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D COERCION IN ALCOHOL TREATMENT Constance M. Weisner At present, a wide range of measures representing varying degrees of coercion is an established component of entry to both public and private alcohol treatment. Although this development has occurred relatively recently within the context of the modern alcohol treatment system, the use of coercion is not an entirely new topic of debate. Involuntary treatment was an issue that received much discussion in English-speaking countries at the turn of the century, and the inebriate legislation that was passed to provide for coerced treatment still exists in many places. Coercion is defined in this paper as a form of institutionalized pressure (with negative consequences as an alternative) that results in an individual entering treatment. In the cases in which it refers to pressure by the family, coercion means those procedures in which there is an organized strategy involving some institutional contact. The types of coercion that are found in alcohol treatment today and that are discussed here are civil commitments, referrals to alcohol treatment from the criminal justice system, workplace referrals, and family and early intervention programs. These categories form a rough continuum of coercion, ranging from those that are legally mandated to those that are less explicit. In addition, there is variation within each category in the level of coerciveness and the range of practices used. Major shifts have occurred in all types of coercion within the past 20 years, and these rapid changes, along with its greater use, have gone largely unresearched. Many questions remain unanswered. Included among them but not addressed here is whether the treatment system is expanding to include these new groups of individuals or whether the new groups are replacing those who have traditionally been served. In the sociological literature, issues related to the interface between the medical and treatment systems and the criminal justice and other coercive systems are usually discussed in terms of the nmedicalization of deviance" (Conrad and Schneider, 1980~. American society in recent decades has seen a shift from frank punishment to the therapeutic treatment of deviance, although countertrends are also present (e.g., for opiates , . _ . A_ ~ ~ .. . . - at. , ~ ~ ~ , - 1n tile Lagos, and more generally In the Decline In tnerapeuuc corrections meals In criminology in recent decades). The "medicalization of deviance" literature reminds us that there are losses as well as gains in the shift from punishment to treatment-especially when one considers that frank punishment is often replaced by punishment cloaked as treatment but minus the civil liberties protection that accompanies punishment (Christie and Bruun, 1969~. Although different issues relating to coercion may surface depending on the type of treatment involved, some issues are common. For example, proponents of employee assistance programs as well as those who favor the use of the criminal justice system describe their client groups similarly as having a health problem and as Deviants" (Trice and Beyer, 1984~. It remains to be seen whether there will be long-term effects from rede The author is a senior scientist with the Alcohol Research Group, Institute of Epidemiology and Behavioral Medicine, Medical Research Institute of San Francisco. Preparation of this paper was supported by a National Alcohol Research Center grant (AA05595) from the National Institute on Alcohol Abuse and Alcoholism to the Alcohol Research Group. The author wishes to thank Thomas Babor, Herman Diesenhaus, Frederick Glaser, Robin Room, and Laura Schmidt for their consultation on earlier drafts of this paper. 579

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580 APPENDIX D fining the treatment population using a focus on deviant behavior rather than on illness. The objective of this paper is to describe the patterns of coercion in public and private alcohol treatment programs today. More specifically, it describes (a) the nature and prevalence of coercive referrals to alcohol treatment; (b) the distribution of criminal justice and workplace referrals in public and in private programs; (c) the epidemiology of alcohol problems within these clinical populations; (d) treatment outcome related to these programs and populations; and (e) the general impact of the presence of a largely coerced population in the alcohol treatment system. Before beginning the paper's main discussion, it should be noted that there are large gaps in the data related to these patterns and even in the vocabulary available for exploring these issues. First, definitions are problematic. In the literature, what is meant by coercion is often unclear; alternatively, varying terms and conceptions may be used. Second, data are lacking on the number and outcomes of coercive referrals to treatment. In a discussion of treatment outcome, examining the relationship between coercion and outcome seems crucial. This literature is not well developed, but related research suggests that coercion must affect motivation and readiness for treatment, the process of treatment, and the outcome of treatment. Wherever possible in this report, national data sets are used. Otherwise, state- and county-level data are presented to illustrate prevalent patterns across the United States. It should always be kept in mind, however, that there is often great diversity from state to state. Types of Coercion As noted earlier, there is a range of types of coerced treatment for people with alcohol problems forming a continuum from mandatory to less explicit coercion. These treatment types are discussed below. Involuntary Treatment: Civil Commitments Civil commitments lie at the most severe end of the coercion continuum. Commitments have long characterized mental health referrals; in fact, early psychiatric hospitalization was entirely involuntary. (It was not until the enactment of an 1881 Massachusetts law that voluntary admission to psychiatric hospitals was officially acknowledged and permitted.) By the 1870s, however, reform movements were under way to establish specific procedures for involuntary treatment, in part as a result of alleged misuse of the mechanism by the medical profession and because of cases of "railroading" by the families of some of those committed (Fox, 1978~. By the end of the nineteenth century, these reforms had led to requirements for independent examinations and trial by jury in many states (Appelbaum, 1985~. In addition to psychiatric hospitals, in some states, inebriate asylums provided treatment for alcoholism. These large, publicly run institutions for the involuntary treatment of alcoholics were founded during the 1870s, 1880s, and 1890s (Baumohl, 1986; Baumohl and Room, 1987~. They developed alongside community based Inebriate homes that had only voluntary admissions. Although only a few inebriate asylums were ever actually funded and established, the agitation to build them was a mark of therapeutic and public opinion regarding the historical place of involuntary treatment for alcohol problems. Influential doctors in the inebriate asylums movement spoke out strongly against voluntarism: "any concern about the liberty of drunkards was just so much sentimental nonsense'." (quoted in Bauhmohl, 1986~. There was a general feeling that voluntary inebriate homes were "wasting philanthropic dollars" and not adequately protecting families

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APPENDIX D 581 or society. The temperance physician and author of the mid-1800s, Henry Gibbons, recommended that asylums be Placed on a proper footing to consist of a rural asylum operated under medical direction with patients committed by the courts." Proponents of temperance also recommended that they become state institutions in order to have "powers to restrain patients (quoted in Baumohl and Room, 1987~. In an 1874 statute, Connecticut passed legislation allowing the involuntary commitment of inebriates to private institutions; other states soon followed its example. From the early l900s until the late 1960s the predominant criterion for involuntary commitment, whether under mental health or inebriate laws, was "need for treatment." Most commitments of inebriates were to mental hospitals under mental health law for "alcoholic psychosis. Under the Lanterman-Petris-Short Act, however, California in 1969 changed its criterion for mental health commitment to require evidence of dangerousness to self or others or evidence of "grave disability. That landmark legislation influenced the enactment of statutes in most other states (Hoge et al., 1989~. Consequently, in recent years, the focus of civil commitment in most states has been on mental illness resulting in imminent danger to the self or others (Dunham, 1985~. There are several issues relevant to a discussion of involuntary commitment today and its application in the field of alcohol problems. The issues discussed here are (a) the alcohol specificity of statutes (as well as specifications for procedures and the length of commitment); (b) the frequency of alcohol-related commitments; (c) changes in the criteria of dangerousness or of need for treatment used in statutes; (d) the philosophy of the least restrictive alternative, including outpatient commitments; and (e) distinctions between voluntary and involuntary admissions, including the official and unofficial functions served by commitments. Related to each of these issues is the question of alcohol's specificity-do alcohol-related commitments generally fit the pattern of commitments for mental illness? Statutory Specif~caimns for Alcohol-related Commitments States vary as to whether they have alcohol-specific commitment statutes, whether alcohol problems are included as a criterion within more general mental illness commitment laws, or whether alcohol problems are excluded as a criterion for commitment. There are also differences from state to state in the number and characteristics of different commitment sections in the various statutes. Within the general framework of commitment, there are many subsidiary issues (e.g., commitment for primary rehabilitation and extended care versus emergency commitment)." The states also differ in which departments are designated as responsible for commitment proceedings. Grad and colleagues (1971) reported that 35 states had involuntary commitment procedures for alcoholism, whereas 32 states had some organizational division or commission on alcoholism that was listed as having programmatic responsibility for commitments. The Grad team's compilation was a by-product of discussions in the late 1960s on decriminalizing public drunkenness arrests. There has not been a similar compilation since that time. More recently, Beis (1983) reviewed involuntary mental health commitment legislation across the 50 states, although not with a focus on alcohol problems. His brief descriptions of commitment criteria include only six states in which alcoholism, chemical dependence, addiction, or substance abuse are named in the criteria. Three states explicitly exclude alcoholism. The picture is actually more complicated than this, however, and a reading of the broader literature reveals examples of states that have alcohol statutes but that are not listed in Beis's review (e.g., see Gilboy and Schmidt, 1979; Mestrovic, 1983; Carlyle, 1988~. It is perhaps indicative of the low profile of alcohol problems in recent years in studies of mental health commitments that there has been no overall compilation of state laws focusing on involuntary commitment for alcohol problems since the early 1970s. Across state statutes, the provisions for commitment often vary for mental health and alcohol problems in terms of the length of commitment and the specific commitment

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582 APPENDIX D Across state statutes, the provisions for commitment often vary for mental health and alcohol problems in terms of the length of commitment and the specific commitment procedures. For example, Texas does not require a medical certificate for an alcoholism commitment unless the court orders an examination; for a mental health commitment, however, two certificates are required (Carlyle, 1988~. Because of the variation across states and the lack of comprehensive reviews on the subject, it is difficult to gauge the place of alcohol in the overall civil commitment framework. Frequent of Akohol-K - d Involuntary Commitments Little is known about the frequency of such commitments, although some figures are available on the total number of admissions for alcohol problems. Room (1980) reported that, for the United States, there were about 15,000 state and private mental hospital admissions for alcoholism in 1942 and about 128,000 in 1976 (from population bases of 133 million and 214 million persons, respectively). The proportion of involuntary admissions is unknown. Cameron (1983) reported that the rate of involuntary alcohol-related commitments to state hospitals in California per 100,000 persons in the civilian population aged 20 and older was 37.3 in 1950 and 0.2 in 1970. The peak was 45.6 in 1961, after which the rate gradually began to decline. It seems significant that a dramatic drop in the rate took place between 1969 and 1970 (18.7 to 0.2) after the commitment criteria were tightened (Cameron, 1983~. Recently, there have been a few state-level studies that include prevalence rates for alcohol-related commitments. It is not possible to generalize from the conclusions of these studies, however, because they include different alcohol-related categories (e.g., polysubstance abuse, substance abuse, alcoholism) and use different criteria (dangerousness, need for treatment, or both). One of these studies gives an indication of how prevalence rates for commitments might be affected by the use of different criteria. The Hoge team's (1989) study in Massachusetts found that substance abuse disorders were responsible for 15 percent of the primary diagnoses of all patients coming to emergency mental health services. Of those who met the criteria for commitment under the Massachusetts law (which uses the dangerousness and gravely disabled criteria), 9.5 percent had a primary diagnosis of substance abuse. Of those who met the criteria but did not voluntarily accept treatment, 12.3 percent had a primary diagnosis of substance abuse. Of those who met the Stone criteria,2 8.6 percent had a primary diagnosis of substance abuse. Thus, regardless of the criteria used, the proportion of cases with a substance abuse primary diagnosis remained about the same. There are also some data available from other states. Mestrovic (1983) reported Ahoy 177 n~r`~P.nt Of ~ ~mnl~ from ~ New York State osvchiatric hhosPita1 had symptoms .,, . a, ., if_. was ~ an. _ _,., _ ~ _ . . . Of alcoholism (18.2 percent had symptoms of drug use). , ~ , (New York's state statutes do not include dangerousness as a necessary part of the commitment criteria; two-physician certificate is sufficient for establishing the need for treatment iMestrovic, 19833.) Faulkner and colleagues (1989) reported that in a sample from an Oregon county, about half of the emergency commitment group and half of those in a temporary police holding group had a secondary diagnosis of either substance abuse or personality disorder. Cohen's (1987) study of civil commitments in Colorado found that polysubstance abuse was the fifth highest disability (14.9 percent) among commitments. Finally, an Illinois study by Gilboy and Schmidt stresses the importance of examining the role of alcohol in commitment as seen by the courts even when alcohol problems are not reported as the primary diagnosis. They describe a commitment case in which the doctor gave a diagnosis of mental illness, and the judge asked outright, "Is the basis of this, alcohol?" The doctor responded: "There is underlying mental illness, but alcohol is a contributing cause" (Gilboy and Schmidt, 1979:447~. Trends in Statutory Criteria of Dangerousness or of Need for Treatment Whether existing criteria should be relaxed is perhaps the most widely debated issue involving mental health commitments today. This discussion is not related specifically to alcohol ~^~ ,, - , ~ ,, ~ _ _ _J -J J

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APPENDIX D 583 commitments, however, and there is no extant body of research to inform a discussion of how alcohol-related cases would be affected by changes in commitment policy. Many of the writers who discuss suggested changes in criteria point out that there has always been dissatisfaction with the approach of any era. This viewpoint is summed up by Lidz and coworkers (1989:176~: The routine use of civil commitment distinguishes psychiatric care from other medical specialties, and the proper restrictions that should be placed on this nrofec.cinnal practice have been the source of continuing rid r controversy. In general, the history or civil commitment In the mu.. nas been a series of swings between rigorous, rule-bound standards and looser, more discretion-based procedures. Strict procedural systems have usually led to objections that people needing treatment were not receiving it. Looser standards have usually produced an outcry against the infringe- ments of civil liberties accompanying the application of broad clinical discretion. The 1960s and 1970s saw the most recent swing in this contin- uing cycle, with the growth of more rigid standards of commitment focused around the notion of dangerousness to self or others.3 Appelbaum describes the move at the end of the 1960s to increase civil liberties by providing extensive legal safeguards and focusing on dangerousness as a decriminalizations of the commitment process and the mental health system (Appelbaum, 1985~. He also makes the case that these changes, in their departure from the notion of a need for treatment, were intrinsically different from criteria that had been considered basic throughout the nineteenth and twentieth centuries (Appelbaum, 1985~. In fact, the controversy over the boundaries of civil commitment may simply reflect the ongoing tensions among disciplines over the mental health domain. Psychiatrists and other mental health professionals have traditionally argued for greater discretionary power over commitment decisions; the legal profession, on the other hand, has favored enhanced legal and judicial checks on the commitment process and assurances of the protection of patient civil rights (Fox, 1978~. The changes during the past 20 years that have precipitated the move toward a criterion based on dangerousness have resulted in a different set of criticisms from mental health professionals and patients' family groups. Many of these criticisms center around dissatisfaction regarding access to care and "right to treatment" issues (Dunham, 1985; Stone, 1985~. Currently, there is a move to broaden the criteria again. In 1983, for example, the American Psychiatric Association (APA) published its contribution to the debate, the Model State Law on Civil Commitment of the Mentally Ill (Stromberg and Stone, 1983~. Essentially, the APA model law argues for a "seriously deteriorating" criterion to be appended to the existing dangerousness criteria upheld by most states. It has been greeted with varying responses from the psychiatric, patients' rights, and legal communities, as evidenced by the broad range of literature on the subject. Some states (e.g., California) have proposed legislation that would implement a seriously deteriorating criterion; the presentation of the model law in 1983 reflects a general trend, supported by psychiatrists, to relax involuntary commitment criteria. There are good arguments on both sides of these issues. Civil rights proponents claim that relaxing the criteria would remove legal safeguards, and this significant change would occur without knowing whether inpatient hospitalization were effective (Rubenstein, 1985~. Wexler (1985) claims that the process would not ensure fair, independent, and multiple evaluations. There are also concerns regarding the financial impact of relaxed commitment laws. On the other side, Dunham (1985) argues that such a statute change would make it possible to get help earlier for people with problems.

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584 APPENDIX D examined the impact of such legislation. In one of the early efforts of this group of studies, Durham (1985) in Washington State, reported that, after statutes were relaxed (in 1979), involuntary commitments increased by 91 percent the year after passage of the legislation. The "grave disability" criterion embraced three-quarters of the cases. One of the repercussions of the changes in criteria was that there were not enough facilities or resources available; as a result, involuntary commitments were given priority over voluntary admissions.4 As might be expected, such findings have intensified the concerns of those who felt that the broadening of commitment criteria would result in undesirable net-widening. Yet at least one other study had different results. The Hoge team (1989) conducted a study in Massachusetts that compared the number of applicable commitments under the Stone commitment criteria and under the dangerousness criterion. The study found that fewer people were committed under the dangerousness criterion. The sample for this and other similar studies, however, constituted those who were already there-that is, those who had been referred under the more stringent criteria. Thus, the change was likely to be in referrals to treatment, and the available pool of patients was likely to be larger if the criteria were relaxed. Interestingly, it was thought that the requirement of the Stone model that Efficacious treatment" for the subject's condition be available would be a sufficiently restrictive criterion to keep commitments down. Instead, the study found that this particular criterion was not restrictive, as 87 percent of patients were rated by psychiatrists as being able to be effectively treated. The authors attributed this sizable proportion to the availability and current popularity of pharmacological treatments. Of course, for alcohol-related commitments, this finding may not apply because the field cannot rely on such treatments to the same extent as in mental health. Minnesota followed a course different from most of the other states by tightening its commitment laws in 1982. The criteria it uses include recent and overt dangerous behavior, a determination that the person has received full protection under prevailing due process guarantees, routing to the least physically restrictive treatment alternative, and screening by independent agencies of all applications. However, given such changes, no significant differences were found in numbers of commitments (Greeman and McClellan, 1985~. There is little research on the characteristics of persons admitted to institutions under the different types of criteria, but there is some suggestion the criteria may make a difference. In his review of civil commitment standards in three countries, Segal (1989) found that the criteria across the three nations could be divided into two categories: need for treatment and degree of dangerousness. His study showed that the different criteria brought different categories of individuals into treatment. Thus, although the field of alcohol problems is at an important juncture regarding shifts in civil commitment criteria, research to date does not give any clear direction regarding the effects of different legislation. In the absence of extensive and replicated research, professional and other interests appear to have dominated the literature in this area with rhetorical arguments for and against their positions. The historical tension between the individual's right to treatment and his or her civil rights remains visible and central to discussions of civil commitment criteria. Two institutional strains characterize the debate over commitment decisions. First is the strain between the legislature and the judiciary. The judiciary tends to hand down ~unimplementableH civil rights decisions. For example, decisions made in the Right-to-treatment" cases of the late 1970s required treatment of an intensity that many facilities cannot manage. The judiciary has clearly found "need-for-treatment" statutes unconstitutional, yet under the pressure of psychiatrists (e.g., the APA model law dictum) states still try to legislate such statutes. The second strain is the tension between civil rights lawyers on one side and psychiatrists and patients' family groups (i.e., the National

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APPENDW D 585 states still try to legislate such statutes. The second strain is the tension between civil rights lawyers on one side and psychiatrists and patients' family groups (i.e., the National Association for the Mentally Ill) on the other. This tension is the result in part of an old debate over professional boundaries (Schmidt, 1986~. Although this debate takes place in the mental health arena, the issues relevant to alcohol commitments are carried along with it without being separately examined. Commitment to the Least Restacfive Akerr~ive~ This concept came out of the same movement that produced deinstitutionalization, patients' rights, and mainstreaming. It recognizes the existence of a continuum within the larger involuntary commitment spectrum, referring both to issues of setting (inpatient versus outpatient) and to type of treatment (e.g., electro-shock, psychotropic medications) (Keilitz et al., 1985~. It can affect Recommitment screening and evaluation, involuntary civil detention procedures, and the continuity of community-based services, as well as release, transfer and diversion, and guardianship. Keilitz and coworkers (1985) argue that although the concept is difficult to apply in real-world practice and does not deal with the issue of quality of care, it remains an important principle in guiding procedures at every level. "Involuntary outpatient civil commitment (IOC)-the legal and psychosocial process whereby an allegedly mentally disordered and dangerous person is forced to undergo mental health treatment or care in an outpatient setting" is the most common implementation of this concept today (Keilitz and Hall, 1985:378~. In their review of state laws regarding compulsory outpatient treatment, Keilitz and Hall define IOC as "the dispositional options (lying between inpatient hospitalization and outright release) available to a civil court after an 'adjudication' of involuntary civil commitment" (1985:378~. Most states insist that the same criteria be applied to IOCs as apply to involuntary hospitalization, although four states use different criteria for the two types of commitment, and at least one of them appears explicitly to attempt to increase the potential of commitment with its use of the BLOC mechanism. Almost all states now allow for the use of IOCs, whereas 26 states and the District of Columbia have explicit provisions for it; nevertheless, there are also many differences in procedures and approaches across jurisdictions. The Distinction Between Involuntary and Voluntary Commitments This distinction is another important factor in an understanding of commitment. In fact, the issue of civil commitment cannot be understood without examining the underlying reasons for involuntary treatment. Although they are seldom addressed in the literature, the so-called "latent" or "unofficial" functions of treatment are central to understanding why patients are involuntarily treated. For example, Baumohl and Room (1987) describe the latent functions being served by involuntary commitment in the late nineteenth century: What inebriety doctors sought from the state, at least in English-speaking countries, pointed in two directions-toward fee-paying, private patients, and toward poor, urban drunkards. For private, fee-paying patients, doctors sought procedures to complement treatment. At a minimum, doctors wanted to be able to enforce the completion of treatment where patients had voluntarily entered into it. Beyond that, they wanted provisions to compel private patients into treatment. Essentially, this meant putting a tool in the hands not only of the doctor but also of the drinker's family. (p. 45) Sixty years after the period of the "inebriety doctors," Selzer (1958) reported that state boards of alcoholism and private psychiatrists were beginning to change their opinions about the motivational problems of involuntary commitments and to favor such commitments (because too many people left before treatment really began).

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586 APPENDIX D Some of the literature discusses the complicated question of the extent to which voluntary commitments are really voluntary. For instance, the appendix to the task panel reports of the President's Commission on Mental Health (1978) discussed three studies (with mixed results) that investigated whether voluntary or involuntary commitment was longer in duration and whether individuals who were voluntarily admitted really wanted to be there. Voluntary commitments may serve specific "latent functions; for example, Gilboy and Schmidt (1979) reported on the practice of persuading people to sign a ~voluntary" admission form to avoid a police custody form. The complexity and contradictoriness of the commitment process may also affect voluntary and involuntary commitments. For example, Mestrovic (1983) examined the intake process in a state hospital and reported on how the actual intake decisions were made. Some commitments were ~overturned" by staff at different levels of the institution, and some intakes became "involuntary" when patients refused to sign voluntary forms. His study is especially rich in exploring the arbitrariness of the process of admission and commitment. The commitment process is further complicated by a kind of plea bargaining that may occur when the patient waives due process rights in order to negotiate sanctions. Describing the process of deciding between voluntary and involuntary commitment, Cohen (1987) suggests the analogy to criminal plea bargaining. She summarizes the arguments on both sides of the issue, pointing out that the existence of involuntary commitment has had the overall effect of criminalizing the mental health system, whereas voluntary commitment uses fewer financial resources and often results in fewer sanctions for the individual. The motives of the person facing a commitment are an additional factor. Lidz and colleagues (1989) point out that for some the hospital is a place to receive "safe and timely" housing. Mestrovic (1983) also describes this room and board function, pointing out that admission is often sufficiently important to people that they fake suicide attempts to gain admission. The existence of social support to the persons facing commitment has been reported as an important variable in hospitalization (Schmidt, 1986~. At the institutional level (as in Baumohl and Room's description of an earlier period), involuntary commitment is a way to avoid the early termination of treatment (Lidz et al., 1989~. Lidz and coworkers also claim that the current treatment reimbursement structure often makes it financially imperative that a person be committed rather than admitted voluntarily. Another related issue involves determining for whom the commitment is being made. Is it for the sake of the person, the family, or the community (President's Commission on Mental Health, 1978~? Makela (1980) discusses the functions of commitment in solving family and community problems and argues: "It should not be up to the medical profession to take care of public order and the safety of the drunkard's family (p. 229~. It is important to examine the area of civil commitment because, although alcohol treatment commitments are rare in comparison with alcohol treatment generally, the coercion issues raised by the commitment process are more clear-cut and easier to discern. Diversion from the Criminal Justice System Referrals from the criminal justice system to alcohol treatment are the next level on a continuum of coercion.6 Diversion programs came originally from a focus on drug abuse. Programs in several of the states influenced the federal interest-for example, California's Civil Addict Program of 1961 (Anglin, 1988), which allowed for a seven-year commitment, and New York's 1966 civil commitment program of the Narcotic Addiction Control Commission (Inciardi, 1988~. This interest resulted in the passage in 1966 of the Narcotic Addict Rehabilitation Act (P.L. 89-793), which developed relationships between criminal justice and treatment agencies. It also allocated demonstration treatment funds

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APPENDIX D 587 and influenced the establishment of drug programs throughout the United States (Leukefeld and Tims, 1988). In 1972 the Treatment Alternatives to Street Crime (TASC) nrnoram It in motion :' ~f..ri~c of community-based diversion Programs (Cook and Law Enforcement r ~e, ~ .. v_. . ..~ A. _ _. _ , r Weinman, 1988). Such projects were often funded by the U.S. Assistance Administration (LEAA) and focused on crimes associated with drugs (Mecca, 1975). They commonly included panels of criminal justice representatives, treatment officials, and citizens who assessed cases for diversion from the criminal justice system to community alcohol treatment programs.7 Although federal funding of most such projects has ended, in some areas they were followed by state or locally funded formal diversion schemes. Even in areas in which no subsequent programs were developed the effects of the projects may still be felt. Their most important achievements were that they set a precedent and left behind an informal system of contact among the courts, probation officers, public defenders and other attorneys, and individual treatment agencies for referring people who commit a wide variety of criminal offenses. Today, these offenses include public drunkenness, alcohol-specific crimes, and non-alcohol-specific crimes in which alcohol is nevertheless considered to be a factor in the offense. Diversion technically indicates the transferring of the individual from the criminal justice system to a treatment program before sentencing and the removal of criminal sanctions from the case on the successful completion of treatment. In common practice, however, it has evolved to more loosely designate referral to treatment at any point in the adjudication process; such treatment then becomes either part or most of the sanctions imposed. Using this definition, diversion may occur both formally and informally.8 In some instances, a case is made by a probation officer, a public defender, a private attorney, or the defendant that the defendant has a serious problem with alcohol, that the alcohol problem is responsible for or related to the committing of the offense, and that alcohol treatment is more appropriate than the sanctions of the criminal justice system (Mosher, 1983~. Cases in this category are sometimes referred to treatment after sentencing, and treatment is considered to be part of the sanctions. On the whole, courts first convict an individual and then take alcohol into account (Mosher, 1983~. The offense is considered a crime, but the handling of it takes place in the alcohol treatment sector rather than solely within the criminal justice system. Sometimes the individual enters treatment through the suggestion of a police officer or through the encouragement of (or even a referral by) a public defender, attorney, or probation officer. The person may also enter treatment on his or her own initiative before the adjudication process is completed, a move that often affects later sentencing. The literature on diversion for drug abuse is helpful in understanding the alcohol case because drug-related diversion policy has been more clearly specified and there are many commonalities between it and alcohol-related diversion categories. The report of a joint German-American commission studying coercion in drug treatment (Brown et al., 1987) details the points in the criminal justice process at which diversion can take place. Diversion can be pre- and postadjudicatory. Preadjudicatory diversion can take place in lieu of arrest for instance, when a policeman gives someone an opportunity to go to a treatment facility rather than be arrested. (This particular category may be even more common on the alcohol side for public drunkenness, alcohol-related domestic violence offenses, and other such Crimes. There is also postarrest but preadjudicatory diversion, which can take place after arrest but prior to filing charges, at the district attorney's discretion, or after filing charges. Preadjudicatory diversion can also involve conditional release (often with the treatment program having some or all responsibility for the diverted person); treatment referral with disposition to be decided later, depending in part on treatment outcome (case responsibility is placed with the district attorney, the judge, or some other party); or a plea of guilty prior to adjudication for a negotiated treatment option. Postadjudicatory diversion can occur before sentencing, at which point a referral

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588 APPENDIX D can be made before the verdict is given or in lieu of a different sentence. Diversion can also occur after sentencing; in this case, sentencing is deferred while the individual is in treatment, or alternately, treatment may be a condition of release. These alternatives usually involve probation supervision as well (Brown et al., 1987~. All of these points at which diversion may occur represent different levels of judicial review, different levels of potential alternative sanctions, and different levels of interaction between the criminal justice and treatment systems. All of these points are defined for drug-related diversion; however, the categories and processes are similar to those for diversion to alcohol treatment. Historically, diversion for public drunkenness has received the most official attention. In 1971 the National Conference of Commissioners on Uniform State Laws recommended that all states enact the Uniform Alcoholism and Intoxication Treatment Act. This act was the culmination of a long history of attempts by various medical and legal interests to provide more humane treatment of the public inebriate (Kurtz and Regier, 1975~. Its objective was to handle this population within a medical rather than a criminal justice framework. It suggested a policy stating that "alcoholics and intoxicated persons may not be subjected to criminal prosecution because of their consumption of alcoholic beverages" (Hart, 1977:674~. As of 1985, 34 states had fully implemented the Uniform Act (Finn, 1985~. To be in compliance, states were required to have a plan in place that provided for continuity of care. This requirement was instituted to avoid the fragmentation of services and to ensure entry into the full range of services an individual might need. To be in compliance, states were also required to have appropriate commitment legislation and judicial safeguards. This legislation could be part of the mental health civil commitment statute, or it could be a specifically alcohol-related commitment statute. Each state considered meeting the Uniform Act criteria, but there were many factors that deterred across-the-board compliance, including the mandate to provide a full range of services. Because its purpose was to decriminalize an offense, the Uniform Act made diversion for public drunkenness significantly different from other types of criminal justice diversion. Yet its success is less than clear. Finn (1985) found mixed results in relation to how far responsibility for the public inebriate had moved from criminal justice to treatment. Overall arrest statistics indicated fewer arrests, but they had not always decreased as much as might be expected from the intent of the legislation. In addition, several states reported increases in other types of arrests, which suggested a possible legislative transfer function. Finn also reviewed the literature on the effectiveness of these programs and concluded that "the health care system has not improved the physical, emotional, or social condition of most public inebriates" (1985:16~. It is interesting to note that this is one area of criminal justice-treatment interaction that was fully and officially sanctioned by law; yet it has not been fully implemented, either legally or practically. Aside from public drunkenness, in which decriminalization is the issue, there are two types of cases that are diverted. First there are alcohol-specific criminal offenses, such as driving while intoxicated (DWI). Although there had been a history of traffic safety schools in many U.S. communities, the national attention given to a treatment approach for DWI individuals through the Alcohol Safety Action Projects has been important in establishing such interventions. Today alcohol treatment is an established sanction for DWI offenses, and in fact, many states have transferred much of the handling of DWI offenses to alcohol treatment programs. In some jurisdictions, many DWI drivers are given their choice of alcohol treatment or criminal justice sanctions; in other jurisdictions, they are automatically referred to alcohol treatment (U.S. Department of Transportation, 1976; Weisner, 1986; Stewart et al., 1987~. Whether sanctions involve alcohol treatment alone or a combination of treatment and criminal justice generally depends on the policy of a particular state and on the number of DWI offenses a person has committed. The social movement (e.g., Mothers Against Drunk Driving) toward more stringent sanctions for

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APPEND D 589 drinking drivers has been quite influential in promoting these changes and has resulted in a strong criminal justice function for alcohol treatment in the context of this treatment population (Reinarman, 1988~. The second diversion category includes offenders who are diverted because of their history of alcohol abuse or the involvement of alcohol in a non-alcohol-specific crime. The distinction here is that the individual is not referred to treatment because of an intrinsic condition as much as for a legal problem related to alcohol. The types of offenses range from burglary to domestic violence. These cases fall under the various diversion categories described earlier. In many criminal justice diversion cases, there are other coercion-related issues involving the type of treatment setting and the type of treatment modality. For example, in some programs, the individual is required (either by the court or by the program) to take disulfiram (Antabuse) (U.S. Department of Transportation, 1976; Bloom et al., 1988~. This requirement is a subtle form of coercion; an individual is not involuntarily given disulfiram but simply referred Back to the legal authority if he or she refuses it (see, for example, Bloom et al., 1988~. Another related issue is that an individual may not be given a choice between inpatient versus outpatient treatment settings. In fact, there is some indication that the treatment setting decision between residential and outpatient treatment is made on the basis of the seriousness of the crime rather than on the seriousness of the alcohol problem (Weisner and Room, 1984~. Raising issues on the other side, however, are recent moves toward evaluation and screening of individuals for referral into different types of treatment based on the seriousness of the alcohol problem (especially multiple-offender DWIs) (Klein, 1983~. This practice raises difficult legal questions concerning punishment that fits the crime rather than the condition of the offender. These questions will need to be resolved if the trend toward diagnostic-based referral continues. The Prevalence of Criminal Justice Referrals Referrals to alcohol treatment from the criminal justice system are numerous (Boscarino, 1980; Furst et al.,1981; Speiglman, 1984; Weisner, 1987a,b; Connecticut State Drug and Alcohol Abuse Criminal Justice Commission, 1988;), a state of affairs that seems to prevail at the international level as well. (A World Health Organization study found that 20 of the 43 countries researched had some type of diversion legislation [Curran et al., 19871.) There are two data systems that provide statistics on the prevalence of criminal justice referrals in treatment. NIAAA and NIDA collect data through the National Drug and Alcohol Treatment Unit Survey (NDATUS), a point prevalence survey of alcohol and drug treatment programs throughout the United States that has been carried out intermittently since 1979. Although it collects data on categories of individuals treated, the NDATUS does not collect individual-level data. Data are also compiled by the National Association of State Alcohol and Drug Abuse Directors, under contract with NIAAA and NIDA, and presented in the State Alcohol and Drug Abuse Profile (SADAP). The profile reports data from individual programs by state and is limited to those programs that are receiving some portion of their funds from the state. Because states do not organize services in the same way, the proportion of programs receiving funds from them varies dramatically. For some states the SADAP primarily excludes private for-profit and some nonprofit agencies. It has sociodemographic data on individuals in treatment, but the data are aggregated by agency for each program, which precludes individual-level data analysis. Thus, as will be discussed later, neither data system offers enlightenment us about the epidemiology of specific treatment populations because neither provides adequate client-level data. Also, neither provides data on the ~unduplicated" client count.

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600 APPENDIX D and family adverse consequences from drinking (Lettieri et al., 1985~. These measures, however, seem to focus on these consequences in terms of motivation to do well in treatment or remain sober and assessments of these factors. They do not obtain information on the importance or role of the adverse consequences in encouraging the individual to enter treatment; they also do not assess whether the negative consequences were contingencies to enter treatment or whether they were connected with treatment entry at all. Simply put, what is missing are such items as, "Did your spouse/the court, etc., insist that you come here?" or "Are you glad to be here?" Although the appropriate clinical approach takes the client pool as a given and assesses the motivational factors that affect staying sober, the appropriate policy approach would be to assess the effects of the various types of contingencies on the motivational measures. Thus, an understanding of the contingencies that affect entrance into treatment, the treatment process, and treatment outcome is important. Rather than understanding coercion as a dichotomous variable of coerced versus noncoerced, there is reason to examine it as a multifaceted concept. The degree of coercion and the types of contingencies vary greatly. The crucial ingredients may include the immediacy, strength, enforceability, duration, and consistency of contingencies. In addition, the relationship of contingencies to treatment readiness, motivation, and other individual factors warrants consideration. Implications for Alcohol Treatment As the discussion has shown, in the past 20 years there have been many changes that affect the entry into and the conditions of alcohol treatment, and those changes have not been well documented. As a result, any attempt to understand the effects of those changes is more likely to raise questions than to provide answers. First, although the data are persuasive that a significant shift has occurred in the manner of entering both public and private treatment, even basic statistics on the size of that change are lacking. The first task is to document the number of individuals who come to treatment by means of the various types of institutionalized coercion. This is not an easy assignment, given the nature of the health care system in the United States and the lack of overall and systematic data collection. Epidemiological data (e.g., sociodemographic characteristics, drinking patterns and problems, other drug use) for the various coerced populations should also be collected. If, for example, individuals in alcohol treatment increasingly have polydrug problems, the nature and prevalence of coercion are likely to be affected because coercion and diversion programs have much more of a footing in the drug treatment field. A second issue relates to overall access to treatment. Is the treatment system expanding to include these new groups, or are they replacing those traditionally served? National data seem to indicate that the public system has not grown in proportion to the _ ~ ~ ~ ~ ~ _ of_ ~ ^~ ~ ~ ~ A_~__ Abut Aid- ~ number of new referrals discussed here. lne growth In tne private sector also urn llo' appear to offer a solution because the private sector provides many of its services to different groups of people (Jacob, 1985; Yahr, 1988~. In those instances in which treatment services have expanded to accommodate these new client groups, are the numbers still so large that they overwhelm the alcohol treatment agenda? There appear to be tremendous differences across states in the proportion of services directed toward some of these new treatment groups (Diesenhaus, 1989), but there has been no consideration of the consequences of these differences for access and of the characteristics of treatment populations. Third, does treatment work for these new groups? Treatment outcome studies are lacking. It is difficult to understand how such a systemwide transformation in treatment

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APPENDW D 601 could take place without a solid research base. As has been pointed out, the outcome research is sparse and has methodological problems. Behind some of these problems (e.g., interchangeable comparison groups, mixed outcome measures) is the lack of conceptual framing to the point that there may be no theoretical base even for the existence of these coercive programs. Is the purpose to provide access to new treatment populations so as to intervene in alcohol problems early on? Is it to treat those individuals for whom drinking is related to legal problems? Is it to be more humane, more effective, or even simply more efficient than other sanctions? Is it to solve overcrowding within the criminal justice system? For work referrals, is the primary motivation to treat individuals whose drinking is causing job problems, or is it to fill empty treatment slots? It is simplistic to answer that all of these purposes can be served, because these functions do not easily coexist. Indeed, the conflicts in purpose among the programs can be seen in looking at outcome measures in the research. To some extent, the alcohol treatment system, through these new programs, has taken on broad responsibility for major social problems. Some of the larger questions relate directly to the functions of treatment (Speiglman, 1984~. How far is the alcohol treatment field willing to go in taking on a social control function? Are there contradictions in combining social control and medical functions? For example, is it consistent to define alcohol problems in treatment as health problems, even as disease, and at the same time as deviant behavior? The EAP as well as the criminal justice literature uses both conceptions. Perhaps this inconsistency is the result of treatment referrals based more on individuals' unacceptable behavior than on their health problems. There are also complex ethical issues regarding coercion that must be addressed by the alcohol field. One concerns the ethics of coercing someone to enter treatment when the effectiveness of that treatment is unknown. This issue is especially important in situations in which assessment for referral to appropriate treatment does not take place. This concern speaks to the lack of outcome research on coerced populations in general, as well as to the lack of outcome measures related more specifically to the different types and levels of coercion. As discussed earlier, individuals who enter treatment under pressure from one institution or another should not lose their rights; they should have alternatives to choose from, including an alternative to treatment itself. A second ethical issue relates to informed consent and the importance of providing the person with a full understanding of the proposed treatment program, as well as what is known about its efficacy. For both of these issues, it seems reasonable to extend the same protections as are granted individuals involved in research projects to persons entering treatment, especially when a person is entering treatment for reasons other than his or her own choosing. Finally, what will be the long-term effects of the public image of the alcoholic or problem drinker the image of who belongs in treatment? Although one hears about celebrities who enter treatment, the mainstream treatment client whose presence is felt in communities across the United States is increasingly seen as deviant. Will the long-term effect of coerced treatment, whether through criminal justice or the workplace, be to erode the hard-won nonstigmatized public perceptions of this problem as a health issue? This paper has attempted to point out that there are some strong, basic similarities related to coercion in treatment that cut across public and private institutions and across criminal justice and work-related referrals. It has also noted that there are new populations entering treatment, populations that are often entering treatment earlier in their experience of problems than in the past and whose diversity is invigorating the alcohol field and broadening its horizons. These populations also bring with them dilemmas and important overarching questions whose solutions must be vigorously sought if the field is to serve them effectively.

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602 APPENDIX D NOTES 1. Gostin (1987) provides an interesting description of the types of powers available for compulsory treatment of drug abusers in the context of testing for the human immunodeficiency virus (HIV) considered to be the cause of AIDS. In so doing he also provides a framework for looking at parallel issues for alcohol. Gostin describes three types of powers: (1) civil commitment, (2) referrals to treatment from the criminal justice system, and (3) public health powers (community health orders). 2. The Stone commitment criteria were developed by Dr. Alan Stone, who became one of the authors of the American Psychiatric Association's model act. His criteria are similar to the provisions of the model act, with two main exceptions: (1) the act does not have a criterion for dangerousness and (2) does not require a determination of incompetence to make a treatment decision (Hoge et al., 1989~. 3. The judiciary took action in a number of states during the 1970s, striking down need-for-treatment legislation on the basis of due process and equal protection rights. The following discussions are relevant: Alabama~ynch v. fly, 386 F. Supp. 387 (1974~; Michigan~ell v. Wayne Corny General Hospital at liaise, 384 F. Supp. 1093 (1974~; Kentucky~Ye~ v. True, 391 F.Supp. 419 (1975~; and Nebraska~oremus v. Farrell, 407 F. Supp. 514 (1975) (Schmidt, 1986~. 4. Zusman (1985) also speaks to this issue, saying that the changing of criteria has no practical implication in the real world if the system is not designed to handle the changes. 5. Appelbaum and colleagues (1987) elaborate a further question they consider pertinent to the overall discussion of voluntariness: Is the important issue involuntary versus voluntary treatment, or is it really which type of treatment should a person receive? Should a person who is being committed have the right to decide what type of treatment he or she will receive? 6. Treatment programs within the jails are the oldest interface of criminal justice and treatment. Modern examples date back to the 1940s, but programs in jails can be identified as far back as the early 1900s (Baumohl and Room, 1987~. 7. Unlike the alcohol treatment sector, the drug treatment sector has a tradition of compulsory programs. Perhaps as a result of that history, as well as the fact that the drug sector is concerned with drugs as illegal commodities, coercion in treatment entry has not raised the same issues for that field as has been the case for alcohol treatment. 8. The fact of diversion outside of formal diversion programs cannot be overlooked. Informal diversion is found even in the drug treatment system, in which official diversion programs are more the case than in treatment for alcohol problems. For example, Hubbard and colleagues (1988) found that data from five cities involved in the Treatment Outcome Prospective Study (a long-term longitudinal study of drug users who receive treatment from publics funded programs) indicated more criminal justice-referred clients who were non-TASC clients than TASC clients. They also found that TASC clients were referred earlier in the legal process than non- TASC criminal justice-referred clients. 9. In both of these studies (Yahr, 1988; Jacob, 1985), the distinction between public and private is not always clear because there are some nonprofit agencies in the public and some in the private sector. There are also agencies with mixed funding. It is assumed that "public" includes nonprofit agencies with some public funding to the agency, as opposed to agencies operating solely on a fee-for-service basis. 10. There is a body of outcome research on the treatment of the public inebriate, the group that, in general, lacks the characteristics discussed as most related to successful outcome. Finn (1985) reviewed this literature as part of an assessment of the Uniform Act and pointed out that outcome measures are most often based on recidivism rates in detoxification centers. Although the results are not usually favorable, it also bears mention that these treatments are often brief and custodial (see Chapter 16~. 11. Much of the evaluation literature on referrals stemming from the workplace is related to cost- effectiveness. Some short-term studies of employed clients have found that health care costs decrease after they receive treatment (Holder and Hallen, 1981; Holder and Schachtman, 1987) (see Chapter 19~. 12. Recently, there have been studies that examine outcome in terms of compliance (treatment completion). For example, the Colorado State Alcohol and Drug Abuse Division (1988) found significantly higher success rates (i.e., lower rearrest rates) among those who completed treatment. In all of these studies, results may

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APPENDIX D 603 be biased by the characteristics of those who complete treatment and by the types and effect of the different contingencies that are applied. 13. The Walsh team's study (1988) currently in progress is significant in its design and should address some of the issues of concern here. It has three comparison groups: the first is an inpatient program with intensive follow-up and supervision; the second is similar except that those in this group receive outpatient rather than inpatient services initially; and the third invokes client participation in selecting one of the two programs. REFERENCES Alcoholics Anonymous World Services, Inc. (AA). 1987. A A. Guidelines: Cooperating with Court, A S.A P., and Similar Programs. New York: Alcoholics Anonymous World Services, Inc. Anglin, M. 1988. The efficacy of civil commitment in treating narcotic addiction. Pp. 8-34 in Compulsory Treatment of Drug Abuse: Research and Clinical Practice, C. G. Leukefeld and F. M. Tims, eds. Rockville, Md.: National Institute on Drug Abuse. Appelbaum, P. S. 1985. Special section on APA's model commitment law: An introduction. Hospital and Community Psychiatry 36:966-968. Appelbaum, P. S., C. Lidz, and A. Meisel. 1987. Informed Consent: Legal Theory and Clinical Practice. New York: Oxford University Press. Armor, D., J. M. Polich, and H. B. Stambul. 1978. Alcoholism and Treatment. New York: John Wiley and Sons. Atkinson, R. 1985. Persuading alcoholic patients to seek treatment. Comprehensive Therapy 11~11~:16-24. Azrin, N. H. 1976. Improvements in the community-reinforcement approach to alcoholism. Journal of Behavioral Research and Therapy 14:339-348. Azrin, N. H., R. W. Sisson, R. Movers, and M. Godley. 1982. Alcoholism treatment by disulfiram and community reinforcement therapy. Journal of Behavioral Research and Therapy 13:105-112. Baumohl, J. 1986. On asylums, homes, and moral treatment: The case of the San Francisco home for the care of the inebriate, 1859-1870. Contemporary Drug Problems 13:395-445. Baumohl, J., and R. Room. 1987. Inebriety, doctors, and the state: Alcoholism treatment institutions before 1940. Pp. 135-175 in Recent Developments in Alcoholism, vol. 5, M. Galanter, ed. New York: Plenum Press. Beis, E. 1983. State involuntary commitment statutes. Maryland Law Review 7~4~:358-369. Bloom, J., J. Bradford, and L. Kofoed. 1988. An overview of psychiatric treatment approaches to three offender groups. Hospital and Community Psychiatry 39:151-158. Boscarino, J. 1980. A national survey of alcoholism centers in the United States: A preliminary report. American Journal of Drug and Alcohol Abuse 7:403-413. Brown, B. S., G. Buhringer, C. D. Kaplan, and J. J. Platt. 1987. German/American report on the effective use of pressure in the treatment of drug addiction. Psychology of Addictive Behaviors 1:38-54. Butynski, W. 1985. State Resources and Services for Alcohol and Drug Abuse Problems: An Analysis of State Alcohol and Drug Abuse Profile Data, Fiscal Year 1984. Washington, D.C.: National Association of State Alcohol and Drug Abuse Directors, Inc. Bu~nski, W., N. Record, P. Bruhn, and D. Canova. 1987. State Resources and Services for Alcohol and Drug Abuse Problems, Fiscal Year 1986: An Analysis of State Alcohol and Drug Abuse Profile Data. Washington, D.C.: National Association of State Alcohol and Drug Abuse Directors, Inc. Cameron, T. 1979. The impact of drinking-driving countermeasures: A review and evaluation. Contemporary Drug Problems 8~4~:495-565.

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604 APPENDS D Cameron, T. 1983. Trends in alcohol problems in California, 1950-1979. Pp. 124-145 in Consequences of Drinking: Trends in Alcohol Problem Statistics in Seven Countries, N. Griesbracht, M. Cahannes, J. Moskalewicz, E. Osterberg, and R. Room, eds. Toronto: Addiction Research Foundation. Carlyle, E. U. 1988. Hospitalization for mental disorders and substance abuse. Texas Bar Journal 51(6~:568-574. Chopra, K, D. Preston, and L. Gerson. 1979. The effect of constructive coercion on the rehabilitative process. Journal of Occupational Medicine 21:749-761. Christie, N., and K Brunn. 1969. Alcohol problems: The conceptual framework. Pp. 65-73 in Lectures in Plenary Sessions. Vol. 2 of the Proceedings of the 28th International Congress on Alcohol and Alcoholism. Highland Park, NJ.: Hillhouse Press. Cohen, I. 1987. Civil commitment: A study of legal intervention. Working paper, Colorado Alcohol and Drug Abuse Division, Colorado Department of Health, Denver, Col. Colorado Alcohol and Drug Abuse Division, 1988. The effectiveness of education and treatment in reducing recidivism among convicted drinking drivers. Office of Planning and Evaluation, Colorado State Alcohol and Drug Abuse Division, Colorado Department of Health, Denver, Cot. Connecticut State Drug and Alcohol Abuse Criminal Justice Commission. 1988. The drug and alcohol abuse crisis within the Connecticut Criminal justice system. Connecticut State Drug and Alcohol Abuse Criminal Justice Commission, Hartfort, Conn. Conrad, P., and J. W. Schneider, 1980. Deviance and Medicalization: From Badness to Sickness. St. Louis, Mo.: Moseby. Cook, L. F., and B. A. Weinman. 1988. Treatment alternatives to street crime. Pp. 99-105 in Compulsory Treatment of Drug Abuse: Research and Clinical Practice, C. G. Leukefeld and F. M. Tims, eds. Rockville, Md.: National Institute on Drug Abuse. Con, W. M., and E. Klinger. 1988. A motivational model of alcohol use. Journal of Abnormal Psychology 97:168-180. Curran, W. J., A. E. Arif, and D. C. Jayasuriya. 1987. Guidelines for Assessing and Revising National Legislation on Treatment of Drug and Alcohol-Dependent Persons. Geneva: World Health Organization. Dalen, M. 1987. Ethical Considerations in Evaluation and Treatment of Court-Referred Clients. Mission, Kan.: Alcohol and Drug Services, Inc. Diesenhaus, H. I. 1989. Memo and worksheets on coercion. Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, April. Donovan, D., G. A. Marlatt, and P. Salzberg. 1983. Drinking behavior, personality factors, and high-risk driving. Journal of Studies on Alcohol 44:395-428. Dunham, A. 1985. APA's model law: Protecting the patient's ultimate interests. Hospital and Community Psychiatry 36:973-975. Durham, M. 1985. Implications of need-for-treatment laws: A study of Washington state's involuntary treatment act. Hospital and Community Psychiatry 36:975-977. Fagan, R., and N. Pagan. 1982. The impact of legal coercion in the treatment of alcoholism. Journal of Drug Issues 12:103-114. Faulkner, L. R., H. M. Bentson, and J. D. Bloom. 1989. An empirical study of emergency commitment. American Journal of Psychiatry 146:182-186. Faulkner Training Institute. 1983. Intervention Workshop. (brochure for a training workshop for alcohol treatment professionals). Austin, Tex.: Faulkner Training Institute. Fillmore, K, and R. Caetano. 1982. Epidemiology of alcohol abuse and alcoholism in occupations. Pp. 21-88 in Occupational Alcoholism: A Review of Research Issues. NLAAA Research Monograph No. 8. Washington, D.C.: U.S. Government Printing Office.

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APPENDIX D 605 Finn, P. 1985. Decriminalization of public drunkenness: Response of the health care system. Journal of Studies on Alcohol 46:7-23. Fox, R. W. 1978. So Far Disordered in Mind: Insanity in California, 1870-1930. Berkeley, Calif.: University of California Press. Freedberg, E. J., and W. E. Johnston. 1978. Effects of various sources of coercion on outcome of treatment of alcoholism. Psychological Reports 43:1271-1278. Furst, C., L. Beckman, C. Nakamura, and M. Weiss. 1981. Utilization of Alcohol Treatment Services in California. Los Angeles: Alcohol Research Center, Neuropsychiatric Institute, University of California, Los Angeles. Gallant, D. M. 1968. A comparative evaluation of compulsory and voluntary treatment of the chronic alcoholic municipal offender. Psychosomatics 9:306-310. Gilbert, M. J., and R. C. Cervantes. 1987. Alcohol services for Mexican Americans: A review of utilization patterns, treatment considerations and prevention activities. Pp. 61-95 in Mexican Americans and Alcohol, M. J. Gilbert and R. C. Cervantes, ed. Los Angeles: Spanish Speaking Mental Health Research Center, University of California, Los Angeles. Gilboy, J. A., and J. R. Schmidt. 1979. 'voluntary" hospitalization of the mentally ill. Northwestern University Law Review 66(4):429-453. Gostin, L. 1987. Public health and police powers available to government to impede the spread of HIV. Working paper. National Institute on Drug Abuse, Rockville, Md. Grad, F., A. Goldberg, and B. Shapiro. 1971. Alcoholism and The Law. Dobbs Ferry, N.Y.: Oceana Publications, Inc. Greeman, M., and T. A. McClellan. 1985. The impact of a more stringent commitment code for Minnesota. Hospital and Community Psychiatry 36:990-991. Gurnack, A. M. 1986. Factors related to compliance to Wisconsin's mandatory assessment policy for alcohol-impaired drivers. International Journal of the Addictions 21:807-812. Hart, L. 1977. A review of treatment and rehabilitation legislation regarding alcohol abusers and alcoholics in the United States: 1920-1971. International Journal of the Addictions 12:667~78. Heyman, M. M. 1976. Referral to alcoholism programs in industry: Coercion, confrontation, and choice. Journal of Studies on Alcohol 37:900-907. Hingson, R., T. Mangione, A. Meyers, and N. Scotch. 1982. Seeking help for drinking problems: A study in the Boston metropolitan area. Journal of Studies on Alcohol 43:271-288. Hoffmann, N., F. Ninonueve, J. Mozey, and M. Luxenberg. 1987. Comparison of court-referred DWI arresters with other outpatients in substance abuse treatment. Journal of Studies on Alcohol 48:591-594. Hoge, S. K, P. S. Appelbaum, and A. Greer. 1989. An empirical comparison of the Stone and dangerousness criteria for civil commitment. American Journal of Psychiatry 146:170-175. Holder, H., and J. Hallen. 1981. Medical Care and Alcoholism Treatment Costs and Utilization: A Five-Year Analysis of the California Pilot Project to Provide Health Insurance Coverage for Alcoholism. Prepared for the National Institute on Alcohol Abuse and Alcoholism. Chapel Hill, N.C.: H-2, Inc. Holder, H., and R. Shachtman. 1987. Estimating health care savings associated with alcoholism treatment. Alcoholism: Clinical and Experimental Research 11:66-73. Hubbard, R. L., J. J. Collins, J. V. Rachal, and E. R. Cavanaugh. 1988. The criminal justice client in drug abuse treatment. Pp. 57~1 in Compulsory Treatment of Drug Abuse: Research and Clinical Practice, C. G. Leukefeld and F. M. Tims, eds. Rockville, Md.: National Institute on Drug Abuse. Hunt, G. M., and N. H. Azrin. 1973. A community-reinforcement approach to alcoholism. Behavioral Research and Therapy 11:91-104.

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606 APPENDIX D Inciardi J. A. 1988. Some considerations on the clinical efficacy of compulsory treatment: Reviewing the New York experience. Pp. 126-139 in Compulsory Treatment of Drug Abuse: Research and Clinical Practice, C. G. Leukefeld and F. M. Tims, eds. Rockville, Md.: National Institute on Drug Abuse. Jacob, O. 1985. Public and Private Sector Issues on Alcohol and Other Drug Abuse: A Special Repon with Recommendations. Rockville, Md.: Alcohol, Drug Abuse, and Mental Health Administration. October. Johnson, V.E. 1980. I'll Quit Tomorrow. New York: Harper and Row. Johnson, V. E. 1986. Intervention: How to Help Someone Who Doesn't Want Help. Minneapolis, Minn.: Johnson Institute Books. Johnson Institute. 1983. Intervention Skill Development Seminar (brochure for a training workshop for alcohol treatment professionals). Minneapolis, Minn.: Johnson Institute. Johnson Institute. 1987. How to Use Intervention in Your Professional Practice. Minneapolis, Minn.: Johnson Institute Books, Professional Series. Keilitz, I., and T. Hall. 1985. Some statutes governing involuntary outpatient civil commitment. Maryland Law Review 9(5):378-397. Keilitz, I., D. Conn, and A. Giampetro. 1985. Least restrictive treatment of involuntary patients: Translating concepts into practice. St. Louis University Law Journal 29:691-745. Klein, ~ 1983. Alcohol, the lubricant of crime. The Judges' Journal 22~4):4-7,55-57. Kramer, A. 1983. The drunk driver Where is he heading? The courts need a new sentencing policy to get the alcoholic offender on the right road to recovery. The Judges' Journal 22(4~:8-11,63 64. Kurtz, N., and M. Regier 1975. The Uniform Alcoholism and Intoxication Treatment Act: The compromising process of social policy formulation. Journal of Studies on Alcohol 36:1421-1440. Kurtz, N., W. Googins, and W. Howard. 1984. Measuring the success of occupational alcohol programs. Journal of Studies on Alcohol 45:33-45. Lettieri, D. J., J. E. Nelson, and M. A. Sayers, eds. 1985. Alcoholism Treatment Assessment Research Instruments. NL\AA Treatment Handbook Series No. 2. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. Leukefeld, C. G., and F. M. Tims, eds. 1988. Compulsory Treatment of Drug Abuse: Research and Clinical Practice. Rockville, Md.: National Institute on Drug Abuse. Lewis, J. S. 1987. Fifteen years of alcoholism coverage--1972-1987: The thick and the thin. 16~2)1-8. Lidz, C. W., E. P. Mulvey, P. S. Appelbaum, and S. Cleveland. 1989. Commitment: The consistency of clinicians and the use of legal standards. American Journal of Psychiatry 146:176-181. Logan, D. 1983. Getting alcoholics to treatment by social network intervention. Hospital and Community Psychiatry 34:360-361. Makela, K 1980. What can medicine properly take on? Pp. 225-223 in Alcohol Treatment in Transition, M. Grant, ed. London: Croom Helm. McConnaughy, E. A., C. C. DiClemente, J. O. Prochaska, and W. F. Velicer. 1983. Stages of change in psychotherapy: Measurement and sample profiles. Psychotherapy: Theory, Research, and Practice 20:368-375. Mecca, A. 1975. A state of the art assessment of the treatment alternatives to street crime programs. Doctoral dissertation, School of Public Health, University of California, Berkeley, Calif. Mestrovic, S. 1983. Need for treatment and New York's revised commitment laws: An empirical assessment. International Journal of Law and Psychiatry 6:75 88. Miller, W. R. 1985. Motivation for treatment: A review with special emphasis on alcoholism. Psychological Bulletin 98:84-107.

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APPENDIX D 607 Masher, J. 1983. Alcohol: Both blame and excuse for criminal behavior. Pp. 437 460 in Alcohol and Disinhibition: Nature and Meaning of the Link, R. Room and G. Collins, eds. Washington, D.C.: U.S. Government Printing Office. Masse, P. R. 1989. Growth and Development of the Alcohol Treatment System in the U.S. Prepared for the National Institute on Alcohol Abuse and Alcoholism. Alcohol Research Group, Berkeley, Calif. New York State Governor's Task Force on Alcoholism Treatment in Criminal Justice. 1986. Alcoholism Treatment in Criminal Justice: Task Force Report to the Governor. Albany, N.Y.: New York State Governor's Task Force on Alcoholism Treatment in Criminal Justice. October. Parker, D., and G. Farmer. 1988. The epidemiology of alcohol abuse among employed men and women. Pp. 113-129 in Recent Developments in Alcoholism, vol. 6, M. Galanter, ed. New York: Plenum Press. Peachey, J. E., and B. M. Kapur. 1986. Monitoring drinking behavior with the alcohol dipstick during treatment. Alcoholism 10:663 666. Perrine, B. 1986. Varieties of drunken and of drinking drivers: A review, a research program, and a model. Alcohol, Drugs, and Traffic Safety-Ted, Proceedings of the 10th Annual International Conference on Alcohol, Drugs, and Traffic Safety, Amsterdam, September 9-12. Perrine, M. W. 1984. Analysis of DUI processing from arrest through post-conviction countermeasures. Vol 1 of An Evaluation of the California Drunk Driving Countermeasures System. Sacramento, Calif.: Research and Development Office, Department of Motor Vehicles. Phillips, M. 1989. The American criminal justice system and mandates to alcohol treatment: The role of Alcoholics Anonymous. Alcohol Research Group, Berkeley, Calif. President's Commission on Mental Health. 1978. Appendix. Vol. 4 of the Task Panel Reports Submitted to the President's Commission on Mental Health. Washington, D.C.: U.S. Government Printing Oface. Prochaska, J. O., and C. C. DiClemente. 1986. Toward a comprehensive model of change. Pp. 3-27 in Treating Addictive Behaviors, W. R. Miller and N. Heather, eds. New York: Plenum Press. Read, E. 1987. The alcoholic, the probation officer, and AA A viable team approach to supervision. Federal Probation 50~1):11-15. Reinarman, C. 1988. The social construction of an alcohol problem: The case of Mothers Against Drunk Driving and social control in the 1980s. Theory and Society 17:91-120. Reis, R. E. 1981a. Analysis of the Court Referral and Random Assignment Process: Internal Validity of the Research Designs-1980 Annual Report, vol. 30. Final Report, DOT HS 806-553. Washington, D.C.: U.S. Department of Transportation, National Highway Traffic Safety Administration. Reis, R. E. 1981b. Analysis of the Traffic Safety Impact of Educational Counseling Programs for Multiple Offense Drunk Driver~1980 Annual Report, vol. 5. Comprehensive Driving Under the Influence of Alcohol Offender Treatment Demonstration Project (CDUI). Interim Report, DOT HS 806-555. Springfield, Va.: National Technical Information Service. Reis, R., and L. A. Davis. 1979. DUI client characteristics: An interim analysis of the random assignment process. Comprehensive driving under the influence of alcohol offender treatment demonstration project, DOT HS-805-587. County of Sacramento Health Department, Sacramento, Calif. Roizen, J. 1982. Estimating alcohol involvement in serious events. Pp. 179-219 in Alcohol Consumption and Related Problems. Alcohol and Health Monograph No. 1. Washington, D.C.: U.S. Government Printing Office. Roman, P. 1988. Growth and transformation in workplace alcoholism programming. Pp. 131-158 in Recent Developments in Alcoholism, vol. 6, M. Galanter, ed. New York: Plenum Press. Room, R. 1980. Treatment-seeking populations and larger realities. Pp. 205-224 in Alcoholism Treatment in Transition, G. Edwards and H. Grant, eds. London: Croom Helm.

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608 APPENDIX D Room, R. 1987. The U.S. general population's experiences with responses to alcohol problems. Presented at the Alcohol Epidemiology Section of the International Congress on Alcohol and Addictions, Aix-en-Provence, France, June 7-12. Rosenberg, C. M., and J. Liftik. 1976. Use of coercion in the outpatient treatment of alcoholism. Journal of Studies on Alcohol 37:58~5. Ross, H. L. 1984. Deterring the Drinking Driver Legal Policy and Social Control. Lexington, Mass.: Lexington Books. Ross, R., and L. Lightfoot. 1985. Treatment of the Alcohol-Abusing Offender. Springfield, Ill.: Charles C. Thomas. Rubenstein, L. S. 1985. APA's model law Hurting the people it seeks to help. Hospital and Community Psychiatry 36:968-977. Ryan, L., and B. Segars. 1983. San Diego County first conviction program population description. Alcohol Program, San Diego County Department of Health Services, San Diego, Calif. January. Schmidt, L. 1986. The proposed "seriously-deteriorating" commitment standard: Some concerns for California mental health. Working paper, Alcohol Research Group, Berkeley, Calif. Scripps Memorial Hospital. 1984. Intervention (brochure for a training workshop for alcohol treatment professionals). La Jolla, Calif.: Scripps Memorial Hospital. Segal, S. P. 1989. Civil commitment standards and patient mix in England/Wales, Italy, and the United States. American Journal of Psychiatry 146:187-193. Seizer, M. 1958. On involuntary hospitalization for alcoholics. Quarterly Journal of Studies on Alcohol 19:660 667. Shain, M., and J. Groeneveld. 1980. Employee Assistance Programs: Philosophy, Theoty and Practice. Lexington, Mass.: Lexington Books. Smart, R. 1974. Employed alcoholics treated voluntarily and under constructive coercion: A follow-up study. Quarterly Journal of Studies on Alcohol 35:196-209. Speiglman, R. 1984. Alcohol treatment and social control: Contradictions in strategies for California's skid rows. Presented at a meeting of the International Group for Comparative Alcohol Studies, Stockholm, October 23-27. Speiglman, R., and C. Weisner. 1982. Accommodation to coercion: Changes in alcoholism treatment paradigms. Presented at the Annual Meeting of the Society for the Study of Social Problems, San Francisco, September 3~. Stewart, K, L. G. Epstein, P. Gruenewald, S. Laurence, and T. Roth. 1987. The California first DUI offender evaluation project: Final report. Prepared for the California Office of Traffic Safety. Pacific Institute for Research and Evaluation, Berkeley, Calif. February. Stitzer, M. L., and M. E. McCaul. 1987. Criminal justice interventions with drug and alcohol abusers: The role of compulsory treatment. Pp. 331-360 in Behavioral Approaches to Crime and Delinquency, E. K Morris and C. J. Braukmann, eds. New York: Plenum Press. Stone, A. A. 1985. A response to comments on APA's model comm, itment law. Hospital and Community Psychiatry 36:984-989. Stromberg, C. D., and A. A. Stone. 1983. A model state law on civil commitment of the mentally ill. Harvard Journal on Legislation 20:275-396. Trice, H. 1983. Treatment and rehabilitation. Pp. 53-58 in The Encyclopedia of Crime and Justice. New York: The Free Press. Trice, H., and J. Beyer. 1982. Social control in worksettings: Using the constructive confrontation strategy with problem~rinking employees. Journal of Drug Issues 12:21-49. Trice, H., and J. Beyer. 1984. Work-related outcomes of the constructive-confrontation strategy in a job-based alcoholism program. Journal of Studies on Alcohol 45:393-404.

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APPENDIX D 609 Trice, H., and W. Sonnenstuhl. 1988. Constructive confrontation and other referral processes. Pp. 159-170 in Recent Developments in Alcoholism, vol. 6, M. Galanter, ed. New York: Plenum Press. U.S. Department of Transportation. 1976. Vol. 1, Description of ASAP Diagnosis, Referral and Rehabilitation Functions. Vol. 1 of Program Level Evaluation of ASAP Diagnosis, Referral and Rehabilitation Efforts. Final Report, Contract No. DOT-HS-191-3-759. Washington, D.C.: National Highway Traffic Safety Administration. Vingilis, E. 1983. Drinking drivers and alcoholics: Are they from the same population? Pp. 299-342 in Research Advances in Alcohol and Drug Problems, vol. 7, R. Smart, F. Glaser, Y. Israel, H. Kalant, R. Popham, and W. Schmidt, eds. Toronto: Plenum Press. Walsh, D. C., R. W. Hingson, and D. M. Merrigan. 1988. A randomized trial comparing inpatient and outpatient alcoholism treatments in industry a first report. Presented at the Annual Meeting of the Alcohol Epidemiology Section of the International Council on Alcohol and Addictions, Dubrovnik, Yugoslavia, June 9-13, 1986. (updated, January 1988~. Wanberg, K W., and J. L. Horn. 1983. Assessment of alcohol use with multidimensional concepts and measures. American Psychologist 38:1055-1070. Wanberg, K W., J. L. Horn, and F. M. Foster. 1977. A differential assessment model for alcoholism. Journal of Studies on Alcohol 38:512-543. Ward, D. A. 1979. The use of coercion in the treatment of alcoholism: A methodological review. Journal of Drug Issues 9:387-398. Weisner, C. 1984. The changing alcohol treatment system: A profile of clients. Presented at a meeting of the International Group for Comparative Alcohol Studies, Stockholm, October 23-27. Weisner, C. 1986. The transformation of alcohol treatment: Access to care and the response to drinking-driving. Journal of Public Health Policy 7:78-92. Weisner, C. 1987a. The social ecology of alcohol treatment in the United States. Pp. 203-243 in Recent Developments in Alcoholism, vol. 5, M. Galanter, ed. New York: Plenum Press. Weisner, C. 1987b. Studying alcohol treatment as a system: Research issues and data sources. Presented at the Alcohol Treatment Service Systems Research panel at the Alcohol and Drug Problems Association National Conference, St. Louis, Missouri, September. Weisner, C. 1988. The alcohol treatment seeking process from a problem perspective: Responses to events. Presented at the 14th Annual Alcohol Epidemiology Symposium, Kettil Brunn Society, Berkely, Calif., June 5 11. Weisner, C., and R. Room. 1984. Financing and ideology in alcohol treatment. Social Problems 32:167-188. Wexler, J. D. 1985. APA's model law: A commitment code by and for psychiatrists. Hospital and Community Psychiatry 36:981-983. Wilson, J., and B. Jonah. 1985. Identifying impaired drivers among the general driving population. Journal of Studies on Alcohol 46:531-536. Yahr, H. T. 1988. A national comparison of public- and private-sector alcoholism treatment delivery system characteristics. Journal of Studies on Alcohol 49:233-239. Young, T., and G. Lawson. 1984. AA referrals for alcohol related crimes: The advantages and limitations. International Journal of Offender Therapy and Comparative Criminology 28:131-139. Zusman, M. D. 1985. APA's model commitment law and the need for better mental health services. Hospital and Community Psychiatry 36:978-980.

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