Client Engagement in Legally-Mandated Addiction Treatment: A Prospective Study Using Self-Determination Theory

Objective: Mixed evidence on the effectiveness of using legal referrals to leverage treatment participation may reflect unmeasured variability in client motivations for seeking care. We hypothesized that associations between legal referral and client engagement would be moderated by reasons that clients sought treatment, as conceptualized by self-determination theory (SDT).

Methods: Adults entering a Western Canadian residential addiction treatment program (N=325; 49.2% male; 54.5% First Nations, Métis, or Inuit; 15.1% legally referred; M age=32.9 years, range=18-63, SD=10.3) rated the extent to which treatment was being sought because of coercive social pressures (external motivation; α=.85), guilt and shame about continued substance misuse (introjected motivation; α=.82), or a valued commitment to the goals of the program (identified motivation; α=.91). Six weeks later, clients rated their level of cognitive involvement in treatment (83.4% completion rate); chart reviews assessed retention status and number of days retained until drop-out.

Results: Multivariable Cox regression and logistic regression analyses showed that legally-mandated clients who reported low admission levels of identified or external treatment motivation were most likely to exhibit early dropout. Legally-mandated clients who reported high admission levels of introjected motivation were most likely to be retained in treatment with high cognitive involvement.

Conclusions: SDT provides a useful framework for describing how associations between legal referral and client engagement in treatment vary, depending on their reasons for seeking care.