138303022860Qualitative Interview followed by Demographic VariablesSelf-Efficacy Scale [DTCQ8]Addiction Severity Index [ASI]Depression Anxiety Stress Scale [DASS 21]Confidence Scale for Treatment [1-10 analogue scale]Attributions for Treatment Outcomes Scale 1 [ATOS1]Stages of Change Readiness and Treatment Eagerness Scale 8D--------------------------Semi-structured Qualitative Interview00Qualitative Interview followed by Demographic VariablesSelf-Efficacy Scale [DTCQ8]Addiction Severity Index [ASI]Depression Anxiety Stress Scale [DASS 21]Confidence Scale for Treatment [1-10 analogue scale]Attributions for Treatment Outcomes Scale 1 [ATOS1]Stages of Change Readiness and Treatment Eagerness Scale 8D--------------------------Semi-structured Qualitative Interview9525022860Stage 1Measures T1Qualitative Quantitative---------Qualitative00Stage 1Measures T1Qualitative Quantitative---------Qualitative490664512573000342074512573000182054512573000104775176530Stage 2Measures(6 months follow-up T2)Quantitative00Stage 2Measures(6 months follow-up T2)Quantitative1371600168909Outcome measures from Stage 1 treatmentSubstance misuse behaviour in the previous 6 monthsConfidence Scale for TreatmentSelf-Efficacy Scale [DTCQ8]Addiction Severity Index [ASI]Depression Anxiety Stress Scale [DASS 21]Attributions for Treatment Outcomes Scale 1 [ATOS1]Stages of Change Readiness and Treatment Eagerness Scale 8D00Outcome measures from Stage 1 treatmentSubstance misuse behaviour in the previous 6 monthsConfidence Scale for TreatmentSelf-Efficacy Scale [DTCQ8]Addiction Severity Index [ASI]Depression Anxiety Stress Scale [DASS 21]Attributions for Treatment Outcomes Scale 1 [ATOS1]Stages of Change Readiness and Treatment Eagerness Scale 8D3.6Ethical Considerations Research ethical approval was obtained from the University and the local Research and Development (R&D) department of the NHS Trust (appendix J). National research ethics approval was secured from the National Research Ethics Service (NRES) specialist committee at Cardiff, due to potentially vulnerable participants and prison participants being involved (see appendix D). Every person who entered the three treatment groups within the commencement time frames was presented with the Research Participant Information Sheet version 4 (RPIS 4), and a research consent form (see appendices B and C). The change for participant numbers within groups is addressed later and received NRES approval (for three groups and not four) with no increase in total study numbers (n=72). All participants who entered into the study did so voluntarily and this was scrutinised by the treatment environment staff and also on contact with the researcher. Confidentiality issues were covered in all treatment contexts to ensure that the interviewer did not become a vicarious third party in any criminal activity. It was ethically and legally necessary to emphasise that immediate illicit drug use prior to interview (irrespective of setting) may preclude the interview taking place. This exclusion condition ensured that the researcher was not compromised legally by being implicated in the administration of drugs and that data gathered was not significantly influenced from the immediate effects of heroin. Heroin use immediately prior to interview was explored to ensure this had not occurred and to obtain a valid consent to study participation. The timing for arranged interviews also considered heroin use that tends to be used in the morning with afternoon and evening appointments preferred for outpatient and inpatient participants. Heroin use in prison is used during cell confinement and therefore mornings were preferable appointment times. However, other influences operate on individual participants that have been considered above (see section 3.5.2). Participant study inclusion was confirmed verbally whilst jointly reviewing Research Participant Information Sheet 4 (RPISv4) and only then was written consent taken (see appendix B and C). Ethical consideration was given to the order in which the research interview was held so that no undue duress was placed upon the participant to comply with the research whilst attending pre-arranged heroin treatment appointments (Lidz et al, 1995; Hoyer, 1999). Participant informed consent to participate in the study was paramount to ensure a reasonable level of understanding. Literacy and levels of understanding amongst prisoners are not representative of the general population, but are that of a collective sub group (Social Exclusion Unit, 2002). There was a concern for literacy levels amongst prisoners which are frequently cited to be lower than those of the general population (May, 2005). In designing the participant information sheet, serious consideration was taken of the relatively low reading age of the prison population (below age 13), compared to the general population, by using the readability statistics available through Microsoft Word 2007. The information sheet had a Flesch-Kincaid reading grade of 9.8 years indicating that it was suitable for an average reading age below 13 years (Kincaid et al, 1988). Prisoners generally tend to be from the younger age groups, and also from certain socio-economic groups (Wheldall and Watkins, 2004; Clark and Dugdale, 2008). The ethical necessity was to ensure participants had a reasonable understanding of the study they were entering, and fundamentally for this ethical reason this study did not offer incentives (Greene and Hall, 2010; Biddle and Schafft, 2014). Incentives can take many forms for participants and also have many different motivations that should be taken into account and measured. For example, prison participants missing a timetabled group, for any other reason than an arranged healthcare visit, could incur a loss of prison earnings and therefore research interviews competed with a loss of finances. Privileges for prison participants would take priority over research projects; they could include loss of earnings from prison work, or visits from family members irrespective of the setting. This was a crucial ethical consideration for the researcher to address throughout the data gathering stage. For future studies the opportunity to discuss drugs issues with a researcher (outside of the prison staff group), with a drink and chocolate was more appealing and could also be viewed as incentivising even if within ethical boundaries. The issue of not incentivising also addressed concerns as items if not consumed could be traded, perhaps in some cases for illicit substances. A future design consideration for researchers would be to ensure that participants are not penalised by a loss of earnings for attending a research interview and could perhaps retain the restructured financial reward to avoid a paradoxical potential ethical flaw (Festinger et al, 2005). The briefing of participants prior to data collection and debrief after the interviews was to address issues of confidentiality, trust, and power imbalances that might otherwise have influenced the data gathered to some degree had this had not been undertaken. An additional measure to enhance ethical scrutiny was by presenting opportunities throughout the interview for participants to ask any questions relating to the interview or any of the questions administered. This process had the benefit of placing the participant at the centre of the study, pacing the interview, and also limiting opportunities for power imbalance. Equally, it could be argued that this process may also limit opportunities for participants to say what they think the researcher wants to hear. Data from the transcripts and all written data gathered on the psychological measures will be kept for five years in line with Trust and NRES approval guidance, and then shredded and all electronic data deleted. Until that date all materials will be kept secure in a double locked cabinet, to which only the researcher has access. The process of recruiting and fully considering participants’ understanding of the study they are entering into was ethically paramount. Ethical consideration for inpatient and outpatient participants on mobile phones was necessary to establish identity at T2, as mobiles are often sold on to raise funds by participants. The risk of not being able to identify the service user on the phone also posed a risk for mistaken identity on contact and had to be addressed at first interview. Equally, leaving a voice mail or texting a participant in an attempt to secure follow up was of limited value and this is supported in drug misuse studies (Barendregt et al, 2006; Hakansson, 2011). Some data was also gathered via phone contact to establish drug relapse or not for some participants at T2.Chapter Four: Results for Pre Treatment Measures4.1IntroductionThe second research question previously stated in section 3.1 was examined and some quantitative results reported. How did treatment groups differ at T1 with regard to demography, drug misuse history, treatment history, and relevant psychological variables that influenced participant status at T2?Between group differences in terms of some demographic, substance misuse history and treatment experience provide a potential source of variability regarding how participants may interact with their treatment contexts, with potential implications for treatment outcomes. Consequently, it was important to examine these areas and relate the findings to the existing literature previously discussed (Hermalin et al, 1990; Baron, and Hartnagel, 1997). Conceptually, the treatment journey is considered in three contexts representing different formal and informal coercive structures. Relationship stability has been reported to promote treatment seeking behaviour, treatment programme completion, and lowering drug relapse rates (McLellan et al, 1992a; Murphy and Bentall, 1997; Simpson and Broome, 1998; Gossop et al, 2003; Tracey et al, 2005). Associations between heroin use and crime were investigated to raise group specific insights, as involvement in criminal behaviour has been linked to heavier drug use and relapse (Chandler et al, 2009; NTA, 2009). Lifetime heroin use with regard to duration and amounts used provided a measure of heroin use severity across the groups, whilst route of heroin administration, prescribed methadone, and mental health service use were considered with regard to inter-group differences in the light of previous findings (Murphy et al, 1989). Stability in drug use and factors that operate throughout lifetime use are important to investigate. Variables identified from the literature are important to consider with regards to the treatment journey in these different contexts, and establish who the participants are when exploring dimensions of coercion (Belenko, 1998; Miller and Flaherty, 2000; Pinfold et al, 2001; NTA, 2009). 4.2Method4.2.1Design and Participants This study draws upon data collected at T1 (see subsection 3.4.1). The study utilised a between-participant design with one independent variable comprising the three treatment contexts. An account of participant recruitment from three treatment settings, prison, outpatient and inpatients has previously been given (see subsection 3.2.3). The dependent variables reported concern employment, substance misuse, legal history, relationships and mental health services use. All interviews occurred at baseline entry to the study (T1) and were conducted by one interviewer. The quantitative data collection is detailed in chapter three (see subsection 3.4.2).All demographic data was obtained from the Addiction Severity Index (ASI 5) (McLellan et al, 2006). The ASI measured problem severity over the participant’s lifetime and before interview. The variables extracted from the ASI included socio-demographic indicators; relationship status, drug use history, legal history, mental health services use and previous treatment (see subsection 3.4.1). 4.3Results4.3.1SampleA total of 72 participants were included in the study from the three groups with n=24 in each group. The mean age for the whole sample was 39.4 years (SD = 6.1 years). The corresponding statistics for the respective groups was M = 38.0 years (SD = 6.0 years) for the prison group, M = 40.1 years (SD = 5.3 years) for the inpatient group, and M = 40.1 years (SD = 6.8 years) for the outpatient group. There was no significant effect for age across the three participant groups (F < 1). Consequently, participants in the three groups did not differ significantly in age.4.3.2Heroin Lifetime UseHeroin lifetime use for all participant groups at T1 was M = 14.99 years (SD = 8.27 years). The corresponding rates for individual group lifetime heroin use was M = 15.83 years for the prison group, M = 16.13 for inpatient and M = 13.00 for the outpatient group. The main effect for this variable across the three groups was not significant (F (2, 69) = 1.046, ns.). Consequently, participants in the three groups did not differ significantly in lifetime heroin use.4.3.3Participant Relationship StabilityRelationship stability was defined as being either married or in a long-term cohabiting relationship. The numbers in brackets are the expected frequencies (E values) under the null hypothesis of no association between relationship stability and participant group (see table 3). The significant chi square value for the results in table 3, χ2(2) = 8.357, p = .015, indicated a higher prevalence of relationship stability in the prison group than would be expected by chance. Furthermore, the converse is shown for the outpatient and inpatient groups, where stable relationships are less prevalent than would be expected by chance (see table 3). This association cannot be attributed to age differences between the groups, as these were reported earlier as having been non-significant. It should be noted, however, that these results provide no real information regarding the emotional quality of participants’ personal relationships.Table 3: Summary of relationship stability across participant group Current stable relationshipNo current stable relationshipPrison n=2410 (5.3)14 (18.7)Inpatient n=242 (5.3)22 (18.7)Outpatient n=244 (5.3)20 (18.7)Total n=721656Participant relationship status data reported are self-descriptors that relate to participant marital status and no analysis could be undertaken with these values to offer any more meaning due to the low E values (<5.0). The number of participants cohabitating or married was low, relative to the remainder of the sample (n=18) 25%. Relationship status by group is summarised in table 4. Table 4: Summary of relationship status within the groups at T1Married/ in relationshipDivorcedNever marriedPrison n=241077Inpatient n=2421012Outpatient n=24699Total1826284.3.4Employment The majority of study participants received unemployment or other state benefits. Employment trade was defined by participant self-report from work related experience. The prison and inpatient groups’ employment status prior to treatment unit or prison entry was collected and presented in table 5. There was no significant association between employment and treatment group.Table 5: Summary of group employment ratesEmployedNot in employmentPrison n=24123Inpatient n=24321Outpatient n=24321Total765Participants who considered themselves employed were all in the building trade or held manual labouring positions. The table defines profession by self-report in the 12 month period preceding interview at T1. The building trade provided a majority of employment positions (n=36) 50% from the total across the groups. The data in table 6 are descriptive only due to the low E values preventing further chi squared analysis. Table 6: Summary of participant self-reported past employment PrisonInpatientOutpatientNever worked548Building trade151110Shop work111Armed forces100Ancillary staff285Total2424244.3.5EducationEducation history was recorded as the age participants failed to attend or dropped out from regular school education. The variable reported was the age at terminating secondary education by participant self-report. For prisoner participants the mean age of terminating school education was 14.67 years (SD = 1.43), for inpatients 15.46 years (SD = 1.14), and for the outpatients 15.13 years (SD = 1.19). There was no significant main effect on this variable between participant groups at T1, although the nonparametric ANOVA (Kruskal-Wallis) did approach significance ( χ2(2) = 5.545, p= .063), with the age for the prison group having been younger than the inpatient group when education had been completed. However, this difference was not significant when compared to the Bonferroni adjusted alpha level for post hoc comparisons (n1 = 24 = n2, U = 183.50, P = .022, two-tailed). Consequently, there was no evidence to support the existence of a significant difference between the three groups regarding the termination of schooling.4.3.6Self-reported crimeCriminal Records Board (CRB) checks to corroborate offences from participants was not ethically sought. Criminal offences and conviction data was gathered via the ASI by self-report. Data was derived from the large values for theft, burglary and drug related offending (see table 7).Table 7: Summary of the total number of self-reported offences across the groupsShop theftDrug offencesForgeryWeaponsBurglaryRobberyAssaultsArsonDisorderly conductOthersPrison M SD18.6740.572.212.702.179.351.583.196.928.71.831.311.672.06.042.201.832.78 2.8311.14Inpatient M SD12.2117.86 .751.29 .251.22.29.468.761.49.13.341.001.29.041.20 .711.12 .58 1.02Outpatient M SD18.6331.441.632.78.462.04.671.243.508.41.25.53.751.19.00.001.542.21 .00 .00Total M SD16.5031.081.532.40.965.56.852.043.767.38.40.881.141.59.028.171.362.17 1.14 6.48Nonparametric ANOVA showed no significant main effect for the number of shop theft offences ( χ2(2) = 1.711, ns.), indicating that no difference existed between the participant groups for such offences. However, the main effect for drug offences was significant with χ2(2) = 6.947, p = .031. Post hoc analyses showed that the prison group reported more drug offences than the inpatient group (n1 = 24 = n2, U = 170.50, P = .010, two-tailed), with the other inter-group comparisons not showing significant inter-group differences. There was a significant main effect for self-reported cases of burglary with χ2(2) = 14.866, p = .001. The prison group reported significantly more offences than the inpatient group (n1 = 24 = n2, U = 109.00, P < .000, two-tailed), and also more offences than the outpatient group (n1 = 24 = n2, U = 168.50, P = .012, two-tailed). The comparison between the inpatient and outpatient groups did not show a significant inter-group difference for this type of crime. 4.4Time Served in Prison The amount of time spent in prison produced a significant effect with the longest prison time being reported by the prison group participants (see Table 8), with a nonparametric ANOVA yielding χ2(2) = 12.757, p = .002. Post hoc analyses showed that the prison group reported more time in prison than the inpatient group (n1 = 24 = n2, U = 130.00, P = .001, two-tailed), and the outpatient group (n1 = 24 = n2, U = 148.50, P = .004, two-tailed). The inpatient and outpatient groups did not did not show a significant inter-group difference in time served in prison.Table 8: Summary of self-reported mean time in prison served in monthsGroupMeanPrison129.21 (SD=102.18)Inpatient45.79 (SD= 40.69)Outpatient55.79 (SD= 59.66)4.4.1Heroin Route of AdministrationThe preferred route of taking heroin was by smoking it by prison participants as shown in table 9. This was possibly due to restricted access to Intra-Venous (IV) drug use paraphernalia.Table 9: Summary of self-reported preferred route of taking heroinGroupSmoking heroinIV heroin usePrison n=24231Inpatient n=24168Outpatient n=24231The participant preferred method of taking heroin was by smoking the drug (n=62) and over the groups IV use was less prevalent (n=10). Although it is interesting that eight drug users from the inpatient population used IV heroin, no firm conclusions can be drawn. E values were too low and therefore unable to progress analytically. Financial mean cost of heroin per day whilst in prison was ?30.35, for inpatients prior to admission ?40.52, and outpatient use ?38.63 by participant self-report (costs reported in 2012).4.4.2MethadoneMethadone was prescribed individually and dependent on the severity of heroin addiction. Methadone dosages varied considerably with some participants on reducing regimes that can occur over months and some on maintenance regimes who have a fixed dose to stabilise/stop illicit drug use. The dosage mean score per group is in mls for description only (see table 10). Table 10: Summary of current methadone use and lifetime use at T1GroupMethadone at T1Methadone lifetime yearsPrison Mean N S/D30.262312.737.54247.92Inpatient Mean N S/D26.622122.7610.25248.17Outpatient Mean N S/D44.482118.056.63247.10TotalMeanNS/D33.686519.458.14727.79 The main effect across groups for prescribed methadone dosages at T1 was significant, F (2, 62) = 5.707, P = .005. Pairwise post hoc comparisons showed that the outpatient group were receiving significantly higher dosages than both the prison and inpatient group (P = .012 and P = .002, two-tailed), respectively. The prison and inpatient groups did not significantly differ from each other in terms of methadone dosage. The main effect across groups for lifetime use of methadone in years was not significant ( χ2(2) = 3.192, ns.), indicating that there was no significant difference across participant groups in the lifetime use of this drug.4.4.3Other Drugs UsedCannabis use by self-reports found a significant difference for the prison and inpatient groups against the outpatient group with an adjusted alpha level .017. Kruskal-Wallis provided a significant difference ( χ2(2) = 9.131, p = .010). Post hoc comparisons showed that the prison group reported longer use of cannabis than both the inpatient group (n1 = 22, n2 = 24, U = 152.50, P = .012, two-tailed) and the outpatient group (n1 = 22, n2 = 24, U = 145.50, P = .008, two-tailed). The inpatient and outpatient groups did not significantly differ in their reported duration of cannabis use.4.4.4Mental Health Service ContactsParticipant use of mental health services did not feature highly across all the groups (n=72). The prison group (n=2), inpatient group (n=5), and outpatient group (n=4). Although, on further questioning of participants who experienced mental health problems as a consequence of their addiction, the figures increased in the groups, prison (n=12), inpatient (n=8) and outpatients (n=7). Therefore 27 participants over the three groups (n=72) acknowledged experiencing mental health problems throughout their drug use careers, 43 did not report any concerns.4.5Interim Discussion Chapter findings present some early differences between the groups from early education, drug use, relationships, and mental health service use. Treatment journey characteristics are established to provide a sense of who the participants are and places them within their respective contexts. The mean age for all participants found little difference between the groups who represented longer term heroin users. In terms of lifetime use of heroin the three groups did not differ in age nor lifetime use of heroin and resemble participant characteristics from national studies (Gossop et al, 1998; NTA, 2009). Education history was recorded when participants failed to attend regular school education and the age at terminating secondary education was by participant self-report. Whilst there was no significant main effect on this variable between participant groups at T1 and no difference to report, consequently the treatment journey of the three groups would not have been influenced by this variable. Identifying individuals who experiment with drugs is challenging unless parents, other statutory agencies, or the young person themselves acknowledge it (Heale and Lang, 2001; McKegany et al, 2004). Relationship stability is interesting and indicated a higher prevalence in the prison group than would be expected and the converse was shown for the outpatient and inpatient groups, where stable relationships are less prevalent than would be expected by chance (Rush and Wild, 2003; Gregoire and Burke, 2004). Relationship stability could potentially provide increased support opportunities from family members, in partnership with drug services above others who do not have this informal support system present (Polcin and Weisner, 1999; Best et al, 2006). There was no association with age as there was little age difference reported between the groups. Prison participants had spent a longer time incarcerated than the other two groups. With regards to the treatment journey they have extensive experience of this context and its requirements. The literature review did not establish evidence on length of time in prison and treatment effectiveness. However, the longer a person remains in treatment, the more attempts they have at treatment, and the longer their addiction course, which combined improve successful outcomes (Young and Belenko , 2002; Gregoire and Burke, 2004; Monahan, 2005; Best et al, 2006; Perron and Bright, 2008). Prescribed methadone use was highest in the outpatient group who received significantly higher dosages than both the prison and inpatient group, whilst the comparison of methadone use between the inpatient and the prison group did not differ. With regard to methadone use and lifetime years on methadone there was a non-significant difference. This might provide improved treatment outcome opportunities associated with being older, regular contact with a family or services, and future plans for participating in an abstinence treatment (Miller, 1989; Backmund et al, 2001; Klag et al, 2005). In terms of other drugs used in addition to heroin, the prison group reported significantly longer term use of cannabis than both the inpatient and the outpatient group, whilst the inpatient and outpatient groups did not significantly differ in their reported duration of cannabis use. Participant use of mental health services did not feature highly across the groups and provided some evidence that entry into mental health services was limited with mild to moderate concerns raised as a consequence of heroin use (Banducci et al, 2013). In conclusion the prison group presents as more steeped in criminal activity, and has more exposure to the pressures associated with incarceration and treatment. Participants in the prison group are more likely to be in a stable relationship above levels reported from the other two groups and not attributed to age. The findings from this chapter provide some group demographics and some early differentiation between the groups. The next chapter reports on pressures to enter, and remain, in drug treatment that are coercive to further address study research questions. Chapter Five: Qualitative Data Findings5.1IntroductionTo meet the research aim regarding the construal of coercion a semi- structured interview was employed. The qualitative analytic strategy adhered to the process previously detailed in chapter 3 (see subsection 3.3.2).Two overarching themes emerged from the data which had an overall level of consensus reported by the participants; the influence of self and family coercion with subordinate sub-themes emerged from the data (see figure 6). There are two examples of deviant cases (Silverman, 2012) presented at the conclusion of the data findings section. The presented quotations in this chapter are best exemplars from the participants.Figure 6: Themes – sub-themes identified from the data5.2 Motivation and Coercion The pressure participants considered they had responsibility for and some influence over is aligned to motivation. The participants believed that the sub-themes of social-coercion included normality and stability, physical/mental health and financial pressures. 5.2.1Normality and stabilityAttaining some normality in life was developed by offering something back toward family members for missed family events and a theme relayed from one respondent. “My main aim is to is to like to give me back my normal life off the drugs, I am off the drugs now, and I going to stay off them and I am going to give my mum ‘n dad something back. I want a big family and all that. Kids and all that, my brothers have. But I have none of that, I have a girlfriend but what I have found is they have parties and all that like close and all that at birthdays, I never went to no parties and all with the family and that is the hardest to stay off the drugs and all that and be trusted, go out with the family, and make them smile at me, and tell me all that” (Inpatient participant 13)Stability featured for participants when addressing a lifestyle beyond heroin addiction. One participant contributing what all family members wanted for his more normal life.“I just want to be stable in drug treatment and to just live a stable life, they want me (my family) they want me not to take the drugs, and not be in trouble with the police. And live a normal life and to be happy and healthy”(Prison participant 3)Regret about what has been missed in life, lost or replaced with heroin with some determination to seek out a normal life with improved stability. One respondent reporting “I just want to be stable, and not be scoring the street drugs for the first time in years. With the drugs I was on outside, feel like there was something missing and my body is letting me know that as well….”(Prison participant 3)Interestingly another respondent relayed a period of stability when off heroin that was his only period outside of prison, linking drug use to crime and incarceration.“Since I was 15 and now I am 28, I have done I think in 14 years… I have done about 10 and half years of that in prison, and it’s all drug related. Apart from in 2000 to 2002, I got out and stayed off everything for 19 months, and the only reason I came back in then was because I swapped beer for gear (heroin), and the drinking was still making me do stupid things (offending). Because the only thing I have known all my life is to steal then I started stealing for my drink, then they put me back inside again but it has been a vicious circle and I just don’t see my way out of it”(Prison participant 1)Irrespective of treatment context some degree of environmental restriction was necessary and freedom for this participant was reported as staying away from heroin. “Uhm I am gaining a lot more, I am gaining a life of freedom away from heroin, and I am gaining a normal life and living a normal life and basically living a healthy life as well”(Inpatient participant 13)The treatment journey was far from over when walking out of the inpatient unit as one participant identified. “I want to be able to walk out the door after I have finished treatment here and be recovered enough to continue on if you are recovering from long term addiction”(Inpatient participant 8) 5.2.2Physical and Mental Health Individual physical factors are considered, for example when deciding to reduce, cease, or substitute heroin for methadone. Participants wanted to be healthy, to eat normally and to sleep naturally following treatment and achieve all of this without the aid of heroin. One participant reported “My physical health is a lot better now, I am more stable and healthier, eating, gaining weight, I have an appetite now and sleep ok, something I didn’t do much before coming into treatment” (Inpatient participant 8)The length of time using heroin combined with heavier use of the drug over many years presented participants as chronic users, with length of time addicted considered a reason to start withdrawal treatment. One respondent was concerned about the condition of his veins and physical health. “Yes I want to get off drugs I have been on them for over 20 years, I was using drugs as I was really depressed and I getting to a point now where it won’t be long before I lose my legs unless I stop doing it (injecting)” (Inpatient participant 12) Similarly another participant reported physical concerns as a consequence of IV heroin use with some situational desperation.“Yes I have a problem; I inject speed (amphetamine) and heroin (speed balling). I use my groin and arms to inject and have done so for 12 years, and can’t use my arms anymore, and I swore I would never use my groin cos it leaves such a horrible mess I tried it myself in all kinds of places, so you get and carry on doing it years and years and get away with it. I was injecting me methadone into me groin thinking 50-60 mls at a time. Then I started getting leg ulcers”(Inpatient participant 12)Taking heroin over many years had consequences that are considered a form of punishment that remove the participant from his family. In addition to social distancing from the family a fragmentation of mental health was communicated from one participant “Ongoing drug health problems since age of 16 yes, but before that it was since 10 or 11, LSD and smoking cannabis, ecstasy and stuff like that. So it’s like no wonder me head is in a million bits, I am very paranoid about a lot of things”(Prison participant 1)Motivation was commented upon by one respondent that accompanied the second main theme of family coercion examined later in this chapter. One participant brought together motivation and perceived family support that influenced treatment entry. “They are made up and can’t wait for me to get off it (heroin) to be honest, they don’t like it at all, yes that my family are supportive and I have used drugs for years and they say that now is the chance. They have tried to push me into getting drug free yes, I have got in the rehabs and stuff a couple of times, and did it myself. I have been told it’s an addictive personality, and I don’t know if that’s rubbish or not. It’s just doing the withdrawal you know you have got to do it” (Prison participant 9) 5.2.3Financial Being coerced into treatment by limited finances to fund heroin use competed with the fear of withdrawal. One respondent stating the tension between wanting treatment, sufficient funds, and avoiding drug withdrawal “Uhm, yes the fact that I couldn’t earn the money to score pressed me to come down here, for methadone treatment and I was worrying about going ‘cold turkey’ (withdrawing) and things” (Outpatient participant 12)One respondent reporting that value for money from the product was no longer experienced combined with more finances for his family“Drugs don’t interest me as much now, they are cut too much (with adulterants) and not much heroin in the bag you buy, and also I now have more money for me children” (Inpatient participant 13) Poor quality heroin and a significant daily amount used lead to treatment seeking for financial and relationship preservation as one participant reported “I want to come off the drugs and yes it was with drugs that I got me pleasure, now I am coming off it for financial reasons, I just can’t afford it, and I am not willing to go back to prison for my habit, and I am in a relationship now where I want to keep where it is, I spend about ?400-500 a week on drugs, by whatever means I could. (Inpatient participant 3) Resultant financial pressures in the form of drug debt can impact upon family with withdrawal of housing and emotional support due to debt collector threats.“………there was a lot of pressure on me because I owed ?500 to some scousers (originating from Liverpool) and there was my mum’s old phone number and left a message saying they were going to burn me mum’s house down. So me mum wouldn’t even let me come in the house until I had spoken with them and say I had paid the debt off”(Prison participant 1)Withdrawal from heroin could be considered under a physical heading, but provides example of how themes combined with using his children to earn funds for heroin relayed by one participant “cos I need to have a toot (smoke heroin) not rattling (withdrawing) cos I want to have the kids and not that’s not fair cos you can’t go on like that borrowing off your ex-girlfriend. I will have the kids if you lend me ?15 to buy gear (heroin) and it is just not fair”(Inpatient participant 10)Nonetheless, a more pragmatic approach to finance concerns was taken with one respondent reporting prescribed methadone made much more financial sense than illicit street drugs“The main reason I am here getting treatment is ‘cos of the obvious, it is cheaper than street methadone”(Inpatient participant 3)5.3Family Coercion Family coercion was the pressures exerted by others upon participants that included the sub-themes of shame, being clean and loss.5.3.1ShameShame experienced though heroin use by taking finances away from the family to support drug purchases provided additional pressure. Shame and low mood were difficult to separate in some theme combinations with being clean off heroin. The multifaceted nature and origins of shame were manifest. A respondent described the course of heroin addiction and pressures that emerge suggesting a need for change“My girlfriend, mother, brothers and sisters have been through a nightmare of a time with me, and I have put my mum through hell……It is also best for me now to give up (heroin) I am too old, I have a partner, child, never had a job, no money to my name and time to change” (Outpatient participant 5)Shame experienced by participants was also experienced by family members. Some families remained in close contact and continued to care for the person addicted; that may have inadvertently compounded levels of shame experienced. “Me mum and brothers and sisters who are old enough to know all want me off it (heroin) me dad like mum and dad have split up and he doesn’t want me nowhere near it and I suppose the family are like ashamed of me, they still stick by me through thick and thin” (Prison participant 1)Coercion from families in a ‘tough love’ approach towards participants could be perceived positively or negatively. Family compassion and understanding may reduce after many years of heroin use commented upon by one participant.“My family call me ‘soft sh**e’ all the time, and they say you know I should stop being selfish, and that we are always arguing all the time. At the end of the day it’s me”(Prison participant 6)Heroin use impacted upon the immediate family unit and not just the drug user. It is interesting that heroin use over many years was considered a form of punishment or imprisonment. A participant reported treatment compelling treatment entry pressures from his partner and children. “Yes my kids have influenced me, I am not with me girlfriend now but I still see her all the time, and I see my kids every day and that is one of the reasons. That’s the main reason really, I know they say you should want it for yourself, but I do want to come off it, but I feel I am not very confident or mature, cos I have been on the gear (heroin) for 20 years and I have always relapsed in and out of jail. I hope I do but I don’t know. I look at the gear as a life sentence but I know that is a bad way to think and I have been on it for over half me life, since I was about 19, since 1983….25 years….long time”(Prison participant 16)The individual reasons for treatment entry and remaining in treatment were considered with matriarchal pressure levied upon one respondent reported “Yes me mum has influenced me to come into treatment, me mum was talking to me, has been giving me ?20 every single day while I was on the waiting list to get in here (drug treatment unit) instead of going stealing and all that and ending up in jail, me mum was giving me the money every day for about four to five months so I could get in here, like I worked out I was on ?220.00 per week (on drugs) and she was just lending it me it like that is what it was, and she didn’t want me to go to prison and all that, it was like my life was before I came in here, I was in prison three times every single year for a couple of months a time, in and out of prison and in and out of hostels. Sleeping in hospital toilets and sort of living like, that’s the main thing I was thinking of…wherever I was staying, everything I do when I get up at me mum and dad’s, I get me drugs and go in the shed and smoke (heroin) and then like I was only getting ?20 a day off me mum now and again I might get ?15, but like most of the time me mum thought I was just taking ?20 worth of drugs, but when that ?20 had gone I was going out stealing just to like score (purchase drugs) again, sort of getting drugs twice a day’’ (Inpatient participant 13)Heroin use facilitated an escape from the pressures of life irrespective of environment. Participants’ children held influence when contemplating heroin treatment and letting them down associated with longer term use as one participant stated“I have no f*****g choice cos it costs me money if I don’t (take prescribed methadone in prison) and I miss Christmas, and I have three kids out there, and I don’t need to be going round buying crack with it. I need a bit of help and I am getting it, and it is murder getting it” The need for help in treatment and difficulty encountered to maintain that help was recognised as originating from a few areas that included neglected parental responsibilities, pressure from current partner supporting the family that resulted in an ultimatum as one participant relayed“To stop me withdrawing while I am in here (prison) and I want to stay off it (heroin) cos my partner she doesn’t like me using, I have got four kids and another one on the way, I need to sort myself out now. She (partner) has told me to sort myself out cos of the kids and all that, she has said that before but I think she means it now, finally had enough now. I have three brothers, they are all in their forties and I don’t really see them much now. I want to stop ….I really do want to stop. She (partner) has tried to find a new house so that when I do get released we will be away from the area”(Prison participant 1)The finality that continued heroin use has upon families and the many associated life consequences that included loss of children, family and loss of partner could be coercive irrespective of intent. This was interesting with family pressure, particularly from mothers, to withdraw from heroin frequently experienced but clarity in what takes families to breaking point was not that clear. The matriarchal coercion commented on by one participant “My family, I just want to come off, my mother is the biggest pusher (to come off drugs)”(Prison participant 17)The routine daily life on heroin reported as restrictive and drugs orientated included illicit and prescribed substances“Uhm…I just want to get somewhere in my life, and progress in my life. One thing is to make sure my family want me and I want to stop feeling ashamed and feel good about meself. I feel like a big nuisance to them really, it is from me. Uhm… well ideally yes, but I have been in that many times and they just wonder why I am doing it I am just like it, I can’t give up trying, I can’t be such a hopeless case that I don’t go on trying, every time I come into treatment. I want to become uhm… drug free so I am not reliant on heroin or substances. I feel like I can’t go anywhere, I have to take methadone every day, go to the chemist every day, and then you are not doing that because you have to buy gear off the dealer, and your whole day has gone and you can’t do anything cos drugs do it all. It takes up all of my time and I end up socialising with people I wouldn’t normally do, you know what I mean? It is my life” (Inpatient participant 12) Close family members become aware of the smell of heroin used in addition to prescribed methadone. Honesty from one respondent’s child acknowledges that there is little escape from some of the signs of continued use. “Previous people who used to be on drugs with me when I was younger, they are like on methadone, like 200 or 300 mls a day, which is like I know is a lot, they still graft (theft) you know what I mean, you know my son also says to me you know dad you shouldn’t smoke gear, they can smell it on you (son) the smoke”(Prison participant 5)Families were important for motivation in treatment seeking and in this respondent’s case historical events also influenced current emotional state “Well what it was I have my little son down in Devon nine months and she (partner) was at home and she also came out of treatment and I missed him like (my son), know what I mean? And what it was, I will be honest with you….. I used to cry my eyes out”(Inpatient participant 1)Pressure from family members encouraged their relative into treatment that increased feelings of unhappiness one participant conveyed “My mum, sister’s children and step sister want help for me and wanted me in here, my previous children about age six put pressures on me now it is all that I felt a mess……. I didn’t like myself or what I was becoming, I didn’t the way things were, so the only way to get back, I turned to more sedation and I am in an invisible bubble and wait for my sanity really….I now have been here six times, I come to the unit, do my detox with a lot of help and support from the staff and they help you through it, the bad times and a lot of good times uhm….I have an illness”(Inpatient participant 15) 5.3.2Being CleanLanguage used to describe the addiction as being clean when not using heroin and being dirty when using heroin suggests the potential influence of stigma. “Obviously they want me clean won’t they? Cos it is no good borrowing off your mum every day as it is sometimes I have the kids and I can’t get by without me gear and if I have the kids I have to get a half (half a bag of heroin) (Inpatient participant 10) The shame pressures of being dirty had potential to impact on the whole family. One participant commented on being clean and that life had passed him by with many treatment attempts and not being present to observe his children grow up.“This time I have had enough, using Class A drugs for over 25 years, tried numerous times to get free of them and get clean, I haven’t seen my kids grow up and it has all evolved around me” (Inpatient participant 6)Being clean and being in employment when combined would move the participant away from feelings of being abnormal and unemployable, with one respondent reporting“I have come into treatment just to get off heroin, cos I want to get clean and go back to work”(Inpatient participant 7)Being clean and feeling proud by providing a negative urine screen can boost motivation and esteem. Being clean was an aim and move away from the stigma of heroin reported from one inpatient. “Uhm, buying crack and smack and the reason is I just want my life back, my mum got sick and I had to look after her, after six years of being clean, I used to work two-three weeks without a day off, it was a job and god it varies, when I was at me worst time I could spend ?250 a day, and the last month or two…. without using and I have just given a clean sample (of urine)” (Inpatient participant 3)5.3.3LossLoss was also experienced in the family relationship by being a parent with one participant saying“I haven’t seen them grow up cos I was involved in heroin, and I have seen them (parents) grow older, never participated in them growing up” (Inpatient participant 3) Loss of children through a drug use lifestyle in terms of being taken into care was balanced against a life time of heroin use and socio-familial harms for some. Participants identified in some cases that it was having their children removed that triggered drug treatment seeking. However, seeking treatment was not triggered solely by the children being removed“One of the reasons is I have recently had my kids took off me, and they have been placed with my family and until I get clean and my partner gets clean we can’t have them back and also the place where we are living isn’t big enough for the kids and that is what started it all off”(Inpatient participant 3)Some participants wanted their children back after they were taken into care with separation loss continued. Heroin treatment reached beyond treatment contexts and one respondent acknowledged that he had to change his social circle “Drug treatment and withdrawal is a process irrespective of environment and stretched beyond environments when change is required, it is not just the addiction or drug you have to get away from, but the circle of friends and people you know when on drugs”(Prison participant 15) One participant reported loss of self from the daily routine was encountered and replaced by heroin. This loss of self and routine irrespective of being inside or out of prison had impact upon mood state and feeling sad “I know I will use (heroin) when I get out of prison but I hope in a safer way. I’ve been on drugs for 20 years, end up depressed, and now getting to the point when I will lose myself, and my whole day revolves around drugs” (Prison participant 21) Fears of parental death and a life lost are relayed from one participant. A fear of life substituted by the use of drugs, but reflecting on time loss summed up poignantly from one respondent“The reason why I have had enough out there is cos I was bored stiff with what I was doing over and over again and I wasn’t doing anything with my life, that was my life, I was just doing anything to get money for drugs and it was harassing me mum and dad and he made a statement to the police over it saying he was getting an injunction and all that to stay away, and I thought I have got a sister on drugs and she has six children, and as soon as she had the children they went to me mum and dad to look after or be put in care, so me mum and dad have always took her kids on and about the last year I just thought it is not fair on my mum and dad they are getting on and mostly everyone says that I just can’t do it to me mum and dad, cos I can’t stop thinking about what it must be doing to them and me brothers and sisters doing it, cos I have another two brothers on heroin and just thought it is not fair, and I have to give them something back before it is too late. And I want to do this for myself as well”(Inpatient participant 13)Consideration of the consequences of heroin use on others in the family is raised and the egocentric nature of the lifestyle captured. One respondent reports loss of time with his mother through drug use and a time pressure conveyed “I want time with my mother before it’s too late for both of us” (Inpatient participant 7)Heroin use isolates the user though reduced support albeit self-imposed and was concerning for one participant “It’s seeing them upset, and worrying about me all the time, and I don’t like them worrying for me and usually I am on my own, all my other brothers are close, and although I am close, I always go my own way, and I would rather do things myself”(Inpatient participant 6)Life before drugs had been taken away and heroin use did not provide happiness reported from one participant. “I take heroin and crack and when I stopped using (drugs) I started drinking and got a drink problem, basically switching one for another....I am not happy on drugs and I have never been happy on drugs, and I am not happy now, I just want my life back. (Outpatient participant 4) Loss with heroin use was exacerbated as parents became older adding to an increased sense of failure conveyed from one respondent. “Because they don’t want to see me ill, and like this cos they have seen me clean before and they want it, they love me when I am clean, and they have seen me kill myself, know what I mean, it is like killing myself slowly cos that is what I am doing”(Inpatient participant 5)5.4Deviant CasesFormal coercion delivered by a probation court order on one participant was reported as beneficial and is considered a deviant case (Silverman, 2012). Deviant case as formal coerced treatment issued by the court was positively reported from the respondent. The respondent’s favourable reply goes against all other participant data that suggested family coercion was perhaps more coercive than legal sanction “I haven’t told no family or friends it’s all secret and that lying all the time, I feel so sad telling all these lies, once I have had me gear (heroin) I just go on a downer and I shouldn’t say that, the amount of times I have gone without gas and electric. I was in Torquay and I was in the house and the parents got me ‘Lemsip’ cos I had the flu, it was so pathetic cos I was on the gear, not the flu. My dad died after that. I felt so bad, I used to miss me other two kids and I got to see them and I took them to the fun factory and I was only there a half hour ….I was thinking about excuses to call their mum to pick them up, and I came off the gear and into rehab after that, that’s all I need now. I am 44 and I going to end up dead on the couch or something, all around are dying…... That’s all I want and I say it’s because I haven’t been helped and the only person that has ever has was a South Devon magistrate, he put me on fast track (to drugs treatment) and that is the only one who has ever helped me…. (Outpatient participant 1)Coercion into treatment provided leverage from a key worker and a second deviant case. One respondent reporting some combined benefit from family and drug service worker pressure “I have been on a (methadone) script now for around 20 years, but I am still using heroin on top of it and me key worker wants me, and I want to stabilise anyway, she has got me in here to keep me on 65 mls a day (methadone) but I have got this habit of smoking gear, brown (heroin), she (key worker) said if I don’t get into treatment she will stop me script ( Methadone) cos I am on the both at the moment and she (partner) wants me off the brown and I have to” (Inpatient participant 10)5.5Interim discussion This chapter has presented the qualitative findings that capture the views and perspectives of the heroin users. This was identified as a gap in the literature in chapter 2 (Wild et al, 2002; Klag et al, 2005; Petticrew and Roberts, 2006). Two interrelated key themes emerged highlighting the influence of set and setting which highlighted, firstly family coercion that included issues regarding loss, being clean and shame (Best et al, 2006; Orford, 2008). The second theme was self-motivation which included issues related to normality and stability, physical/ mental health and lastly financial pressures (Murphy and Bentall, 1997; Miller et al, 1999). Empirical attention has focussed on mandatory criminal justice sanctioned treatments which have developed a partial knowledge base, with other influences being underexplored. For example Macarthur and the OCTET studies (Kelly et al, 2006; Monahan et al, 2005; Burns et al, 2011) focussed on statutory compulsion into treatment. However, these studies had only a limited level of qualitative investigation into the wider treatment entry pressures experienced by patients, including family related pressures. The present findings provide some qualitative investigation into these areas, bringing to light the potential contributions of family members and self-motivation, respectively. However, it is acknowledged that there is a methodological limitation in the present study with regard to the data having been gathered in one region of the UK. Furthermore, there is also the limitation that the views of family members were not explored directly. Nevertheless, there is a strength of the findings in this chapter, in that they add to a relatively small collection of studies which present qualitative findings from heroin users within the three treatment settings examined here (Ford et al, 2003; McSweeney et al, 2008; Oliver et al, 2010). These findings are further discussed in Chapter 9.Chapter Six: Pre-treatment Psychometric Measure Results6.1Introduction Chapter six considers results from pre-treatment psychometric measures and the literature relevant to the measures deployed. Relevant psychometric measures adopted aimed to identify differences between groups at the start of their treatment journey and within the different treatment contexts. Individual psychological variables that could promote treatment entry and retention may include internal and external attributions (Miller et al, 1999).The research question specifically addressed for this chapter is stated as followsHow did treatment groups differ at T1 with regard to demography, drug misuse history, treatment history, and relevant psychological variables?Difference between data from the preparedness for treatment instruments was examined to provide a sense of who the participants were by exploring any potential differences at T1. Self-efficacy is linked to achievement belief at the time of treatment entry which may be related to positive outcomes under some circumstances (Burling et al, 1989; Dean et al, 2011; Tsai, 2011; Lintonen et al, 2011). In the present study self-efficacy was captured by measures of treatment effectiveness confidence. Self-efficacy could be an important determinant in treatment progression as a relationship exists between time to relapse and self-efficacy scores (Carbonari and DiClemente, 2000; Harkaway, 2001; Carpenter et al, 2002). Attributions specific to this study were for failures to stop using heroin. Confidence in their ability to complete a treatment programme has potentially important implications for outcomes because remaining in drug treatment can provide more positive treatment outcomes when examined alongside readiness to change (McLellan et al, 1994; Gossop et al, 2001; Carey et al, 2002; Gregoire and Burke, 2004; Oliver et al, 2010; Orford et al, 2010). A positive relationship exists between heroin use and recognition factors in the SOCRATES (Miller and Tonigan, 1996). Examining the psychological stage of change that participants reside within could identify areas for investigation that include problem recognition and treatment readiness on SOCRATES (Marlowe et al, 1996; DiClemente et al, 1999; Boyle et al, 2000; Rapp et al, 2003). Combinations of factors are often attributed responsibility for heroin relapse but a persistent negative mood state is an interpersonal trigger identified as being particularly important (Unnithan et al, 1992; Young and Belenko, 2002; Hammerbacher and Lyvers, 2006). The DASS 21 scales were used to capture stress, mood and anxiety at treatment entry to investigate group or setting results (Stevens et al, 2005). 6.2Method6.2.1Design and ParticipantsThe study draws upon participant data collected at T1 (see chapter three, figure 5). An account of participant recruitment from three treatment contexts has previously been given (see subsection 3.2.3). The dependent variables tested feature, treatment motivation, treatment confidence and readiness, attribution, depression, anxiety and stress. 6.2.2Psychological MeasuresAll data were obtained from five quantitative measures previously detailed in chapter three (see subsection 3.3.1): Self-efficacy Scale (DTCQ8) (Sklar and Turner, 1999), Depression Anxiety Stress Scale (DASS 21) (Lovibond and Lovibond, 1995), Confidence scale for treatment, Stage of Change and Treatment Readiness (SOCRATES 8D) (Miller and Tonigan, 1996) and Attributions for Treatment Outcomes Scale (ATOS) (Joe et al, 2002). The data collection process was previously detailed in chapter three (see subsection 3.3.2 and figure 4). 6.3Results6.3.1Attributions for Responsibility Regarding Cessation of Using HeroinTable 11 shows the means and standard deviations for the attributions for treatment outcome scales. The only attribution scale to show a significant main effect across treatment groups was the scale for luck as a determinant of treatment outcome (Kruskal Wallis ( χ2 [2] = 6.816), p=.033). Despite a significant main effect having been identified across the three groups by the Kruskal Wallis ANOVA, it was not possible to identify individual inter-group differences on this scale. However, none of the post hoc intergroup comparisons were significant when evaluated against the Bonferroni adjusted alpha level of .017 (see table 11). Table 11: Mean attribution scores by group at T1 Mean and S/DAttribution treatment responsibility: difficulty Prison Inpatient Community3.46 (1.35)3.21 (1.14)2.88 (1.19)Attribution treatment responsibility: effort Prison Inpatient Community3.63 (.92)3.42 (.88)3.46 (1.18)Attribution treatment responsibility: knowledge Prison Inpatient Community3.21 (1.25)3.46 (.83)3.13 (.90)Attribution treatment responsibility: person Prison Inpatient Community3.25 (1.11)2.71 (1.08)3.08 (.93)Attribution treatment responsibility: luck Prison Inpatient Community2.58 (1.02)1.88 (.80)2.58 (1.14)6.3.2Confidence Scale and Self-efficacy (DTCQ) ScoresGroup means and standard deviations for the treatment confidence scale and DTCQ self-efficacy scale are shown in table 12. There was a significant main effect across the treatment groups for the treatment confidence scale (Kruskal Wallis ( χ2 [2] = 7.252), p=.027). The post hoc comparisons evaluated against the adjusted alpha level showed that the confidence ratings of the inpatient group were significantly higher than those of the prison group (n1 = 24 = n2, U = 163.500, p = .009, two-tailed). Neither of the other two post hoc comparisons showed any significant inter-group differences. This shows that the inpatient group reported significantly higher confidence for successful treatment completion than the prison group. Confidence levels did not significantly differ between groups in the other two comparisons (see table 12). Table 12: Treatment confidence and self-efficacy Confidence Scale Mean and (SD) DTCQ Mean and (SD)Prison51.75 (33.53)320.00Inpatient77.83 (27.03)573.33Outpatient66.41 (30.28)400.00There was a significant main effect across the three groups for total DTCQ scores with F (2, 69) = 6.056, P =.004, ?p2 = .149. Post hoc comparisons showed the inpatient group had significantly higher scores than the prison group (P=.001, two tailed). This shows that self-efficacy was significantly higher for the inpatient group than for the prison group. Although neither of the other two comparisons were statistically significant, the comparison between the inpatient and outpatient group approached significance (P = .023, two tailed). The inpatient group were higher with the revised alpha level of .017 that was used to evaluate this probability level. 6.3.3SOCRATES ScalesTable 13 below shows the means and standard deviations for the three SOCRATES scalesTable 13: The means and standard deviations for the SOCRATES scalesMeans(SD) RecognitionMeans(SD) AmbivalenceMeans (SD) Taking StepsPrison29.08 (S/D 4.34)16.17 (S/D 2.66)34.88 (S/D 3.54)Inpatient31.04 (S/D 3.26)16.33 (S/D 2.08)34.33 (S/D 3.40)Outpatient28.17 (S/D 28.17)16.33 (S/D 1.83)33.29 (S/D 3.64)The main effect for the recognition scale showed a significant main effect with F (2, 69) = 3.319, p < .042, ?p2 = .088. The only post hoc comparison to show a significant inter-group difference was that between inpatient and outpatient groups (P=.014, two tailed) with the inpatient group scoring significantly higher. This means that the inpatient group showed significantly higher problem recognition than did the outpatient group. There were no significant main effects for the ambivalence scale and taking steps scales with F< 1 and F (2, 69) = 1.249, ns, respectively. 6.3.4Depression, Anxiety, and Stress Scores The table below shows the means and standard deviations for each of the three scales across the groups.Table 14: The means and SD scores for each of the three groupsMeans (SD) DepressionMeans (SD) AnxietyMeans (SD) StressPrison4.92( S/D 5.71)4.67 (S/D 3.65)7.58 (S/D 5.92)Inpatient4.73 (S/D 4.57)3.53 (S/D 3.14)6.87 (S/D 5.57)Outpatient7.50 (S/D 3.87)8.50 (S/D 5.93)8.30 (S/D 4.72)None of the main effects for these three scales were significant with F < 1 for the depression and stress scales, and Kruskal Wallis ( χ2 [2]) = .148), ns, for the anxiety scale. The three groups did not differ in terms of mood on the rating scale. 6.4Interim Discussion In terms of initial mood state and confidence for treatment the depression sub-scale on DASS 21 there is no negative coefficient. There is no significant difference between groups which indicates an important lack of difference at the start of the treatment journey. The DASS 21 depression sub-scale does not correlate with any of the other variables and it is interesting that the groups are not that different in terms of their mood at T1. Participant stage of change reported a significant difference in problem recognition scores between inpatient and outpatient contexts, with the outpatient group scoring lower. SOCRATES heightened problem recognition score may encourage change which could be important as those motivated often do better in drug treatment (Brizer et al, 1990; McMurran, 2006; Best et al, 2008). Confidence scales reported that the inpatient group scored higher than prison group but no other inter-group differences. Collectively, this may indicate that the higher the treatment confidence and problem recognition on treatment entry, the more likely participants will become drug free which could be two measures to take forward. Changes in attributions were examined for treatment failure that differed between those who had stopped using and those who had not. The difference for the people attribution (because of the kind of people they are) was interesting. The findings could potentially lead to assessing differences in this decreased attribution relative to those still using heroin. There were no significant differences among treatment groups in mean attributions for failure to stop using for the ‘kind of people they are’. Furthermore for attributional responsibility to ‘bad luck’ there were no significant intergroup differences. There was a main effect for luck, but again no specific inter-group differences could be identified. None of the other scales showed inter-group differences at T1. There was an overall significant effect found for the prison versus outpatient group, higher ranking by luck for prison participants. The inpatient group had the lowest attributions by their belief in luck highlighting a difference between the groups at treatment outset. This is important as individual heroin users experience the collective emotional and social pressures whilst acknowledging these may alter in priority over time (Seivewright, 2000; Haber, 2009; Strang et al, 2012). Chapter seven follows and examines quantitative group changes between T1 and T2. Chapter Seven: Results for Heroin Use or Abstinence at T2 7.1IntroductionChapter seven investigates treatment differences and participant characteristics between groups from T1 to T2, where treatment outcomes are investigated for participants still using heroin or not. T1 data was examined for those in the study and also those lost at T2 in an attempt to capture some T1 variables for treatment drop out. Data examined in chapter seven also considers outcomes related to treatment effectiveness.Research questions addressed in this chapterHow did treatment groups differ at T1 with regard to demography, drug misuse history, treatment history, and relevant psychological variables that influenced participant status at T2?How treatment outcomes at T2 were related to drug misuse history, cost of drug use, and confidence in treatment at T1?Were the psychological variables influenced between T1 and T2?Attributions that increase the likelihood for behaviour change could provide participant characteristics for improved treatment journey outcomes. In addition, confidence for treatment self-efficacy are considered which could provide context influences for potential drug relapse situational awareness (Witkiewitz and Marlatt, 2004; Brown and Ramo, 2006). Therefore, the higher the confidence rating in the person’s ability to refrain from heroin use when faced with a drug-using situation, the higher the probability for successfully resisting drug use urges (Hays and Ellickson, 2006; Ramo, 2010). These factors were considered important to this study and data was collected on these attribution and confidence measures. The importance of enhancing efforts to develop social supportive networks could support the importance of family involvement sustained during treatment attempts (Flynn et al, 2003). The strongest predictors of treatment success considered are treatment confidence and motivation to change, suggesting those addicted to heroin with higher motivation could have much shorter drug careers by comparison with those who do not (Simpson and Sells, 1990; Hser et al, 2001; Wolfe et al, 2013). The participant treatment journey in different treatment contexts is characterised by different coercive characteristics. Depression, stress, and anxiety are important relapse indicators, including life events, marital conflict and other social pressure (Belenko, 1998; Miller and Flaherty, 2000). Family dysfunction, mood state, primary drug dependence are also cited as relapse indicators (Pinfold et al, 2001; Best et al, 2006). The stages of change and readiness for treatment are considered in this study in combination with other variables through the SOCRATES measure. This incorporates movement and motive by providing a better predictive outcome score than solely abstinence (Isenhart, 1997; Zullino et al, 2007). 7.2Method7.2.1Design and ParticipantsThe study draws upon participant data collected at T1 with all measures repeated at six months follow up at T2 (see chapter three figure 4). An account of participant recruitment from three treatment contexts has previously been given (see subsection 3.2.4). The dependent variables tested feature treatment, confidence and attribution. 7.2.2Measures All data was obtained from quantitative measures. The quantitative data measures are further detailed in chapter three (see subsection 3.3.1). Self-Efficacy Scale (DTCQ8) (Sklar and Turner, 1999), Depression Anxiety Stress Scale (DASS 21) (Lovibond and Lovibond, 1995), Confidence scale for treatment, Stage of Change and Treatment Readiness (SOCRATES 8D) (Miller and Tonigan, 1996), Analogue Scale and Attributions for Treatment Outcomes Scale (Joe et al, 2002). The data collection process is detailed in chapter three (see subsection 3.3.2 and figure 5). 7.3Results7.3.1Availability for follow upA total of 48 participants were available for follow up over all groups, with 24 participants lost from the study at T2 with an attrition rate of one-third (33.3%) at six months over all the groups (n=72). Thirteen prison participants were available for follow up, 18 inpatient participants, and 17 outpatients were available from the original 24 in each group. Chi squared analysis was non-significant for follow up being possible or not by group ( χ2 [2] = 2.625, ns). Treatment attrition and participant availability for T2 interview was examined for participants in relation to being in a stable relationship or not (see table 15). Table 15: Follow up: Possible or notCurrant marital partnerFollow up possible YESFollow up possible NOYes106No3818Total4824There was no significant association between current martial or life partner and availability for follow up ( χ2 [1] =.161, ns).7.3.2Heroin use at follow up by groupTable 16 shows the number of participants who were using heroin or not at T2. The association between heroin use or not at T2 and treatment group was not significant ( χ2 [1] =.4.778, ns). Table 16: Heroin used or not at follow up by groupn=48Heroin usedNo heroin usedPrison85Inpatient108Outpatient152As any attempt to analyse demographic, drug misuse, or preparedness for treatment scores at T1 on the basis of heroin use or not within treatment groups would have resulted in cells of the analysis having very small case numbers, it was not possible to pursue this analytic strategy. Consequently differences in T1 scores on these variables were analysed with regard to heroin use or not across all treatment groups.7.4T2 Heroin use or not by T1 demographic and drug misuse variablesTable 17 shows the means and standard deviations for T1 scores on demographic and drug misuse variables broken down by T2 heroin use or not. Table 17: Means and (SD) for scores on T1 demographic and drug misuse variables broken down by T2 heroin use or not AgeMethadone use lifetime yearsMethadone mls at T1Age when education completed in yearsTime since first use of heroin in yearsHeroin used 41.33 (5.69)7.36 (9.92)36.28 (19.59)15.06 (1.43)17.36 (6.69)Heroin not used 40.36 (6.11)9.40 (8.36)25.87 (14.26)15.33 (0.98)14.93 (8.57)None of the variables reported in table 17 showed significant differences between heroin users and non-users at T2. In detail, for age t < 1; for methadone lifetime use with n1 = 33, n2 = 15, U = 216.5, ns; for T1 methadone dose t (45) = 1.659, ns; for age when education was completed with n1 = 33, n2 = 15, U = 238.0, ns; and for time since first use of heroin t (46) = 1.067, ns. Age, lifetime methadone use, methadone dosage at T1, age when education ceased, and time since first use of heroin were not associated with heroin use at T2.7.4.1T2 Heroin use or not by T1 preparedness for Treatment and Drug Misuse VariablesTable 18 shows the means and standard deviations for T1 scores on the SOCRATES scales, the DASS-21 scales, DTCQ8 scale, and the visual analogue confidence scale, broken down by T2 heroin use or not. Table 18: Means and (SD) for T1 preparedness for treatment scales and heroin use or not at T2SOCRATES RecognitionSOCRATES AmbivalenceSOCRATES Taking stepsDASS DepressionDASS AnxietyDASS StressTreatment ConfidenceTotal DTCQ at T1Heroin used 29.33(3.26)16.00(1.95)33.49(3.52)6.81(5.49)5.94(5.36)7.48(5.46)58.70(30.96)380.61286.60Heroin not used29.60(5.22)15.66(2.32)35.60(3.25)5.07(4.59)6.60(6.41)7.93(5.56)80.20(27.88)570.66252.18Neither the SOCRATES recognition nor ambivalence scales showed any significant differences with regard to T2 heroin use or not (t < 1 in both cases). However, the taking steps scale result was marginally non-significant (t (46) = -1.975, P = .054, two-tailed), with participants not using heroin at T2 scoring more highly on this scale. None of the three DASS-21 scales yielded significant differences with regard to T2 heroin use. For the depression scale, t (44) = 1.060, ns, whilst for the stress scale t < 1. For the anxiety scale, n1 = 33, n2= 15, U = 231.5, ns. The T1 confidence for treatment scores for those not using heroin at T2 were significantly higher than for those who were using heroin (n1 = 33, n2= 15, U = 136.0, P = .012, two tailed). Similarly, T1 DTCQ8 scores were significantly higher for T2 nonusers than users (t (46) = -2.207, P = .032, two tailed). Table 19 shows the means and standard deviations for T1 scores on the attribution scales, broken down by T2 heroin use or not. Table 19: Means and (SD) for T1 attribution scale scores broken down by T2 heroin use or notAttribution for treatment DifficultyAttribution for treatmentEffortAttribution for treatment KnowledgeAttribution for treatmentPersonAttribution for treatmentLuckHeroin used3.06 (1.17)3.45 (1.00)3.03 (0.98)2.94 (0.10)2.24 (1.00)No heroin used3.20 (1.26)3.73 (0.88)3.60 (1.12)3.20 (1.08)2.00 (1.07)None of the T1 ratings on these scales showed a significant difference with regard to T2 heroin use or not. With n1 = 33 and n2= 15 for each of these scales, for the attribution to difficulty scale U = 233.5, ns; for the attribution to effort scale U = 210.5, ns; for the attribution to knowledge scale U = 173.5, ns; for the attribution to type of person scale U = 222.0, ns; and for the attribution to luck scale U = 208.5, ns.7.5Interim DiscussionHeroin misuse history allowed treatment experiences to be explored by obtaining participants’ age at first use of heroin and length of heroin use prior to treatment success. Treatment journey motivators are important when psychological distress and family problems arise, but equally high levels of sustained distress can undermine motivation to follow through on treatment referral (Ryan et al, 1995; Wild et al, 2006). Social and family support are essential stabilising forces when attempting to combat heroin addiction and relationship wellbeing may assist in this process (Granfield and Cloud, 1996; Marlow et al, 1996; Lawental et al, 1996; Best et al, 2006). Participant attrition as discussed was due to participants frequently changing contact details from T1 with a study attrition rate of one-third (33%) at T2 over all groups. There is no significant association for follow up availability being associated with treatment group.It is unfortunate that little data could be gathered on those participants who dropped out of the study before T2 interview. Participants available at T2 only differed in their treatment responsibility for luck, and those who dropped out showed higher initial luck attribution. None of the other attributions, confidence in the treatment, depression anxiety or stress scales of heroin levels significantly differed between those available at T2 or not. Participants with severe problems at treatment entry with heroin and methadone use are at greater risk of premature exit from treatment but have yielded inconsistent results (Zanis et al, 1996; Klag et al, 2005). There is no significant association for heroin use at T2 being associated with treatment group.The SOCRATES recognition sub-scale approached conventional levels of significance at T2. SOCRATES taking steps sub-scale was a non-significant result and the SOCRATES score overall was not predictive. Participant confidence and attributions towards drug addiction treatment with combinations of coercion and readiness for change can improve treatment outcomes; and this study combined quantitative measures to explore relationships between them (McLellan et al, 1994; Gossop et al, 2001; Harkaway, 2001; Carey et al, 2002; Cahill et al, 2003; Gregoire and Burke, 2004; Oliver et al, 2010; Orford et al, 2010). There was no significant association between current martial or life partner and availability for follow up.Confidence and self-efficacy scales were associated with no heroin use at T2 although there were no inter-group differences in drug use or not at T2. Confidence ratings of the inpatient group were significantly higher than those of the prison group at T1 (see 6.3.2). Treatment application exits by refining the treatment focus of self-efficacy and confidence levels pre-treatment might allow heroin relapse prediction model generation whilst improving participants’ coping skills (Litt et al, 2005). The alternative is undesirable for all with premature exit from treatment being typically associated with heroin reinstatement (Joe et al, 1997; Lefforge et al, 2007; Nutt et al, 2007; Gossop, 2007). What is interesting in these results is that participant mood states overall were similar across the groups, with no group being more depressed than another at T1 (See 6.3.2). Chapter Eight: Psychological Changes 8.1Introduction Chapter eight is the final results section investigating changes due to treatment and psychological characteristics among the groups between T1 to T2. Participants who commenced their treatment journey with differing participant characteristics across three contexts are considered. A range of psychological variables were considered that might inform treatment and assessment options. SOCRATES is used as a predictor of outcomes that incorporates both movement and motive (Zullino et al, 2007). Attribution scales acknowledge that there are two possible ways in which people interpret their behaviour by internal and external attribution (Heider, 1958). Attribution may serve to promote the individual’s feelings of self-worth and control over the environment and therefore serves as a protective factor by reducing anxieties and feelings of guilt (Storms and McCaul, 1976). External attribution (or situational attribution) occurs when social or environmental pressure is believed to be the cause of the behaviour and heroin use a consequence (Gudjonsson and Singh, 1989). Research questions addressed in this chapterHow treatment outcomes at T2 were related to drug misuse history, cost of drug use, and confidence in treatment at T1?Were the psychological variables influenced between T1 and T2?8.2Method 8.2.1Design and ParticipantsThe study draws upon participant data collected at T1 with all measures repeated at six months follow up at T2 (see chapter three, figure 4). An account of participant recruitment from three treatment contexts has previously been given (see subsection 3.2.3). For the following analyses a change score was computed for each variable, defined by taking the measured value at T1 subtracted from the measured value at T2 (i.e. T2 – T1). Therefore, the change score served as a dependent variable for psychological outcomes of treatment. 8.2.2Measures All data were obtained from all the quantitative measures that are further detailed and listed in chapter three (see subsection 3.3.1). All interviews took place at a location convenient to participants throughout the North West region of the UK at T2. The data collection process is detailed in chapter three (see subsection 3.3.2 and figure 4). 8.3Results8.3.1Changes in SOCRATES Scale Scores across Groups at T2The table below summarises changes in the SOCRATES scale scores between T1 and T2, for participants for whom T2 data was available.Table 20: Mean difference (SD) scores for the SOCRATES scales between T1 and T2GroupNRecognition scale mean (SD) difference scoreAmbivalence scale mean (SD) difference scoreTaking steps scale mean (SD) difference scorePrison12 -0.5000 (4.210)0.168 (2.855)-1.500 (3.754)Inpatient17 -1.941 (4.408)0.294 (0.711)-0.588 (1.011)Outpatient13 0.615 (4.292)0.000 (0.716) 0.769 (1.167)Total42 -0.738 (4.351)0.167 (0.423)-0.429 (0.628)None of the main effects for treatment groups were significant. For the recognition of a drug problem scale, F (2, 39) = 1.317, ns, whilst F < 1 for both the ambivalence and taking steps scales. There was no significant difference in SOCRATES scores between T1 and T2. A post-hoc statistical power analysis showed power at 0.60 for a large effect size (f = 0.80) for an alpha level of p < .05 for this and other ANOVAs in this chapter (Faul & Erdfelder, 1992).8.3.2Changes in DASS-21 Scales following Treatment The DASS-21 sub scales of depression, anxiety, and stress show a similar pattern of non-significant change across treatment groups. Changes in depression, anxiety and stress were limited between T1 and T2, with F < 1 for the depression and stress scales, and (Kruskal-Wallis ( χ2 [2]) =.4.374, ns) for the anxiety scale. No significant difference in mood scores across T1 and T2.Table 21 summarises the DASS-21 sub scale changes between the groups that did not change across time. Table 21: DASS 21 broken down by group at T2GroupDASS Depression Scale Mean (SD)DASS Anxiety Scale Mean (SD)DASS Stress Scale Mean(SD)Prison(n=9)1.11(6.43)1.72 (5.10)0.60(4.30)Inpatient(n=11)-1.37(4.27)0.46 (3.73)-1.14(7.57)Outpatient(n=10) -1.30(3.47)-2.00(2.26)-1.00(1.63)Total-0.60(4.77)0.13 (4.09)-0.59(5.38)8.3.3Changes in DTCQ Self-efficacy and Confidence Scale Scores following TreatmentTable 22 summarises the changes in DTCQ8 and confidence scale scores following treatment.Table 22: Changes in DTCQ8 and confidence scale scores at T2 broken down by groupGroupnDTCQ8 mean (SD) differenceNConfidence scale mean (SD) differencePrison1278.33 (240.83)122.25 (24.01)Inpatient17-127.78 (246.30)18-12.28 (25.79)Outpatient13118.46 (298.72)153.20 (26.63)Total424.19 (279.85)45-3.24 (26.12)The main effect for DTCQ changes across groups was significant (F (2, 40) = 4.009, P = .026, ?p2 = .167). Post hoc comparisons showed the difference between the inpatient and outpatient groups to be significant (P = .013, two-tailed), with the inpatients having moved on average in the direction of lower T2 than T1 scores, and the outpatients having moved on average towards higher T2 than T1 scores. None of the other post hoc comparisons were significant. The main effect across groups for confidence scale ratings was not significant (Kruskal-Wallis ( χ2 [2]) = 1.720, ns). None of the inter-group comparisons of changes in confidence scale ratings between T1 and T2 were significant. There was a significant difference between the inpatient and outpatient groups for magnitude of change in mean DTCQ-8 (self-efficacy scores) between T1 and T2. No other DTCQ-8 comparisons were significant regarding treatment journeys that started in three distinct contexts with different coercive characteristics. 8.3.4Changes in Attribution Scales at T2Table 23 summarises the changes in the attribution scale scores following treatment.Table 23: Changes in attribution scale ratings following treatmentGroupAttribution to difficulty mean (SD) difference scoreAttribution to effort mean (SD) difference scoreAttribution to knowledge mean (SD) difference scoreAttribution to people mean (SD) difference scoreAttribution to luck mean (SD) difference scorePrison(n = 12)0.25 (1.06)-0.17 (1.70)-0.08 (1.73)-0.17 (1.03)0.33 (0.78)Inpatient(n = 18)-0.06 (1.39)-0.06 (0.10)0.28 (0.90)0.55 (1.10)-0.50 (1.10)Outpatient(n = 13) 0.39 (1.81)-0.46 (1.60)-0.46 (1.51)0.00 (1.58)-0.15 (1.63)Total 430.16 (1.43)-0.21 (1.37)-0.05 (1.36)0.19 (1.26)-0.16 (1.23)None of the inter-group comparisons of changes in attribution scale ratings between T1 and T2 were significant. The Kruskal-Wallis chi-squared values for the respective scales were as follows. For the attribution to difficulty scale, Kruskal-Wallis ( χ2 [2]) = 1.131, ns; for the attribution to effort scale, (Kruskal-Wallis ( χ2 [2]) = 0.570, ns); for the attribution to knowledge scale, (Kruskal-Wallis ( χ2 [2]) =2.289, ns); for the attribution to people scale, (Kruskal-Wallis ( χ2 [2]) = 3.600, ns); and for the attribution to luck scale, (Kruskal-Wallis ( χ2 [2]) =3.932, ns). 8.3.5Correlations between T1 and T2 scores across groupsWhilst sample attrition limits any conclusions which may be drawn regarding the stability of scores on the psychological preparedness variables between T1 and T2, correlation coefficients were nevertheless calculated for these scores in order to make some preliminary investigation of stability. Correlation coefficients were calculated within the outcome groups (i.e. heroin used at T2 and heroin not used at T2, respectively), but across the T1 treatment groups. For participants with T2 heroin use there was a significant correlation for the SOCRATES recognition scale (r (29) = .400, P = .032, two tailed), and a marginally non-significant correlation for the taking steps scale (r (29) = .363, P = .054, two tailed). However, the SOCRATES ambivalence scale showed no correlation (r (29) = -.011, ns). Therefore, those using heroin at T2 showed a measure of consistency in problem recognition and taking steps, but no consistency in ambivalence. For participants who were not using heroin at T2, only the taking steps scale showed a significant correlation (r (13) = .587, P = .035, two tailed). For the recognition scale, r (13) = -.048, ns, and for the ambivalence scale r (13) = .231, ns. For those not using heroin at T2 there was consistency in taking steps, but not for recognition or ambivalence. All three DASS-21 scales showed significant correlations for participants using heroin at T2, with r (25) = .541, P = .005, two tailed for the depression scale; r (25) = .554, P = .004, two tailed; for the stress scale; and rs (25) = .824, P < .000, two tailed for the anxiety scale. Mood was therefore consistent for those who continued to use. However, for participants not using heroin at T2, none of these scales showed a significant correlation. For the depression scale, r (12) = .096, ns; for the stress scale, r (12) = .272, ns; and rs (12) = .321, ns for the anxiety scale. Mood was therefore not consistent for those not using heroin at T2. The DTCQ8 scores were not correlated for T2 outcome group. For participants using heroin, r (30) = .239, ns, whilst for those not using heroin at T2, r (13) = .419, ns. However, the visual analogue confidence scales were significantly correlated for both outcome groups, with rs (31) = .536, P = .002, two tailed, for participants using heroin; and rs (14) = .574, P = .032, two tailed, for nonusers at T2. Confidence scale ratings showed consistency across T1 and T2 regardless of T2 heroin using status, but self-efficacy did not.For heroin using participants at T2, the attribution to difficulty scale showed a marginally non-significant correlation (rs (30) = .358, P = .052, two tailed). However, the correlations were not significant for the attribution to effort scale (rs (30) = .017, ns), the attribution to knowledge scale (rs (30) = .080, ns), the attribution to the person scale (rs (30) = .267, ns), or the attribution to luck scale (rs (30) = .087, ns). With a lack of heroin use at T2 there was consistency with attributions to knowledge and person but not for attributions to effort or luck. For participants not using heroin at T2, marginally non-significant correlations were found for the attribution to knowledge (rs (13) = .548, P = .053, two tailed) and the attribution to the person (rs (13) = .524, P = .066, two tailed) scales. However, the attribution to difficulty (rs (13) = -.198, ns), attribution to effort (rs (13) = .325, ns), and the attribution to luck (rs (13) = .205, ns) scales did not yield significant correlations.8.4Interim DiscussionSOCRATES can be used as a good predictor of outcomes and incorporates different aspects of motivation. The 19-item scale scores from the domains of recognition, taking steps, and ambivalence were considered (appendix K). A high score in the recognition profile is a direct acknowledgement from the participant that they are experiencing significant problems in their drug taking, and have a desire to change that behaviour, for fear of resultant harms occurring without any changes. No significant difference in SOCRATES scores is reported at T1 and T2. DASS 21 mood scores showed consistency for those using heroin at T2, but not for those not using at T2. Participants who had higher confidence scores at programme entry with rising levels of self-efficacy during the course of treatment had better drug abstinence, suggesting the rise in self-efficacy could be an abstinence predictor at treatment exit. In contrast abstinence in the inpatient group showed decreasing levels of self-efficacy along with decreasing levels of confidence in treatment. DTCQ provided a measure for self-confidence, or self-efficacy, were as the visual analogue confidence scales measured individual’s confidence in their treatment programmes effectiveness (McLellan et al, 1994; Gossop et al, 2001; Carey et al, 2002; Gregoire and Burke, 2004; Oliver et al, 2010; Orford et al, 2010). In this case the decrease in self-efficacy predicts treatment effectiveness. Enhancing factors for treatment entry and retention may include, and require, measurement of low mood, motivation, treatment readiness and confidence for treatment as being effective (Anglin and Hser, 1991; Miller, 2000; Ayling and Grabosky, 2006; Braun and Clarke, 2008). The perceived benefits of motivation at treatment entry suggests that the presence of legally mandated referral and social network pressure to quit, does not affect participant engagement at treatment entry (Osborne and Gabler, 1992; Day et al, 2004; Wild, 2006; Campbell et al, 2007; Best et al, 2008). Chapter Nine: Discussion 9.1IntroductionThis chapter will discuss the findings in relation to the evidence base presented in the literature review. Participant perception or construal of coercion was the central research question and study focus. The research question and focus of the study was to investigate “How does the participant construal of pressure influence their entry, retention, and completion of drug treatment programmes?” in three treatment settings.Specific research questions were: How did the treatment contexts with regard to participants’ construal of coercion at T1 influence outcomes at T2?How did treatment groups differ at T1 with regard to demography, drug misuse history, treatment history, and relevant psychological variables that influenced participant status at T2?How treatment outcomes at T2 were related to drug misuse history, cost of drug use, and confidence in treatment at T1?Were the psychological variables influenced between T1 and T2?The main findings related to treatment entry, retention, and pressures to remain in treatment are discussed highlighting group differences. A summary of findings are presented in table 24 below. Table 24: Summary of main study findingsFinding 1: Coercion from self and familyParticipant motivation and family derived coercion (informal) are valued and beneficial; more so than criminal justice (CJ) sanctioned (formal) treatment alone. The importance of family engagement and the social support it offers are paramount. The importance of family relationship support in drug treatment appears to lead to improved outcomes and treatment retention.Finding 2: Pressure construal of heroin treatmentCoercive influences operate across the groups. Pressure from family can be considered more coercive than CJ formal sanctions, and extends across all study treatment programmes.Pressures identified include, loss of opportunity in life, boredom, depression and anxiety. Family perceived pressures, family relationships, drug costs, loss of freedom. Heroin users who experience self and family pressure are more likely to attend treatment sessions and succeed in behaviour change. The prison group had a higher prevalence of secure relationships.Finding 3: DemographicsTreatment groups did not differ in terms of age or lifetime use of heroin. There were no differences in age for education termination. Finding 4: Heroin use at T2Of 48 participants that were available at T2, 33 (45.8%) continued to use heroin and 15 (20.8%) had stopped illicit heroin use. By group drug use in prison (n=13) 8 used heroin and 5 reported no use, inpatient group (n=18) 10 used and 8 reported no heroin use, and outpatient group (n=17), 15 used and 2 did not at T2. Age was not related to heroin use or not at T2. Finding 5: Treatment confidence and self-efficacyThe inpatient group was significantly more confident at T1 than the prison or outpatient group, and also demonstrated higher self-efficacy scores than the other two groups. The outpatient group had lower levels of confidence and family support against prison and inpatient participants. The higher self-efficacy scores and confidence scales at T1, the less likely participants would have used heroin at follow up. Finding 6: AttributionAttribution scores overall show no significant differences between treatment groups. The attribution scales predicted no T2 differences There was a significant difference on the attribution for luck that was borderline between the prison and inpatient groups.Finding 7: Mood Total combined DASS 21 scores at T1 showed no overall difference across the groups. The prison group had slightly higher depression scores than the other two groups. The higher the DASS 21 total the higher the depression and associated significance with self-efficacy was also found.Finding 8: Treatment readiness and eagernessOnly the SOCRATES recognition of a drug problem scale showed a significant effect across the treatment groups, with the inpatients scoring significantly higher than the outpatients. Inpatients showed significantly higher problem recognition than the other two treatment groups at T1. However, with data from all groups combined, abstinence from heroin at T2 was marginally non-significant to T1 scores on patients’ plans to take practical steps to become heroin free, rather than problem recognition. Finding 9: Participant attritionA third of participants were lost at T2 across all treatment groups. This is important to consider from a treatment perspective as treatment retention does improve successful outcomes that strengthens/ or weakens treatment and study outcomes. 9.2Coercion Experienced in Treatment This section will now look at coercion experienced by participants that were self and family originating. As discussed in the literature review coercion is present when pressures are applied and perceived by that individual as directing them into treatment (Klagg et al, 2006; Monahan et al, 2005). Motivation is defined as participant experiences that can be adopted and used as agents of change to either motivate persons or not, whereas family coercion was the perceived pressure influences that originated from family members. Whilst criminal justice sanctioned treatment is one form of pressure, many other forms were experienced across all participant groups from the present study (Kelly et al, 2006; Monahan et al, 2005). The findings did present some analytical challenges as coercion themes were often interlinked as considered in chapter 5. The first of the study theme of motivation is discussed followed by family coercion. Conceptually motivaion is considered as informal and is different from formal criminal justice sanctioned treatment. Coercion it is argued can be experienced in many different forms or types than referral source alone might suggest (Klagg et al, 2006). The qualitative finding of motivation is further divided into normality and stability, physical health concerns, and financial pressures. Formal coercion (external pressure) promoted treatment entry. Being in a stable relationship (married or cohabitating) and having a supportive partner is highly valued throughout the participant treatment journey irrespective of context. The prison group reported significantly higher levels of partner involvement than the other groups. Individual drug treatment within prisons works better when family support networks are maintained to sustain drug treatment, providing support mechanisms after release (Visher and Travis, 2003). In the study the outpatient group had lower levels of family support and this was one of a range of factors that placed this group as less effective in terms of heroin reduction than the other groups (see section 4.3.3). Similarly, lack of a stable family relationship in the outpatient and inpatient groups is noteworthy given that prison participants feel more supported and are the most environmentally restricted. A tripartite partnership between the participant, treatment service, and family is a beneficial aim but is likely to require some concerted mediation. Participants reported concerns for physical health existed as a consequence of many years of taking heroin. In particular participants who used heroin IV were more likely to report severe physical consequences due to poor veins that can lead to loss of limbs. Ulcerated areas reported from IV users acknowledged general poor health and neglect with poor diet, weight loss, dental decay and being prone to infection. Participants’ general health was poor with liver failure and risk of death through overdose feared and supported by national data as high risk activity from heavy heroin use. Worries over health concerns can increase health pressures and the need to commence heroin treatment. Heroin use is a high risk activity and worries can impact on family, due to funding heroin addiction and loss of finances. Children being taken into care through neglect, being made homeless and relationship tension all exacerbated finance concerns. Combined findings in terms of relationship and financial stability suggest that outcomes are more positive when present and the treatment journey is adversely affected when both are compromised (see section 4.3.3). In many respects the construal of coercion from the individual and group perspective may direct the method of entry into treatment programmes (Burns et al, 2011) (see section 5.1). For example if formally court sanctioned then external weighting is attached to treatment retention consequences for failure to comply. Coercion construal is more accurately relayed by the duration and type of coercion which are often significantly sustained in prison. Themes of boredom and captivity either from heroin use or treatment contexts crossed all treatment settings. The criminal justice system provides some initial leverage for treatment entry by enforceable threats that can be used productively (Werthheimer, 1987; Steadman et al, 2005; Skeem et al, 2006). Studies into coercion from mental illness populations have contributed to the growing interest into compulsory treatment (Burns et al, 2011; Monahan et al, 2007). Compulsory treatment from mental health studies has relevance to those addicted to heroin who are pressured into treatment as often overlap exists between groups, but care must be taken in study design and participant selection as mechanisms for entry and individual circumstances vary. The strongest influence reported in the study was that coercion could be experienced internally from individuals as well as externally from family and not solely by criminal justice system (see section 5.5). Internal (self) and external (family) pressures influence individual motivations to enter and remain in treatment. The findings suggest that a combination of pressures that originate from participant self and family coercion are beneficial to treatment outcomes (see section 5.3). This is important as this combination is not fully considered within the coercion literature for drug treatment (Seivewright, 2000; Gossop et al, 2001; Wild et al, 2006). Individuals may experience significant pressure from family and social networks which can be considered equally coercive and which also extend into voluntary treatment programmes. Additionally, this endeavour becomes more important to pursue due to the associations between length of time in treatment and more successful outcomes (De Leon et al, 1982; Ramo et al, 2010). There was no significant association with heroin use or between groups and the ability to secure follow up. Prison and inpatient group figures are similar in terms of heroin use at T2. It has been shown that continued heroin use could be exacerbated by the prison setting, with a lack of social support, isolation, boredom, and an increased desire to escape the prison regime through drug use (Hunt et al, 1986; Leenerts, 2003; Wheatley et al, 2005; Steven et al, 2006a). However, this study challenges this evidence as the prison group, in the main, did not differ significantly from the inpatient group in terms of heroin use. Outpatient participants used more heroin (and methadone) at T2 than the other two groups and provided further evidence for a lack of heroin reduction in that group. 9.3Psychometric measures Problem recognition and stage of change are indicators that could be used to determine the extent that an individual is ready for heroin treatment entry. SOCRATES was used to measure ambivalence and lifetime heroin use. When predicting if the participants could be followed up for the SOCRATES scales there was consistency (shown by correlations) for those using heroin at T2 between T1 and T2 problem recognition and taking steps, but no consistency in ambivalence. Conversely, a low score in recognition reflects denial that drugs are causing serious problems and therefore does not express a desire to change (see section 6.3.3). A high recognition score acknowledged that participants were experiencing significant problems in their drug taking, and had a desire to change that behaviour for fear of resultant harm occurring (Prendergast et al, 2009). Participants that display high levels of motivation to change have the best treatment retention rates, while the opposite exists for those who do not, regardless of the degree of external pressure and is supported from the literature (Ryan et al, 1995; Pulford et al, 2006; Wild et al, 2006).The last scale was taking steps and a high score indicates that participants are already making positive changes in their drug use (see section 6.3.3., 8.3.1). Taking steps was higher for those not using heroin and marginally non-significant. A high score in the taking steps profile has been found to be predictive of successful change (Simpson and Joe, 1993b). Low scores however indicate that they are not currently undertaking changes in their individual drug taking, or have not made recent changes in this regard (Miller and Tonigan,1998). Inpatients had significantly higher scores than outpatients at T1 on the SOCRATES ‘problem recognition scale’. However, SOCRATES scores overall highlight no significant differences and their value in this study was on two sub scales (taking steps and problem recognition) combined with other measures, DASS 21 depression sub scale and DTCQ. Participants who dropped out of treatment showed higher initial luck attribution scores and might have potential for exploration in those who believe luck has been a factor in their drug addiction (see section 6.3.1). This holds the potential to investigate at treatment entry and compare findings against those who exit and those who remain in treatment. Moreover, with study and treatment attrition rates being problematic it is worthy of more detailed consideration at the initial planning stages. Attrition is important as it is associated with heroin reinstatement and weakens study findings. Participant attrition and failure to recruit are further considered in section 10.2.2. The inpatient group was significantly more confident at T1 than the prison or outpatient group, and also demonstrated higher self-efficacy scores than the other two groups. The outpatient group had lower levels of confidence and family support against prison and inpatients participants. The higher the self-efficacy scores and confidence scales at T1, the less likely participants would have used heroin at follow up. Higher confidence scores at programme entry appear to support that treatment is going to be more effective. Increased recognition values for self-efficacy were an indicator for relapse or treatment success prediction on DTCQ8. A statistically significant result in maintaining abstinence was found also in the prison group for self-efficacy. Inpatients had reduced their self-efficacy belief scores in this interval, whilst outpatients had increased their self-efficacy beliefs (see section 8.3.3). In the confidence for treatment scale the prison group was the least confident followed by the outpatient and inpatient groups (see section 6.3.2). Inpatients had higher confidence ratings than the prison and outpatient groups. This is noteworthy, as treatment entry confidence and self-belief is an important psychological construct in this study. The evidence supports the literature in that the higher the confidence rating in the person’s ability to refrain from drug use when faced with a drug using situation, the higher the probability for successfully resisting heroin and urges to use (Hays and Ellickson, 2006; Ramo, 2010). This suggests that refining the focus of self-efficacy whilst the participant is in treatment could have a significant effect in predicting and reducing heroin use in the longer term (Litt et al, 2005). Similarly higher self-confidence on treatment entry is an important finding from this study and associated with improved treatment outcomes.The prison group had slightly higher overall scores on the DASS 21. Therefore this should have predicted that the prison group would have been more depressed, however in this study, surprisingly, they were not so. However, total DASS scores showed no difference across the groups and the sub scales at T1 (see section 6.3.4). The higher the DASS 21 total the higher the depression and associated significance with self-efficacy was also found (see section 8.3.5).The depression sub scale on DASS 21 has a negative co-efficient that suggests the higher the depression the more likely participants are to have used heroin within the six month period after treatment exit (see section 8.3.2) (Peters et al, 1992; Osher and Drake, 1996; Sciacca and Thompson, 1996). Using DASS 21 depression scale and DTCQ measures the score was much higher for the inpatient group, with the prison participants being the lowest of the groups with significant prediction for relapse or not. Higher treatment confidence scores at T1 suggests that treatment is likely to be more effective than not; the degree of treatment confidence and self-belief appears to support better treatment outcomes and is supported empirically (McLellan et al, 1994; Gossop et al, 2001; Carey et al, 2002; Gregoire and Burke, 2004; Oliver et al, 2010; Orford et al, 2010). The findings showed that no significant difference in mood was found between groups at T2. Shame was encountered from many areas in the participant’s life, through death, family life and relationship loss and life substituted by heroin. Again close associations between the coercion themes are often difficult to unpick, in this case feeling shame from losses attributed to heroin use (see section 5.3.1). Language used to describe heroin addiction as dirty or being clean was stigmatising and failed withdrawal attempts compounded feelings of despair (see section 5.3.2). The study identified participant depths of desperation and powerlessness to address the changes required. It is this lack of confidence compounded by myriad factors operating within addiction and choices for withdrawal that suggests outpatient programmes require closer inspection based upon treatment outcomes (Keen, 1999; Gossop et al, 1999; Amato et al, 2005; Campbell and Best, 2007; DH, 2010). The importance of family support and visits whilst in treatment contexts cannot be understated and whilst they may add to some shame experienced they were highly valued. Loss experiences were important and increased participant perceptions of treatment coercion. Coercion was amplified through loss of a normal life substituted by heroin, loss of role within family, loss of children, loss of parents, and the loss of family unit. The importance of family engagement and social support towards those addicted to heroin appears linked to loss, and is supported from this study and the literature (Granfield and Cloud, 1996; Marlow et al, 1996; Lawental et al, 1996; Best et al, 2006). Qualitative findings relay the lengths families would go to trying to persuade participants into drug treatment. Coercive influences on participants included those from their parents, partners, children and siblings and impacted positively promoting treatment programme entry. Heroin use was associated with children being removed, combined with relationship breakdown. Heroin addiction severity and length of time addicted suggests that participants may not be motivated to change until they are devastated by their loss of health, wealth, and close family (Rapp et al, 2003). Drug programme retention is a significant indicator towards successful treatment outcomes; the longer a person remains in treatment the more successful they are in achieving drug reductions (Best et al, 2001; Makkai, 2002; Stevens et al, 2005; Sullivan et al, 2008). A lack of motivation is common in heroin treatment and also a key factor present in less favourable treatment outcomes (Prochaska et al, 1992; DiClemente et al, 1999; Miller et al, 1999; Donmall et al, 2012). The construct of motivation has been a central feature of most studies on coercive treatment (Drieschner et al, 2004; Gregoire and Burke, 2004; Klag et al, 2006). The inpatient group had made a behavioural commitment to treatment compared to the prison group who had not directly made a treatment choice as a consequence of actions that brought about such change.Self-determination theory postulates that participants will be more motivated to change if they perceive that change as self-initiated, rather than being coerced into it. This is at odds with coercive treatment principles that are initiated by others, and in this study the criminal justice system provides that formal pressure (Ryan et al, 1995; Monahan et al, 2005; Wild et al, 2006). However participants can also regress in treatment as well as progress (Prochashca et al, 1992). Separating motivation from coercion presents a conceptual challenge as what one person perceives as motivation another may experience as coercion (Slevin and Sinews, 2000). Coercion does have a role in drug treatment irrespective of environment or treatment setting, but appears to be more effective in some settings than in others (Skodbo et al, 2007). Coercion can be experienced by participants from significant family members and external pressures such as the criminal Justice system. All these factors hold clinical significance when combining motivation, confidence for treatment, self-efficacy, perceived losses, and eagerness for treatment by participants. The relationship between forced treatment and outcomes is at the centre of the coercion debate. At a foundation level it is whether an individual who is compelled into treatment has better treatment outcomes than someone who enters voluntarily. Heroin treatment in prison is not compulsory but the method that propels them into treatment is through court sentencing. DRR group participants would also have to consent to the order being made so is not strictly compulsory treatment, but the consequences for failure to cooperate with the order are. However, it is too simplistic and arguably limiting to identify a programme as coercive or otherwise based upon referral source. This study had this as a philosophical underpinning from the design stage attempting to compare offender and non-offender populations’ perception of coercion. Essentially, the qualitative interview gathered data on participants’ perceived experiences of coercion on their treatment journey, whilst measuring some psychological variables to contextualise participants within the groups. Equally referral source alone does not reflect the degree, severity, or coercive effect on participants as some may enter coerced treatment of their own volition. But it is those who are coerced into treatment who might be self-referred patients or pressured by their family that interest the present study. Some studies suggest that it is those measures beyond referral source where the real predictive value of treatment is by investigating the many reasons for treatment entry (Burns et al, 2007). It is these motivating factors that operate at an individual and group level that open possibilities for targeted treatment combinations that has not been previously undertaken. 9.4Conclusion In essence individual construal of coercion cannot be attributed by court sanctioned treatment only but must consider and account for important influential pressures from self and/or families. Prisons are no more coercive than inpatient or outpatient groups from participant self-report, it is just the range and individual weighting of pressures which differ.When summarising the key findings it is noteworthy that there are more similarities than differences across the groups. From the data collected there was similarity across the study settings in terms of treatment modality and treatment journey. However it is important to acknowledge that consent and cooperation are requisites for all programmes irrespective of the setting, but it can be suggested that the prison setting has potentially reduced options with formal coercion removing some participant decision making consideration. Participants who attend treatment voluntarily are better positioned to make more choices (than those formally coerced).Understanding the components of effective coercive treatment and identifying exactly what works best, and with who, is not very well understood (McSweeney et al, 2008). The data in the study has shown that higher levels of confidence in drug treatment success, greater self-efficacy scores, combined with self-belief and family assistance in the construal of coercion may provide better treatment outcomes in those who have all factors present. Exploration of how participants interpret coercion to enter and remain in treatment could be developed which would take account of self and family pressures irrespective of context, specifically exploring relationship stability, loss, health concerns and finances - this may be valuable to pursue. An assumption might be that the prison group is the most coerced but what stands is that all groups experience coercion and it is individualised. Variables that better predict more successful treatment outcomes are higher confidence in treatment success and self-efficacy scores are beneficial for all groups, but more so for inpatients. SOCRATES recognition scale was predictive for drug abstinence especially for the inpatients group that was higher than the other two groups. None of the mood or attribution scores predicted heroin use at T2. The psychometric measures provide background and some interesting differences between the groups, but most striking is the fact that the groups are not that different from the measures used. There was a significant difference between the inpatient and outpatient groups for magnitude of change in mean DTCQ-8 (self-efficacy scores) between T1 and T2. The inpatients had moved in the direction of lower self-efficacy, and the outpatients had moved in the direction of higher self-efficacy. Mood scores showed consistency for those using heroin at T2, but not for those not using at T2.Therefore in summary the overall findings emerging from this chapter suggest that the outpatient group achieved the worst outcomes in terms of engagement, heroin reduction, retention in drug treatment and also drug abstinence (see table 28). Chapter 10 presents methodological considerations and limitations. Chapter Ten: Methodological Considerations, Limitations and Treatment Journey10.1IntroductionThis chapter considers the study methodological limitations in the interpretation of the findings. The mixed method design enabled the qualitative research to allow the participant perceptions of coercion to emerge, enabling a retrospective examination of participant recall of events surrounding coerced drug treatment and the antecedents of pressure on participants. The quantitative element allowed investigation of some supporting factors attributed to drug treatment success such as confidence for treatment self-efficacy scales therefore allowing a clearer picture of the treatment journey experienced across the contexts. 10.2Methodological Strengths and Weakness10.2.1Participant Considerations for Psychological Measures The process of checking participant understanding and accuracy of the data relayed was paramount to maintain study measures integrity. However, two psychological measures presented comprehension challenges that included the percentage weightings for the questions. Firstly, the DTCQ8 from no confidence to very confident scale (see appendix G). Secondly, the ATOS presented similar comprehension challenges from the four categories from some of the time to all of the time (see appendix F), with all four areas checked throughout the interview. Whilst this is anecdotal interview evidence this is an important consideration and potential study weakness. 10.2.2Participant AttritionOther studies have reported that drug programme attrition accounts for more than 50% of treatment discharges which is not to dissimilar to this study (Pulford and Wheeler, 2007; Woodward et al, 2008; Hay et al, 2011). A minimum 30% participant loss at follow-up is expected when drug treatment studies involve criminal justice referrals (Young et al, 1991; Gossop et al, 1997). US studies propose much higher treatment attrition rates with some reporting 70% of participants on probation or release from prison within the first three months, rising to 90% at 12 months (Taxman, 1999; Marlowe, 2002). Retention in drug treatment services is problematic and especially as there is a link between drug treatment success and the length of time in treatment (Lefforge et al, 2007; Pulford et al, 2010). In practice settings numerous studies have sought to indicate what retains participants in drug treatment, or has a bearing on treatment attrition although findings have been inconsistent for treatment retention and drop out (Stark, 1992; Callaghan et al, 2005; Berman et al, 2008; Oliver et al, 2010). Whilst attrition is expected in studies reasons for study exit, that might include drug relapse, would have been beneficial. Attrition at T2 is one limitation of the study that impacted on the sample sizes and in some cases they were insufficient for analysis of some combined factors (for example, still using heroin at T2). Addiction study findings could have been positively biased towards treatment completers and limits comparison opportunities against those who did not that were lost to the study. Nonetheless, treatment attrition is a fact within this and other studies and making concerted efforts to limit this effect could be a more realistic expectation (McKegany et al, 2006; Barendregt et al, 2006; Hakansson et al, 2010).Within this study a third of the participants were lost at T2 across all treatment groups (see section 7.2.3).The lack of available data for those lost to the study and to treatment services is disappointing and potentially weakens the study, and only allowed T1 measures as predictors to be used against those remaining in the study. Data from the prison participant group represents those remaining in prison at T2 and not those who had been released who were all lost to follow up.10.2.3Failure to Recruit The lack of DRR participants recruited into the study could have been a significant methodological threat placing the study at risk. However, recruiting additional participants to the remaining three groups helped offset this risk. A clear reason why DRR participants could not be recruited or refused was not found. Probation staff received the same briefing as other settings staff and the researcher was in attendance at the times possible participants attended probation appointments in order to clarify any concerns. It might be reasonable to speculate that due to high workloads of probation staff they simply did not approach many participants or participants themselves did not avail themselves to research studies; this needs to be examined and reasons for poor study entry addressed. Refusal may also have implications regarding the coercive nature of the probation context. A consideration for future endeavours investigating DRR populations is to anticipate low numbers and intervene opportunistically with staff and participants. Locating and recruiting participants out of treatment programmes irrespective of group was challenging and follow up over all groups required concerted efforts. One strategy to enhance future study recruitment challenges might be to incorporate targeted sampling from the outset that would bolster a research presence. Targeted sampling not just for DRR participants but all the groups is worthy of future study consideration, especially targeting those released from prisons and DRR attenders based on present study outcomes. Measures were adopted to anticipate recruitment and retention challenges, for example, face to face interviewing and a participant identified location at T2 including telephone and text calls. Follow up interviews were often arranged to coincide with scheduled treatment appointments. Flexibility of location and timing of interviews at T2 was participant selected and beneficial in securing interview combined with interviewer safety considerations. Research interviewer flexibility and being responsive to participant pressures if not addressed would have placed the study at risk. UK substance misuse studies have yielded low numbers at follow up, and in some studies have not been completed due to the problem of retaining participants beyond first interview (Meier et al, 2005; Masson et al, 2007). The study lacked representation from prison participants who were released by T2 follow up and is a weakness as discharged prisoners are not represented. Clinically, what is known is that drug treatment attrition rates are reduced when clinics are more conveniently located, smaller, not centralised, and have higher staff-to-patient ratios (Stark, 1992). Techniques that include reminder phone calls and personal letters could have been employed on a monthly basis in an attempt to prevent or reduce attrition.The challenge for T2 interview from the inpatient group was similar to the prison group as both treatment units were regional centres and participants were discharged throughout the north west of the UK. Discharge from prison and also from inpatient treatment, maybe to a home address, hostel, or in some cases homeless presented challenges for T2 interview. Long term substance misusers often relapse and require substantial and sustained tracking over the period of study to improve participant retention (Scott, 2004). 10.3Design LimitationsAs discussed in chapter 3 a descriptive mixed method design was adopted. For the quantitative element it is important to consider the internal and external validity of the design. Drawing upon the seminal work of Campbell and Stanley (1966) they propose factors that need to be considered including: history: maturation testing; instrumentation; selection mortality; section maturation interaction and statistical regression. Each of these points will be discussed against the study and limitations highlighted but are now summarised in Table 25. Table 25: Design limitations summary (Campbell and Stanley, 1966) Sources of InvalidityComment HistoryPoly substance useUn-natural interview setting, prison, inpatient unit or drug treatment clinic.Differences in interview roomsStage in treatment process and withdrawal stage Methadone maintenance or reducing regimeStandardised interview procedure and instructionsResearcher bias when explaining in more detail to ensure understanding of some of the measures cannot be ruled out, but was controlled for. Not all groups were the same.MaturationInterviews at T1 and T2 were designed for completion in under 60 minutesTiming for interviews specific for each environment due to constraints.TestingNo pre testing of participants on all the quantitative or qualitative measures was undertaken.InstrumentationSome validated quantitative measures did raise some participant understanding concern instances, requiring the researcher to explain the rating scales for two of the measures. SelectionSelection bias from treatment team staff for study inclusion was possible in the two week sampling window for each groupMortalityLosses of participants at follow up across all groups. All prison group participants remained in prison, and lacked discharged prisoner and DRR group members. Selection-maturation interactionAll interviews occurred within a two week period at T1 and T2 for each of the groupsAll data was gathered at one interview at T1 and T210.3.1History Poly drug use is individualised and whilst the primary drug of misuse was heroin in all those selected for the study, the influence of other substances cannot be confidently controlled for (NTA, 2009). Some participants remained on methadone at T2 and combinations with continued heroin use are an extraneous variable. The interview settings were not natural as data was gathered at T1 in treatment units, some having closed circuit television (CCTV) that might have influenced participant behaviour. T2 interviews for the prison group were the same as T1 locations, but for inpatients and outpatients locations changed as they were selected by participants in facilities used by drug treatment services. One example of influence was noise, and for prison interviews this was difficult to control and is variable dependent on the time of interview. Participants in prison treatment did have other considerations to be taken account of, security issues that restricted the time and length of interviews as prison routines could not be changed. Inpatients had similar concerns during a structured rehabilitation programme, and interviews had to take account for this, so the research did not interrupt this process or rush the pace of data collection. The groups are not all the same in the study and differences exist in treatment regimes, environment, and circumstances for treatment entry and completion which could be a study weakness. 10.3.2Maturation and SelectionInterviews conducted at T1 and T2 were designed for completion in under 60 minutes. Time limits influenced the quantitative measures administered for two main reasons. Firstly, participants were in the early stages of a drugs detoxification that was likely to impact on concentration levels if interviews endured for extended periods. Second, that environmental restriction to the prison and inpatient unit specifically time limited participant access to research project interviews. Maturation appears to be an issue particularly for the outpatient group, who were not improving in terms of heroin and methadone reduction in drug treatment programmes. Selection bias from treatment team staff for study selection and inclusion was possible, even with researcher briefing sessions at the start of each group recruitment process. Nonetheless, participants were not randomly assigned to groups but do represent those undergoing treatment in their respective contexts. Differences between the groups on data gathered with the Addiction Severity Index (ASI) were carefully recorded and considered, with all T1 data having been gathered during one interview within a two week period to the respective treatment context. 10.3.3Testing and InstrumentationNo pre-testing of participants on all the quantitative or qualitative measures was undertaken. There were no extreme scores reported in any of the groups at T1 or T2. The validated quantitative measures did raise concerns in some instances, requiring the interviewer to explain the rating scales for two of the scales (DTCQ and ATOS). The rating scales that offered percentage ranges proved the most challenging when divided into 20% bandings, and posed some participant understanding challenges to interpret the scales. Evidence suggests 80% prisoners have the writing skills equivalent to that of an 11 year old, and similarly 50% have a comparable reading age (Social Exclusion Unit, 2002). The scaling of some variables was perhaps not sufficiently sensitive to capture subtle differences with the reduced sample size. 10.3.4MortalityStudy mortality relates to those lost to follow up is important to mention in a drug addiction study, which may also mean lost to the study through death. What cannot be established is whether some of those lost to the study were still alive at T2, for example those discharged from prison are a particularly high risk group from a drug overdose (Home Office, 2009). All participants released from prison could not be found and this weakened the study by a lack of a discharged comparison group, and reduced total group size at T2. All prison group participants who remained in prison agreed to T2 interview, although they were a captive participant group. 10.4Methodological Weaknesses10.4.1External ValidityExternal validity for this research study is summarised by population and ecological validity that will be discussed below (see table 26). Table 26: Summary of research external validityPopulation validityThis Research Study1Differences between the study and target populationUndertaken in north west region of UKRepresentative of three context admissions over two week period for heroin addiction treatment and follow up at six months2Interaction between treatment and subject characteristics Treatment for heroin withdrawal but differences in treatment regimesEcological validity1Adequate explanation of the variables under study Use of standardised and pre-validated measures for the quantitative data2Multiple treatment interferenceTreatment regimens are not standardised. They all involved methadone prescribing but were all different programmes. 3Interaction between history and the treatment effectNA4Interaction of time of measurement and treatment effectsTreatment effects focused on time leading to admission and post treatment at six month follow up5Reactive/interactive effects of measuringParticipants interviewed in side rooms at treatment settingsBase line testing at T1 and repeated at T2 to compare changes6Hawthorne effectParticipants know that they are participating in a study and may influence the reporting accordingly7Novelty and disruption effectSettings used that usually do not attract outside interest due to routines and environmental demands8Researcher effectResearcher interview interest but also suspicion for purpose from participants 10.4.2Population and Ecological ValidityThe study was only carried out in one region across the UK and accepts that treatment programmes can differ within the same region (Hay et al, 2011; NTA, 2012). A representative sample of participants was achieved over a period of two weeks over the treatment contexts. But, some caution in the generalisability of the findings into other populations or localities is required, for example inpatient and outpatient treatments that can be very different (Bernard, 2000). Representativeness may not matter due to sociocultural differences between different populations of drug users in different countries and even in different regions of the same country, where socioeconomic and family variables may differ widely. Study sample representativeness acknowledges the pragmatic approach needed to recruit due to the issue with setting access to the participants. This was an all-male study by design and generalisations and findings from this study cannot be made on female substance misuse contexts. But males are considerably more likely to be imprisoned than women, with a ratio of 15:1 (Nelson-Zlupko et al, 1996; Makkai, 2002; House of Commons, 2013). Every effort was made to reduce the ‘Hawthorne effect’ through consistency of measures with a set format adhered to. The researcher presence and potential influence especially for prison participants was unavoidable due to setting suspicion.10.4.3Qualitative Rigour It is important to consider the rigour and transparency of the design for the qualitative element. Drawing upon the 32 item checklist by Tong et al (2007) Consolidated Criteria for Reporting Qualitative Research (COREQ). COREQ is used by researchers and scientific journals to review qualitative processes adopted. The completed checklist aims to improve the rigour and credibility of the qualitative interview and analytical process adopted and proposes three domains that need to be considered in qualitative investigation including: research team reflexivity; study design and theoretical framework; and analysis and findings (see table 27). The use of the checklist enables identification of weaknesses promoting explicit and comprehensive reporting that in turn strengthens the qualitative results (Tong et al, 2007).Table 27: The assessment of the study using the COREQ toolDomain 1: Research team and reflexivity.Personal CharacteristicsQualitative Interviewer/facilitator which conducted the interview?Credentials of researcherOccupation at time of interviewResearcher gender?Experience and training of researcherWas a relationship established prior to study commencement?Participant knowledge of the Interviewer?Interviewer characteristics reported?Researcher (SJ) conducted all interviews MScLecturerMaleSupervisors for PhD monitoring progressNo participants met the researcher prior to interviewInformation provided and participant information sheetPhD study as part of an education awardDomain 2: study design Theoretical framework Methodological orientation? Participant selection Sampling. How participants were selected? Method of approach. How were participants approached? Sample size. How many participants were in the study? Non-participation How many people refused to participateSetting of data collection. Where was the data collected? Presence of non-participants. Was anyone else present besides the participants and researchers? Description of sampleInterview guide Repeat interviews?Audio/visual recording?Mixed method orientationParticipants selected by treatment unit staff over 2 week consecutive period until target reachedFace to face72(24) Lost over all settings from the study. No DRR participants recruited and no prison discharged group could be locatedPrison, drugs clinic, inpatient treatment unit and if discharged in community treatment locations at T2 No all had private interview space.NoMale, longer term drug users with primary addiction to heroin. Semi structured interview guide designed for the study with prompt questions.All data gathered at one interview at T1 and T2, with no repeat interviewsUse of audio recording device with consentField notes? Duration. What was the duration of the interviews? Data saturation. Was data saturation discussed? TranscriptsField notes were made during and/or after the interview with consent10 minutesData saturation discussed in chapter 3.Transcripts were member checked at T2, and coding reviewed with supervision team Domain 3: Data analysis and FindingsNumber of data coders. How many data coders coded the data? Description of the coding? Derivation of themes?Software? Did participants provide feedback on the findings? Quotations presented? Data and findings consistent? Clarity of major themes Clarity of minor themes. Is there a description of diverse cases or discussion of minor themes?Initial coding by researcher, and then with 2 members of supervision team.Coding process described in chapter 3Themes derived directly from the dataManual coding process adoptedNoNo, and all participants did not want to receive any results/ findingsParticipant quotations presented to illustrate the themes / findings with participant numberThere was consistency between the data presented and the findingsMajor themes presented in the results and discussion chapterTherefore in relation to the above assessment, the study limitations include: treatment unit staff approached participants for study inclusion resulting in potential for selection bias. The lack of DRR participants has removed a group for comparison purposes that could have provided additional opportunity for comparing the data against other groups. Similarly the groups were not that different in terms of coercion encountered, but a coerced outpatient group may have allowed exploration of the phenomenon and is therefore a potential weakness. Although audio recording may have influenced participants into saying what they thought the researcher wanted to hear noting the vulnerability of these participants and also the location of data collection. This influence was reduced by explanation of the purpose of recording for analysis to capture all materials that could contribute to provide new treatment journey interventions. 10.4.4Trustworthiness of the FindingsExploring the trustworthiness of the findings, the study did not incentivise participant involvement beyond the possibility of improving understanding of coercion from participation. Participants were given opportunity at every stage to withdraw from the study during data collection. This was to promote the ethic that data was contributed freely and all were encouraged to be frank in their replies; with no overt consequences implicit upon them (Dervin, 1983; Shenton, 2004). The advantage of conducting the qualitative interview first was in order to avoid shaping participants responses with the quantitative measures, and can be viewed as a strength of the study (Bowling and Ebrahim, 2005). Treatment in all settings involves something being done to participants and institutionalisation does not assist in reducing relationship power influence. The conscious effort to acknowledge participant presence in the interview through a collaborative approach was important (Bowling, 2004). This propels the importance for standardisation of the interview procedure and consistent delivery of the qualitative element. However, with consistency to the forefront and presenting opportunities to check out understanding may raise bias from the researcher upon the participant (Bowling and Ebrahim, 2005). But this was important to ensure contextual clarity and understanding in the interview process. 10.4.5Mixed Method LimitationsHaving discussed the limitations of both the quantitative and qualitative elements of the study, it is important to consider the impact of the overall mixed methods design of the study. As previously discussed in chapter 3, there are recognised strengths and limitations of using a mixed method approach. The limitations in the design of this study are now considered and steps to overcome them where possible.As noted above the three groups represented hard to engage substance misuse populations across different contexts but inclusion of the DRR group may have allowed further comparisons to be made between groups and is therefore is recognised as a design limitation. The quantitative measures add relevant psychological constructs that were brought forward from the literature, operationalised in the form of a set of quantitative psychological measures providing a context for the qualitative interpretation of coercion. However a weakness of the study was in the large sample size with concurrent and follow up data collection times and its subsequent impact on recruitment especially at T2. Strategies were employed to target suitable interview times and venues, but even so this remained a challenge.10.4.6ReflexivityReflexivity considerations are acknowledged with the researcher’s expectations and assumption that the prison group was likely to be the most coerced of all the groups. Researcher presumption bias from study outset was that the referral source and environment could have been the main coercive determinants. However, this presumption was incorrect and was highlighted in the qualitative findings with participant self and family coercion having more influence above the referral source. Bias within substance misuse studies and treatment settings are widely accepted as a significant factor although often poorly defined and limits findings within studies (Moore and Polsgrove, 1991). Researcher bias has to be militated against by adopting reflexivity throughout the research process to limit opportunities of assumptive influence (Koch and Harrington, 1998; Cohen and Crabtree, 2008; Coolican, 2014). However the challenge is that bias and influence cannot be separated out completely from what we know, no matter how objective the endeavours (Sandelowski, 1993; Deetz, 1997; Eakin and Mykhalovskiy, 2003; Cho and Trent, 2006; Braun and Clarke, 2006; Yardley, 2008; Creswell, 2012). 10.5Summary The mixed method design with consistency of interview procedure, and selection of participants attempted to limit the influence upon external validity (Calder et al, 1983: Bowling, 2004). The study design was sufficiently robust in the main, to address internal validity concerns through the accurate use of validated data collection measures. Monthly contacts with participants may have increased ongoing participation. A strength of the study was the representative inference sample of participants following admission into very different treatment contexts (Bernard, 2000). Essentially, study participants were volunteers (not incentivised) and contributed their experiences of heroin treatment that may assist others in the future as a central ethic. On the other hand providing some financial or gift incentives towards participants may have mitigated study attrition rates at T2, but may possibly have contaminated the data. Generalisability to other modalities and treatment groups cannot be applied with degrees of confidence; however the findings are representative for experiences of three treatment groups. In effect, causal relationships between the groups cannot be attributed with confidence, and findings are limited to each group and their treatment experience. Transferability and subsequent external validity are constrained to the contexts to which the study investigated. Dependability is raised through the mixed methods approach establishing coercion origins through the qualitative element. What can be taken forward with some confidence is the study represents group participant perspectives within coerced drug treatment, and allows for criminal justice and non-criminal justice group comparisons. Despite the weaknesses identified the study did have participant response rates comparable to other studies investigating similar populations. In summing up the groups one of the most significant facts is that there are generally more similarities than differences between the treatment contexts, irrespective of being in the outpatient, prison, or inpatient treatment the shared importance of self and family pressures are valuable motivators. This is the only three group study design identified within the literature (to date) that included this specific range of treatment contexts. The study did collect considerable volumes of data over the groups for comparisons to be considered; ultimately the bringing together of the psychological measures and qualitative interview which had not been previously undertaken and was a considerable strength. Chapter Eleven: Contribution to Knowledge, Recommendations and Conclusion 11.1IntroductionThis chapter presents recommendations for further research, clinical practice and the contributions to knowledge that have emerged from the study. The overarching research question for the study presented in chapter one was to explore the effectiveness of coercion in four treatment contexts that later became three. The relationships and outcome differences between the contexts were examined by specific demographic, drug misuse and psychological variables with particular attention being paid to the types of coercion. Coercion was only examined through the qualitative data. The quantitative data addressed variables relevant to the therapeutic journey. The study was designed to meet the main study aim and investigate what coercive factors are beneficial in reducing heroin use. Despite the challenges faced in undertaking this study it has gone some way in answering the research question and achieving the aim of the study. 11.2Contributions to Knowledge The study has produced findings that incorporate an original contribution to the existing literature characterised by two main coercive influences (self and family), and has illustrated how some variables may differ across treatment contexts. Additionally, some variables yield significantly different results across the treatment contexts, whilst other variables do not. Furthermore this study also adds to the literature with regard to retaining participants in drug service programmes. While formal legal coercion is used as a mechanism to refer clients to treatment modalities, prior research remains unclear as to whether differential effects on retention exist among modalities and contexts (Burke and Gregoire, 2007; Easton et al, 2007).This is an important consideration, as the expansion of drug courts and legal mandates to treatment require a more complete understanding of the contexts in which coercion may be most helpful to the clients these policies are intended to assist. Early research into compulsory treatment found legally coerced clients have better post-treatment outcomes but this needs to be developed further following the OCTET and MacArthur study findings (Anglin et al, 1989; Brecht et al, 1993; Fagan, 1999; Polcin, 2001 Kelly et al, 2005; Monahan et al, 2005; Burns et al, 2011). There have been no published studies to date that have examined systematic differences in treatment among legally coerced and voluntary clients that might provide areas to advance understanding. The MacArthur perceived coercion scales provide a numerical rating of coercion and true or false scores to establish a presence of coercion. Coercion is more than being sanctioned to criminal justice programmes and it is important from the outset of treatment seeking to investigate how an individual attaches value to treatment pressures and their origins. Formal coercion provides a strong leverage point for assisting participants into treatment, the influence of service matching on treatment dropout must be considered since the direction of cause has not been established in this study. More specifically, participants may find more treatment benefit if the programme better fits their individual treatment needs. Formal coercion from criminal justice sanctions does have a role to play in directing treatment entry, but coercion levels perceived by participants from self and family are more powerful than criminal justice compulsory treatment. A key finding was that criminal justice treatments provide a mechanism for treatment seekers but not the sole one. The strongest motivational influence from the data was that coercion can be exerted from other sources and is not solely mandated from the criminal justice system. Perceived pressures reside within the individual’s motivation to enter and remain in treatment although a combination of pressures is required from self and family. Considering the evidence it appears that measuring and assessing treatment confidence and self-efficacy changes for all study contexts could be reasonable to pursue and a potentially valuable finding as lowered self-belief is associated with poorer outcomes (see section 8.3.3). 11.3OriginalityThe design of the study using three treatment settings has not been reported in the published literature to date. The three treatment settings provided the opportunity to investigate the role that coercion plays across drug treatment contexts. A unique feature is examining different group participants’ experiences of coercion, and not solely limiting the study to that of comparisons of one group against another. Additionally incorporating the range of psychological quantitative measures is novel and this has not been reported in any published studies to date. The study compared drug treatment contexts while controlling as many threats as was possible to internal validity. The qualitative element increased understanding of the role of family and participant motivation specifically relating them to programme entry and treatment retention. Recommendations for Clinical PracticeParticipants are motivated by seeking normality and stability, physical health and finances hold degrees of influence for treatment entry. Family coercion concerning finances, shame and loss are important with regard to treatment entry. It is suggested motivation and family coercion are considered jointly prior to and at regular intervals after treatment entry. There was the unexpected finding that at T1, the prison group showed significantly greater stability regarding partner relationships (including marriage), than either of the other two groups. The contribution of the greater time spent in prison to the maintenance of relationship stability in this group can only be a matter of conjecture. However, given the evidence from this study which may be argued to show greater alienation from the norms and expectations of mainstream society, this may serve as a basis for concentrating upon informal family based coercion with this group.In the context of the different experience of treatment, including elements of formal coercion, present in the three treatment contexts, it should be noted that whilst not differing from the other two groups in age or lifetime duration of heroin use, the prison group reported significantly longer lifetime exposure to prison than either of the two other groups. In this regard, the prison group reported having committed significantly more burglary offences than both of the other groups, and significantly more drug offences than the inpatient group. Considering formal coercion (and perhaps also informal coercion), there are grounds to regard those receiving treatment in prison as being more firmly entrenched in criminal forms of behaviour and, arguably therefore, more alienated from the norms and expectations of mainstream society. The implications for practice are how a person accommodates the pressures from himself and from family members must be given equal consideration. In addition, participant perceptions of the forces that propel them into drug treatment should receive closer clinical attention as they are different.Quantitative coercion scales could assist in raising the issues that should then be explored further with patients, which is where they could also be practically evaluated. The MacArthur CES measures could be used as a screening instrument for patients before admission to consider the psychological impact of treatment compulsion, but the acknowledgement of the importance of treatment entry pressures has clinical benefit. Clinical staff should investigate heroin treatment seekers perceived pressures on them from self and significant others prior to treatment entry. Both the confidence scale and DTCQ-8 were higher for heroin non-users than users at T2. Confidence ratings scores at T1 were positively associated with not using heroin at T2. The inpatient group was higher in both self-efficacy (DTCQ-8) and confidence for treatment compared to the prison group. With the literature indicating that such measures are positively related to desired treatment outcomes, there should be more of a focus towards promoting self-efficacy and confidence within the prison context, as opposed to a sole concentration upon coercion. Given the contextual differences between these settings for treatment, practice applications exist for developing confidence and self-efficacy measures regarding patients’ ability to successfully complete detoxification treatment. With regards to the psychological outlook on heroin use between participants in the three groups, there were no significant inter-group differences in the attribution scales at T1, and no predictive effect of these scales for treatment outcome. Consequently, the areas of attribution addressed would not seem to be relevant in considering recommendations for treatment which may or may not address coercion.It is notable that the mood scales did not show any significant differences across the treatment contexts. This would imply that adverse mood states do not pose a substantively different issue for treatment in these respective contexts, and for any recommendations for treatment.In the context of the different experience of treatment, including elements of formal coercion, present in the three treatment contexts, there was no association between treatment context at T1 and either availability for follow up at T2, or heroin use at T2.These considerations above would also go some way to establish what treatment and in what circumstances, with coercion and psychological measures considered that may improve treatment outcomes. 11.5Recommendation for ResearchA larger sample may have limited the effects of attrition on the results at follow up and is recommended for future study. Enforced community outpatient treatment in this study was not evaluated due to the absence of a DRR group. Community treatment is generally regarded as better in terms of outcomes and cost effectiveness than incarceration and should be considered for future research, and suggest strategies to address poor recruitment within this population. Participants released from prison prior to follow up interview were uncontactable and therefore lost to the study. Further research following up prisoners post-discharge is recommended and measures implemented that enhance study retention and limit attrition in this high risk group.Whilst this was a prospective longitudinal study, future studies could consider monthly contact with participants. More frequent contact may improve study retention but crucially gather outcome data on reasons for treatment drop out. Future studies might anticipate participant unavailability and include other informants, which might include clinical staff and families. Self-efficacy and treatment confidence characteristics could sit within informal (family and self) coercion more readily than formal coercion and is a suggested research direction.MacArthur coercion scales alongside the qualitative interview is suggested for future mixed method treatment pressures study adoption across a range of contexts (three or more). Incentivising participants considered for groups identified as hard to engage with associated higher attrition rates. No DRR participants were recruited. Studies that investigate how to improve recruitment of DRR participants and reasons for not entering studies or treatment are warranted.This study only focused upon males and further studies that compare gender specific coercion influences are required. Further research on female prisoners is recommended.There is a considerable paucity of studies that investigate the differences of care and treatment among legally coerced and non-coerced treatment groups. Perhaps what could be further explored are potential changes between prison and inpatient treatment contexts.11.6ConclusionThe study has shown that forcing drug treatment upon individuals should not be solely contingent on criminal justice sanctions. Early chapters have examined the literature with no firm conclusions drawn supporting legal formal coercion as a mainstay for heroin drug treatment over a range of contexts. The study set out to establish if coercive approaches lead to drug abstinence, and the presumption was that it would. However, by comparing participants on a range of treatment programmes and contexts it was possible to compare other coercive pressures operating, but not to compare widely between the groups. Treatment effectiveness at T2 was examined and it was noteworthy that despite having significantly higher methadone doses at T1 than the other two groups, the outpatient group did not demonstrate high levels of confidence and self-efficacy for treatment completion compared to inpatients. This finding calls into question what exactly outpatient support offers in the treatment of heroin addiction that leads to abstinence. Whilst heroin use outcomes did not differ across groups at T2, it should be noted that it was the prison group which had the highest levels of family support and long-term stable relationships. The qualitative data suggested that self and family generated pressures seemed to underpin more positive changes in drug habits. The psychometric measures including treatment confidence and self-efficacy could be used by clinical staff to monitor for early signs of treatment attrition when those scores reduce during treatment. 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Zinberg, N.?(1984) Drug, set and setting: The basis for controlled intoxicant use.?New Haven: Yale University Press.Appendix A: Individual Qualitative InterviewIndividual Qualitative Interview (QI) Semi-structured qualitative interview protocol?Introduce researcher and the topic of the research and the purpose of the interview – e.g. I wish to gain an understanding from your perspective on why you are on this treatment programme:1. Why are you on this treatment programme?Prompt-Can you tell me a little bit more about why you are getting drug treatment? 2. Do you consider yourself to have serious drug-related health problems? ?Prompt – Can you tell me more about the nature of these problems??3. Do you feel that anything has influenced you to have treatment??Prompt – Where do you feel this influence comes from??4. Do you have family members or friends who want you to be in treatment? Prompt - What are the attitudes of your family & friends to your being in treatment??5. What do you want to achieve in treatment?Prompt. Is this different from what you want to get from treatment?6. What are the motives of those people who maybe pressing you towards treatment?Prompt- how do you feel about their motives for this??Appendix B: Consent Form (Version 4)Centre Number: Study Number: Participant Identification Number for this trial: CONSENT FORM [Version 4] 29/12/2007Title of Project: The effectiveness of coercive and non?coercive treatment programmes for opiate users.Name of Researcher: Steven JonesPlease initial each box 5372100560070001. I confirm that I have read and understand the research participant information sheet dated 29/12/2007 (Version 4) for the above study. I have had the opportunity to consider the information, ask questions and have had these answered satisfactorily. I agree to the researcher making an audio-tape recording of the interview, but this will remain confidential.5372100164465002. I understand that my participation is voluntary and that I am free to withdraw at any time without giving any reason, without my medical care or legal rights being affected. 5372100427355003. I understand that relevant sections of my medical notes and data collected during the study may be looked at by the research team at Edge Hill University, from regulatory authorities or from the NHS Trust, where it is relevant to my taking part in this research. I give permission for these individuals to have access to my records. 537210069215004. I agree to my treatment unit Doctor being informed of my participation in the study.537210053975005. That the study is part of an educational qualification being undertaken by the researcher.5372100160655006. I agree to take part in the above study and consent to anonymous quotations being used in future publications that may arise from the study.______________ ________________ _________________ Name of Participant Date Signature _________________ ________________ ___________________ Name of Person Date Signature Taking consent When completed, 1 for participant; 1 for researcher site file; 1 (original) to be kept in medical notesAppendix C: Research Participant Information Sheet (Version 4)Research Participant Information Sheet / Version 4[RPIS 4] 29/12/07Taking Part in this Study We would like to invite you to take part in a research study. Before you decide you need to understand why the research is being done and what it would involve for you. Please take time to read the following information carefully. Talk to others about the study if you wish. Ask us if there is anything that is not clear or if you would like more information. Take time to decide whether or not you wish to take part1. Study TitleThe effectiveness of being pressurised into drug treatment units [coercive] and not being pressured into treatment programmes [non coercive] for heroin users.2. Purpose of the StudyViews from you about the pressures and influences that lead you into treatment will be explored. As someone entering treatment for substance misuse problems and treatment, you are invited to take part in a research project exploring the pressures that you have experienced before and on leaving the treatment unit. The researcher is undertaking this research towards a higher degree qualification. 3. Who is carrying out the study?The researcher is Steven Jones from the Faculty of Health, Edge Hill University, Liverpool.4. Why have I been invited? You have been invited to participate in this study as someone who is receiving treatments for drug misuse.5. What will happen to me if I take part? Taking part is voluntary in this study, and there may be some issues raised by the researcher about your situation that may upset you. If you do not want to answer any question asked in the research you do not have to. Taking part in the research or not taking part will not influence your treatment programme, but could well assist others in the future and lead to a better understanding of drug treatments based on your views.6. What will taking part in the research involve?Taking part will involve participating in 2 interviews, during the first week of your treatment and at six months following your treatment. The researcher would like to audio tape record the interview in order to avoid losing crucial information. The audio-tapes will be treated as confidential and will not be available for inspection by any person except the researcher. The tapes will be wiped when written up. During your interview the researcher will also undertake questionnaires. Both interviews will take approximately one hour each. A chart is available to show you the structure of the interview questionnaires [Flow chart 1].7. Do I have to take part? It is up to you to decide. We will describe the study and go through this information sheet, which we will then give to you. We will then ask you to sign a consent form to show you have agreed to take part. You are free to withdraw at any time, without giving a reason. This would not affect the standard of care you receive. 8. ConsentYour fully informed consent will be required to take part in this research. It is important that you give your consent freely and entirely voluntarily. Having consented to take part in the research, you are free to withdraw your consent at any time during the data collection process. You may also request that your data be withdrawn following this study. You will be given a copy of this information sheet and a signed consent form to keep. 9. Are there any possible risks involved in taking part in this study?Taking part in this research should not involve any more risk than that encountered in everyday life. However when asking information that is personal to you, the potential exists to cause you upset. The researcher would suspend the interview should this occur.10. What are the possible benefits of taking part in this study?We cannot promise the study will help you but the information we get from this study may help improve the treatment of people with substance misuse treatment programmes. 11. What if there is a problem? Complaints If you have a concern about any aspect of this study, you should ask to speak to the researcher who will do his best to answer your questions. If you remain unhappy and wish to complain formally, you can do this through the Edge Hill University complaints procedure.12. Will my taking part in the study be kept confidential? We will follow ethical and legal practice and all information about you will be handled in confidence. The interview information will not be disclosed to any other person without your written consent. Exceptions to keeping confidence will be made if you disclose any information, for instance, that you deliberately intend to harm yourself; harm somebody else or were you inform the researcher that you intend to commit a criminal act. The researcher will only disclose information after discussion with you, and will only be information specific to the actual situation.13. What will happen to the results of the research study? The results from this study will be available approximately two years following your interview and you can receive a summary of the whole study by telephoning the researcher on 01695 575171. You may collect or have a copy posted out to you of the research you have participated in.In the event of any publication arising from this research, the identity of all individual research participants will be protected. 14. Who has reviewed the study? All research in the NHS is looked at by independent group of people, called a Research Ethics Committee to protect your safety, rights, wellbeing and dignity. This study has been reviewed and given favourable opinion by Cardiff National Research Ethics Committee on 13/12/07. 15. Contact for further information.If you would like any further information about the study, Steve Jones can be contacted at the following address and will also be visiting the treatment unit throughout the week. You can discuss any issues relating to the study with the researcher by informing treatment unit staff.Steve JonesFaculty of HealthEdge Hill University University Hospital AintreeLongmoor LaneLiverpool Telephone: 0151 529 6242Appendix D: National Research Ethics Board Approval LetterAppendix E: Addiction Severity Index 5Appendix F: Attribution of Treatment Responsibility ScaleAttribution of Treatment responsibility/failings Scale [ATOS] Version 1Many heroin users fail when they try to give up the drug because: Place your cross near to the comment you believe matches the statement on the scaleKey 1=strongly disagree-; 2=disagree; 3=neither agree nor disagree; 4=agree; 5=strongly agree. It is just too difficult for them (EXT STABLE)12345Because they do not try hard enough (INT UNSTABLE) 12345Because they do not know the best way to set about it (INTERNAL STABLE) Ability12345Because of the kind of people they are (STABLE)12345Because of bad luck (External Unstable)12345'Internality - Externality' and 'Stable - Unstable'. ITALICS added for thesis onlyAppendix G: DTCQ 8DTCQ-8Sklar & Turner (1999)Site:____________ S.I.N: ______________ date: ______________INSTRUCTIONS: Please imagine yourself (as you are right now) in each of the 8 situations listed below. Please circle the answer (0, not at all confident; 20, 20% confident; 40, 40% confident; 60, 60% confident; 80, and 80% confident; 100, very confident) that shows how confident you are that you will be able to resist the urge to use heroin.I would be able to resist the urge to use heroin: Not at all very Confident confident 0 20 40 60 80 1001. If I were angry at the way things had turned 0 20 40 60 80 100 out2. If I had trouble sleeping 0 20 40 60 80 1003. If I remembered something good that had happened 0 20 40 60 80 1004. If I wanted to find out whether I could use heroin occasionally without getting hooked 0 20 40 60 80 1005. If I unexpectedly found some heroin or happened to see something that reminded me of heroin 0 20 40 60 80 1006. If other people treated me unfairly or Interfered with my plans 0 20 40 60 80 1007. If I were out with friends and they kept suggesting we go somewhere and use heroin 0 20 40 60 80 1008. If I wanted to celebrate with a friend 0 20 40 60 80 100Appendix H: DASS 21DAS S 21Name:Date:Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.The rating scale is as follows:0 Did not apply to me at all1 Applied to me to some degree, or some of the time2 Applied to me to a considerable degree, or a good part of time3 Applied to me very much, or most of the time1I found it hard to wind down0 1 2 32I was aware of dryness of my mouth0 1 2 33I couldn't seem to experience any positive feeling at all0 1 2 34I experienced breathing difficulty (eg, excessively rapid breathing,breathlessness in the absence of physical exertion)0 1 2 35I found it difficult to work up the initiative to do things0 1 2 36I tended to over-react to situations0 1 2 37I experienced trembling (eg, in the hands)0 1 2 38I felt that I was using a lot of nervous energy0 1 2 39I was worried about situations in which I might panic and makea fool of myself0 1 2 310I felt that I had nothing to look forward to0 1 2 311I found myself getting agitated0 1 2 312I found it difficult to relax0 1 2 313I felt down-hearted and blue0 1 2 314I was intolerant of anything that kept me from getting on withwhat I was doing0 1 2 315I felt I was close to panic0 1 2 316I was unable to become enthusiastic about anything0 1 2 317I felt I wasn't worth much as a person0 1 2 318I felt that I was rather touchy0 1 2 319I was aware of the action of my heart in the absence of physicalexertion (eg, sense of heart rate increase, heart missing a beat)0 1 2 320I felt scared without any good reason0 1 2 321I felt that life was meaningless0 1 2 3Appendix I: Confidence Scale for TreatmentConfidence Scale for Treatment [Version 1] On the scale, how confident are you that you will be drug free following your drug treatment. Place a cross on the line below -----------------------------------------------------------------------no confidence confident extremely confident The information below is for thesis purposes only and was not on the participant sheet.This measure is from the participant perspective at treatment commencement[1-10 analogue scale] 1= no confidence10= extremely confidentAppendix J: NHS Trust Research and Ethics Approval331279516065500Research Governance CommitteeService Governance Support TeamTrust OfficesTop floor, Hostel 2Parkbourn, MaghullMerseyside L31 1LWTelephone: 0151 471 2638Fax: 0151 473 2806Mr S L Jones, Senior LecturerEdge Hill UniversityFaculty of Health University Hospital AintreeLongmoor LaneLiverpool L9 7AL 18 February 2008Dear Mr JonesProject: 2007/18 Effectiveness of coercive and non-coercive treatment programme for opiate users Thank you for letter dated 25th January with enclosures. I note Ethical approval has now been granted by MREC for Wales on the 18th January 2008 and you have provided copies of the revised Participant Information Sheet and Consent form which have had minor changes in line with NRES recommendations. The Research Governance Committee approved your application on the 15th October 2008 and the Drugs & Alcohol Service has confirmed it is willing to support your research. Accordingly, I am pleased to inform you that your project has Trust R&D approval and can now proceed. Trust R&D approval covers all relevant locations within Mersey Care NHS Trust, however, you should ensure you have liaised with and obtained the agreement of individual RMOs, service and/or ward managers regarding recruitment and access.Please take the time to read through this letter carefully and contact the R&D Office should you require any further information. You may need this letter as proof of your approval.Honorary Research Contracts (HRC)All researchers with no contractual relationship with any NHS body, who are to interact with NHS patients in a way that directly affects the quality of their care, should hold honorary NHS contracts. For more information on whether you or any of your research team will require an HRC please liaise with the R&D office. It is your responsibility to inform us if any of your team do not hold NHS contracts.Research GovernanceThe Research Governance Sponsor for this study is Edge Hill University, University Hospital Longmoor Lane, Liverpool L9 7LN Contact: Mr Seth Crofts. Whilst conducting this study you must fully comply with the Research Governance Framework. This can be accessed at website then use the DH search facility. For further information or guidance concerning your responsibilities, please contact your research governance sponsor.Risk and Incident ReportingMuch effort goes into designing and planning high quality research which reduces risk; however untoward incidents or unexpected events (i.e. not noted in the protocol) may occur in any research project. Where these events take place on trust premises, or involve trust service users, carers or staff, you must report the incident within 48 hours via the Trust incident reporting system. If you are in any doubt whatsoever whether an incident should be reported, please contact the R&D Office for support and guidance.Confidentiality and Information GovernanceAll personnel working on this project are bound by a duty of confidentiality. All material accessed in the trust must by treated in accordance with the Data Protection Act (1998). NRRWe are required by DH to register all non-commercial research carried out within the trust on the National Research Register (NRR). These details are published on the internet at . Protocol / Substantial AmendmentsYou must ensure that the approved protocol is followed at all times. Should you need to amend the protocol, please follow the Research Ethics Committee procedures and inform all NHS organisations participating in your research.Monitoring / Participant Recruitment DetailsYou will be required to produce a short electronic progress report annually and at completion. Please make sure that you will be able to supply an accurate account of the recruitment targets and numbers recruited for this Trust. Reporting is kept to a minimum; however, if you fail to supply the information requested, the Trust may withdraw approval.Final ReportsAt the end of your research study, we will request a final summary report so that your findings are made available to local NHS staff. The details from this report may be published on the Trust intranet site to ensure findings are disseminated as widely as possible to stakeholders.On behalf of this Trust, may I wish you every success with your research. Yours sincerelyMrs Anne CleminsonHead of Service Governance and Riskcc:Mr R Dale, R&D Lead for Drugs & Alcohol Service Sponsor: Edge Hill University, University Hospital Aintree, Longmoor Lane, Liverpool L9 7LN Contact: Mr Seth Crofts Appendix K: SOCRATES 8D ................
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