What does it mean to be "mandated" to treatment? Is a court order truly equivalent to leading a horse to water? Maybe. But such mandates are as much a legal fiction as the metaphorical horse who can't be made to drink. In reality, mandates do not exist.

Drug addiction (including to alcohol) is a chronic disease. It does not go away. But like asthma, diabetes, hypertension, or other organic conditions of the human body, there are tools and techniques by which it can be managed. If it is not treated, it will progress. Its course is predictable. At the end of its course, if it is left untreated, it is fatal, if some other disease or accident does not cause death first. Like someone diagnosed with cancer, the choice is not whether or not one will die, but on improving the odds of when and how.

Death is mandatory for all, but recovery remains an option as long as life persists.

"Mandates" sometimes construed as a measure of social control. But free will is a natural law. Natural laws always take precedence over legislation or court orders.

I have had discussions with countless patients, both those who claim they are in addiction treatment because they have "no choice" due to being "mandated" to attend; and those who feel that they enjoy a different status than their peers who are "not there for the right reasons" (i.e. "they" are mandated and "I" am not). The reality is that every addict who enters treatment is mandated - if not by the justice system, then by a spouse or child, by a parent, by a landlord, by an employer, by their liver, or by a desire to live rather than die.

Everyone in the treatment room is mandated or they would not be present. No one in the room is there because they enjoy spending their days talking about how to manage a chronic and progressive disease that has left their lives in chaos and resulted in innumerable losses.

On the other hand, it is equally true to say that no one is mandated. Everyone who enters treatment has freely chosen between that healthy option (recovery) and the less desirable option that some, but not all, describe as a "mandate" - whatever that alternative might be.

I have interviewed enough incarcerated inmates over the years to demonstrate this point by telling me they would rather serve their time in jail than be bothered with rehab. Choosing to engage in treatment is an exercise of free will. One with no desire to change their life may find it more convenient and comfortable to sit in a cell-block watching a television show selected by a corrections officer than to be bothered with the annoyance of counseling sessions and meetings.

The mere presence of a legal mandate is not nearly as influential as the patient's attitude about the significance of legal consequences.

Framed this way, I would hope, patients should be able to identify the nature of the "mandate" (with reference to alternative consequences) which places her or him on the same level as peers whose mandate is jail. We are all the same level; addiction is part of the human condition. It attacks its sufferers by undermining their free will. Paradoxically, they lose their choice over alcohol or drugs, until they make the choice to surrender.

It does not discriminate. Neither does recovery.

"The only requirement for membership is a desire to stop using," the third tradition says.

It doesn't matter what factor tipped the decisional scale motivating a person wants to stop using; or exactly where they might fall on a 10-point motivation scale. If 10 represents someone who is taking action to change, and 1 represents someone with no interest whatever in changing, as long as someone falls between 5 and 10, they are in the same category. It doesn't matter if their incentive is to stay out of jail, not to die of an overdose, or simply to enjoy life more fully. If they have that desire, they have started to get better.

This is more than a semantic point. Identifying with a recovering community is essential to recovery. The 12-step slogan, "Identify, don't compare" urges recovering people to look for similarities between others' stories and their own, rather than differences.

Looking around the room in group and saying, "These people are different from me" is comparison. Looking around for similarities is identifying. One leads to isolation, and the other to peer support.

The reason behind selection of word "Choices" in naming my counseling practice is to stress that free will and motivation are essential ingredients in behavioral change and recovery. If you want to get better, you can. There are no mandates. Some choices are easy, some difficult. The fewer the options that are on the table, the easier it may be to select the healthiest choice that leads to recovery.

Legal coercision, with respect to addiction treatment, often refers to the identity of the referral source. If ordered by a judge, or referred by a probation or parole officer, is more likely to be perceived by the patient as "mandated" by the patient. A perception of coersion occurs when personal autonomy is undermined. Perceived loss of self-determination may result in negative affect and disengagement from treatment activities.

I prefer to recognize the reality that people chart their own course basing informed decisions on awareness of benefits, risks, likely consequences, drawn from both what they learn from both identifying with the stories heard from others, and from their own experiences. Projecting or promoting the legal fantasy of a "mandate", when compulsory recovery is an impossibility, does nothing to promote psychological or physical healing.

See my theoretical orientation page for more on this.

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References

DB Marlowe, et al. (). Efficacy of coercion in substance abuse treatment, in Relapse and Recovery, FM Tims, CGLeukfeld, & JJ Platt ed., Yale University Press, pp. 208-224.

NS Miller & JA Flaherty (2000). Effectiveness of coerced addiction treatment (alternative consequences): A review of the clinical research, Journal of Substance Abuse Treatment, Vol. 18, No. 1, January, pp. 9-16.

TC Wild, B Newton-Taylor & R Alletto (1998). Perceived coercion among clients entering substance abuse treatment: Structural and psychological determinants, Addictive Behaviors, Vol. 23, No. 1, pp. 81-95.