Exploring Dimensions of Coercion across Treatment Programmes for Heroin Users: A Mixed Method Study


Student thesis: Doctoral Thesis


Despite 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.
To explore dimensions of coercion from the perspective of participants on heroin withdrawal programmes across a range of treatment contexts.
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.
The 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 Conclusion
The 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 adds
Essentially 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 study
Chapter 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.
Date of Award22 Nov 2016
Original languageEnglish
Awarding Institution
  • Edge Hill University
SupervisorPHILIP MURPHY (Director of Studies), LESLEY SUMNER (Supervisor), JULIE KIRBY (Supervisor) & BARBARA JACK (Supervisor)


  • heroin
  • coercion
  • Drug Treatment Pressure
  • mixed method

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