Legal Involvement, Engagement, and Substance Use Treatment Outcomes

Background: Mandating substance use disorder treatment is widespread despite mixed research evidence (Israelsson & Gerdner, 2012; Stevens et al., 2005; Wild, T. C., Yuan, Rush, & Urbanoski, 2016) and arguments that it is a humans rights violation (Day, Tucker, & Howells, 2004). Further research is needed to clarify the relationship between the legal system and substance use treatment because it affects people who are in the process of making significant life changes. Therefore, this study addresses the following hypotheses:

1. Clients’ involvement with the legal system is associated with greater engagement in substance use disorder treatment.
2. Clients’ involvement with the legal system is associated with a higher likelihood of completing substance use disorder treatment.
3. Clients’ engagement in substance use disorder treatment has a mediating effect on the relationship between client involvement with the legal system and the likelihood of the client completing treatment.

Methods: Informed by clinical data mining (Epstein, 2010), extracted data from the clinical substance use day-treatment files of 444 clients were analyzed using structural equation modeling with multinomial logistic regression (Hosmer, Lemeshow, & Sturdivant, 2013; Muthén, 2001). The final structural model included the latent variables legal involvement and client engagement, and the outcome variable discharge types. Legal involvement indicators were whether clients had current involvement with the legal system, had a history of involvement with the legal system, and their number of legal contacts. Engagement indicators were the number of process groups attended, the number of times they were screened for substance use, and the number of individual progress notes that indicated a meaningful interaction with the treatment staff. Discharge types were completed treatment, left without completing treatment, changed level of care without completing treatment, and other.

Results: Legal involvement did not have a statistically significant association with client engagement (Hypothesis 1) or with type of discharge (Hypothesis 2). Thus, engagement did not mediate the relationship between legal involvement and type of discharge (Hypothesis 3). However, increased levels of client engagement in treatment was associated with an 82% decrease in the likelihood of leaving treatment (OR= 0.17, p= 0.00), an 88% decrease in the odds of changing the level of care (OR= 0.12, p= 0.00), and a 70% decrease in the likelihood of being discharged for other reasons (OR= 0.30, p= 0.00).

Conclusion: It is important that clients engage in treatment because it seems to increase the odds of them completing it. However, in this study, their involvement with the legal system did not affect their engagement in treatment or whether they completed treatment. Thus, treatment professionals might need to consider or re-think how their relationship with the legal system can work towards assisting clients to engage treatment in life changing ways. While there are multiple factors that influence client engagement, many clients interact with the legal system, which underscores the importance of understanding the relationship between the legal system and treatment and exploring ways to make it a positive one.