CRIMINAL JUSTICE SYSTEM REFERRALS TO SUBSTANCE ABUSE TREATMENT
In 2002, alcohol was the most frequently reported primary substance of abuse1 among all substance abuse treatment admissions.
The criminal justice system was the principal source of referral for 36 percent of all substance abuse treatment admissions in 2002 (655,000 referrals out of a total of 1.9 million admissions).
Compared with people referred to substance abuse treatment from other sources, people referred by the criminal justice system were more likely to:
Report alcohol as the primary substance of abuse.
Be younger than age 25.
Report that they had never been treated for substance abuse problems elsewhere.
Be treated in ambulatory treatment settings.
SOURCE: Substance Abuse and Mental Health Services Administration (SAMHSA). The DASIS Report: Substance Abuse Treatment Admissions Referred by the Criminal Justice System: 2002. Washington, DC: Office of Applied Studies, SAMHSA, July 30, 2004.
1 The primary substance of abuse is the main substance reported at the time of admission.
The terms mandated treatment and coercion often are used interchangeably (Farabee et al. 1998). Mandated treatment is accompanied by “threats of legal consequences if individuals refuse to comply with a referral to treatment” (Polcin and Greenfield 2003, p. 650). Offender perceptions of the likelihood and severity of these sanctions (e.g., jail time or house arrest) are critical determinants of whether these offenders comply with the treatment mandate (Cavaiola and Wuth 2002).
Court-mandated treatment to reduce drinking and driving and treat alcohol problems has been a common element of the sanctioning process, especially for DUI offenders, for several decades. This article focuses on mandated treatment for DUI offenders, who account for a large proportion of those legally required to attend treatment for problems arising specifically from alcohol use (Cavaiola and Wuth 2002; Weisner 1990). The following sections examine forms of mandated treatment; screening, assessment, and referral; the effectiveness of mandated treatment, including treatment matching; DUI events as opportunities for intervention; and brief interventions for offenders outside of mandated treatment. In addition, this article discusses treatment cost-effectiveness and access as well as future research needs and challenges. An exhaustive discussion of research needs for improving alcohol interventions, including treatment, with impaired drivers mandated to treatment in the legal system is beyond the scope of this article.
FORMS OF MANDATED TREATMENT
Mandated interventions for DUI offenders vary in intensity, frequency, and duration, ranging from relatively brief one- or two-session interventions, to multicomponent programs implemented over the course of weeks or months, to inpatient care with lengthy aftercare (Wells-Parker et al. 1995). Treatment referrals may involve several components because DUI offenders are diverse, both in terms of level of alcohol abuse and other characteristics, such as comorbid conditions, that may increase their risk of repeating their offense or becoming involved in a crash (Wells-Parker and Popkin 1994).
DUI offenders who have been mandated to treatment by the courts participate in a wide variety of alcoholism treatment programs (Cavaiola and Wuth 2002; Wells-Parker et al. 1995). Mandated interventions for DUI offenders can include generic alcoholism treatment programs offered in local communities, referral to groups such as Alcoholics Anonymous (AA), and strategies that specifically aim to reduce drinking and driving, such as education programs, supervised probation, and presentations by injured survivors or families of victims killed in alcohol-related crashes (i.e., victim impact panels). Mandated interventions often include supervised probation and other forms of supervision and monitoring as well. In addition to monitoring, these programs can provide supportive contact and assistance with problems that could contribute to the risk of driving while impaired (Wells-Parker et al. 1995).
In the early years of DUI programs, traditional educational programs that focused on teaching offenders about how alcohol impairs driving were based on the premise that most DUI offenders were social drinkers who had too much to drink on one occasion. However, a large body of evidence (Cavaiola and Wuth 2002; Wells-Parker et al. 1995) shows that convicted offenders have a range of drinking problems, as well as other problems that contribute to crash risk, and frequently are at high risk of crashes even when not impaired (Cavaiola and Wuth 2002). As a result of this research, most educational and specialized programs have moved from a primarily didactic approach to interventions with specific protocols (Hon 2003). Specialized interventions are being developed to reduce alcohol-impaired driving and address alcohol problems and other comorbid conditions that frequently occur among DUI offenders (Cavaiola and Wuth 2002; Hon 2003; Wells-Parker and Williams 2002).
SCREENING, ASSESSMENT, AND REFERRAL
DUI offenders mandated by the courts to receive intervention and treatment often are evaluated in terms of their future risk for impaired driving and crash involvement and for any personal problems or circumstances that may need to be addressed during intervention and treatment. The term screening typically is used to describe a less extensive evaluation performed early in the process, possibly before a referral is made or shortly thereafter, and tends to focus on determining the offender’s risk level for impaired driving and the extent of alcohol problems. Screening results often are used to make decisions about what type of intervention is mandated. The term assessment typically is used to refer to a more extensive evaluation that is conducted later, often just before or upon entry into intervention and treatment. Assessment results frequently are used to guide decisions about how to intervene and treat the offender and how long or intense the treatment will be. The ultimate goal of extensive assessment is to match the offender to the most appropriate intervention and treatment according to his or her specific circumstances. Often assessment is integrated into the intervention in order to guide the process and to assure that the offender’s problems are being addressed.
The quality of information provided by either a screening or an assessment is an important part of the intervention and treatment process. One concern about court-referred assessment of alcohol and other substance use problems is that offenders may minimize their involvement with alcohol if they believe their answers could result in harsher sentencing or more intensive treatment (Lapham et al. 2002). In addition, a conflict of interest may arise when the same entity that will provide treatment conducts the assessment, which determines treatment length and cost.
To address these concerns, valid and reliable screening and assessment processes that are not dependent on subjective and unvalidated judgments of assessors ultimately need to be developed. Standards for validating the screening and assessment procedures that inform referral and treatment decisions are critical to ensuring successful outcomes for clients. (For a review of the technical issues surrounding the development of valid and reliable screening and assessment tools and processes for use with mandated populations, and for standards for validating these tools, see Anderson and colleagues .)
EFFECTIVENESS OF MANDATED TREATMENT
Systematic research on mandated treatment for DUI offenders since the early 1980s (Mann et al. 1994; Wells-Parker and Williams 2004) has provided a relatively clear picture of the effectiveness of this treatment as well as its limitations. In general, research has consistently shown that treatment has a modest effect on reducing drinking–driving and alcohol-impaired crashes among offenders who are mandated to attend and who actually receive the intervention (Wells-Parker and Williams 2002).
A meta-analysis of studies of the effectiveness of treatment and intervention with DUI offenders revealed several reliable patterns (Wells-Parker et al. 1995). An examination of crashes and DUI events over several years showed that alcohol-specific interventions and alcoholism treatment were better at reducing alcohol-related driving and crashes than interventions which were not alcohol specific. However, nonspecific interventions—such as revoking drivers’ licenses—were better at reducing all types of crashes (including crashes that did not involve alcohol), probably because they reduce overall driving exposure. Thus, the best strategy is to combine alcohol-related interventions and treatment with licensing actions to reduce impaired driving and crashes in general among DUI offenders who, as a group, are known to be high-risk drivers even when not impaired (Donovan et al. 1988; Donovan et al. 1985). Although the meta-analysis was conducted in 1992, more recent studies generally have confirmed the results (Hon 2003). Combining treatment with nontreatment sanctions that prevent offenders from drinking and driving (e.g., license revocation and alcohol ignition interlocks, which require the driver to pass an alcohol breath test before starting a car) also reduces the public’s risk while offenders are receiving treatment.
Findings from the meta-analysis did not reveal a consistent pattern of results for outcome measures related to drinking problem severity or other non-traffic-related outcomes because most studies focused on recidivism and crashes (Wells-Parker 1994; Wells-Parker et al. 1995). Results of one long-term study in which offenders were randomly assigned to receive treatment suggested that mandated interventions may have benefits beyond the traffic safety arena. In this study (Mann et al. 1994), offenders who received treatment had lower mortality rates after several years than did members of a comparable group who did not receive treatment.
Because only a few rigorous methodological studies have evaluated specific interventions, it was not possible in the meta-analysis to draw broadly substantiated conclusions about most treatment and intervention strategies used with DUI offenders (Wells-Parker 1994; Wells-Parker et al. 1995). The most effective strategy, which had substantial support from rigorously conducted studies, combined education and treatment. The treatment component included counseling or psychotherapy and supportive followup such as probation. Program intensity or length did not entirely explain the superiority of combination programs. Combining strategies may be more effective, regardless of treatment length or intensity, because DUI offenders have diverse and complex problems, and offering varied approaches may help to address this range of problems. Using a combination of strategies also increases the likelihood that at least one of the strategies will be effective for a particular offender.
Some methods may have little effect by themselves but could be useful in combination with other strategies. In the meta-analysis (Wells-Parker et al. 1995), only two reviewed studies evaluated direct court referral to AA, and those studies did not show that mandatory AA participation alone had a beneficial effect on recidivism. However, other studies suggested that combinations incorporating AA attendance often were effective.
A meta-analysis of controlled studies of the effectiveness of AA (Kownacki and Shadish 1999) found that randomized studies, but not nonrandomized studies, of AA alone produced more negative outcomes than no treatment at all. Also, effects of AA-based residential treatment programs were much smaller in randomized studies compared with nonrandomized studies, but the small number of randomized studies resulted in nonsignificant differences when compared with alternative residential treatment. The randomized studies contained several samples of coerced participants, whereas the nonrandomized studies used only samples of voluntary participants, indicating that forced AA attendance may be worse than no treatment (Kownacki and Shadish 1999).
Offenders increasingly are required to attend victim impact panels (VIPs), sometimes in addition to remedial interventions or treatment. However, several rigorous studies have failed to show positive effects of VIPs on recidivism rates (Wells-Parker 2004). Currently, investigators do not know what factors may influence whether VIPs are effective or not in reducing recidivism. Clearly, mandating this form of intervention should await a more thorough evaluation of the effects of VIPs.
Matching Offenders to the Most Effective Treatment Strategy
In addition to alcohol abuse, many DUI offenders have individual characteristics (such as a propensity for risk-taking in general and, specifically, a tendency to take risks while driving [Donovan et al. 1988; Donovan et al. 1985]) or comorbid conditions (such as depression) that either are likely to contribute to harmful consequences associated with alcohol use (e.g., drinking and driving) or must be considered if treatment is to be successful (Cavaiola and Wuth 2002; Wells-Parker et al. 1995). Research that attempts to identify the most effective treatment based on a person’s individual characteristics (i.e., treatment-matching) has been an important issue for treatment research (National Institute on Alcohol Abuse and Alcoholism [NIAAA] 2000).
Although many treatment-matching studies may include DUI offenders, most have not focused on DUI offenders as a distinct group (Wells-Parker et al. 1995). For example, a large treatment-matching study (Project MATCH), which did not focus specifically on mandated offenders (Project MATCH Research Group 1997), found that people in alcoholism treatment who were angry benefited most from motivational enhancement therapy (NIAAA 2000). This form of therapy is designed specifically to lower resistance to treatment and enhance motivation to change (Project MATCH Research Group 1997). Participants without good support systems for drinking cessation and changing problem behaviors fared best in a 12-step program, in which AA attendance was more likely (NIAAA 2000). People with low levels of psychiatric severity also fared best after 12-step facilitation treatment (NIAAA 2000). Because many DUI offenders entering mandated programs are angry about their arrest and sentencing, nonconfrontational strategies that are designed to enhance motivation may be especially appropriate. In addition, some offenders lack social support networks that discourage drinking as well as drinking and driving (Cavaiola and Wuth 2002). Strategies that encourage, but do not mandate, attendance at AA or other support groups are likely to be appropriate for these offenders also.
A recent study (Wells-Parker and Williams 2002) examined the effects of adding a brief individual intervention component to an existing court-mandated group intervention program for first-time DUI offenders. These researchers were particularly interested in which offenders benefited most from the additional supportive counseling. Approximately 4,000 first-time DUI offenders were randomly assigned to either a standard first-offender program or to the standard program plus the brief counseling component (the combination program).
In the standard program, offenders were exposed to cognitive-behavioral and motivational techniques in groups and through homework assignments and some education concerning the effects of alcohol and other drugs on health and behavior. The combined intervention added two 20-minute sessions of supportive counseling that provided individual feedback concerning problems such as feelings of sadness; these additional sessions were designed to enhance motivation and the confidence to change behavior.
The recidivism rate for offenders who did not report depressed mood was similar for the two programs. However, offenders who reported being depressed and who received the combination program had recidivism rates that were 35 percent lower than those of depressed offenders who received the standard program only. Results suggested that depressed offenders initially were more likely to recognize that they had a drinking problem and needed to change, and were more likely to try to change, than those not reporting depression, but the depressed offenders also were less confident in their ability to change. The supportive counseling may have been especially appropriate for depressed offenders who wanted to change their behavior but lacked confidence to do so. For some DUI offenders, depression may be an indicator of readiness to change, but a lack of confidence in their ability to change results in a feeling of hopelessness. Brief supportive counseling may allow the offender to explore and overcome this barrier.
Because many offenders, especially those with more severe alcohol problems, are depressed (Cavaiola and Wuth 2002; Wells-Parker and Williams 2002), it is important to acquire a better understanding of how to target appropriate interventions to depressed offenders. For example, brief supportive counseling that focuses on changing alcohol-related problem behavior seems to reduce recidivism. It is not known, however, whether an intervention that specifically targets depression would be equally or more effective, not only in managing depression but also in supporting change in alcohol-related problem behavior among mandated offenders. More research also needs to focus on the effectiveness of treating other comorbid psychiatric conditions that DUI offenders frequently have, such as anxiety disorders, antisocial personality disorder, mood disorders, and post-traumatic stress disorder (C’de Baca et al. 2004).