Best Practices - Treatment and Rehabilitation for Driving While Impaired Offenders

3. Current Treatment Practice Issues (continued)

3.1 Effectiveness of Educational or Therapeutic Interventions for DWI Offenders (continued)

3.1.1 Indications from the literature (continued)

The results indicated that for all offenders, remedial interventions (education and treatment), but not punishment, were associated with a lower relapse rate. However, the analysis did not consider the combined effects of the remedial programs and punishment. Those who had been given a probation order prior to sentence were less likely to re-offend than others and among first-time offenders there were no significant effects for treatment. For all cases, recidivism was associated with being older and having prior DWI convictions.

DeYoung (1997) examined the effectiveness of alcohol treatment, driver's licence actions and jail terms in reducing impaired-driving recidivism. He used a quasi-experimental design to compare re-conviction rates and time to first re-conviction over an 18-month period for convicted first-time, second-time and multiple DWI offenders receiving various dispositions from the courts. Few details of these dispositions, except for those indicated in Table 1, are provided in DeYoung's report. The sample sizes were very large: 88,552 first-time offenders, 27,292 second-time offenders and 32,787 third-plus offenders.

All analyses controlled for age and gender, class of licence, convictions, total crashes and fatal or injury crashes over the previous three years, and various characteristics of the community of residence (average injury crash rates, moving traffic violations, average time to travel to work, ethnic composition, unemployment rates and income levels).

Results of the analyses showed that for all levels of prior DWI conviction, combining alcohol treatment with either driver's licence restriction or suspension was associated with the lowest DWI re-conviction rates.

Mann et al. (1994) examined mortality rates for convicted second-offence drinking drivers (N=347) who had been randomly assigned either to a brief educational program or to a no-treatment control condition. The report indicates that the goals, structure and contents of the program resembled those for other North American programs operating at that time. For eight weeks offenders met weekly in groups for two hours. They were presented with information on the biological and psychological effects of alcohol, legal aspects of drinking and driving, the nature of alcohol abuse and alcohol dependence, identification of personal problems with alcohol and additional resources for dealing with these problems.

Over a follow-up period ranging from 8 to13 years, 14 (11%) of the controls and 17 (7.7%) of the rehabilitation group died from various causes. Although the difference was not statistically significant using conventional criteria (p=0.08), deaths from accidental and violent causes (but not cirrhosis or alcohol dependence) were significantly lower in the group assigned to education. Additional comparisons involving cases not randomly assigned to the education or control condition generated similar results. The authors speculated that education programs may reduce driving risk behaviours among early-stage or episodic problem drinkers, but may be of limited value for reducing the risk of death from cirrhosis or alcohol dependence among those who have patterns of chronic alcohol use problems.

Nickel (1990a,b) reported on an evaluation of a well-established educational user-pay program for first-time DWI offenders in Germany. The program was based on a group-dynamic approach. DWI offenders were assigned to the program if they were judged unfit to drive without it. Participants signed a contract indicating that they would attend all sessions, be punctual, abstain from alcohol on the day of a session and complete all homework assignments.

The program began with a two-week series of activities in which participants were asked to monitor drinking patterns and complete a series of homework assignments. The main course activities involved six weekly small-group sessions in which the participants discussed drinking patterns, identified drinking and driving habits and learned self-observation and self-control as ways to induce behavioural change. During the subsequent 18 months, participants received information letters and were asked to complete further homework assignments. This continued contact was intended to reinforce the lessons and provide support and encouragement to continue the process of behavioural change. After attending six small-group sessions, participants received a certificate that was to be used to reinstate the driver's licence. The group reconvened after 24 months to discuss any difficulties and problems and to check on progress.

Nickel found that re-conviction rates for 1,544 program participants after 36 months were lower than those for 1,344 convicted DWI offenders who were judged fit to drive without attending the program (13.4% vs.18.8%). After 60 months, the re-conviction rates were also lower for the program participants (21% vs. 26.9%). Although these differences may seem small, they are remarkable because the control groups were assessed as being fit to drive without an education program and would thus be expected to have a lower re-conviction rate.

Nickel found that regional differences in the intensity of law enforcement and drinking habits did not influence differences in re-conviction rates between program participants and others. However, differences were greater for older subjects while the re-conviction rates for those aged 18 to 24 were the same for program participants and others. Among participants, re-conviction rates were also influenced by marital status (higher if not married) and period of licence suspension (higher if period shorter). Among both program participants and others, multiple re-convictions were more common among younger cases, those with a previous hit and run offence, those who had driven without a licence, those who recidivated in a shorter time period, those who reported no impairment with a BAC of 80 mg%, those who were drinking at age 14, and those who reported having problems with their spouses or friends.

Jones, Wiliszowski and Lacey (1996) compared: (1) pre-trial intensive community supervision and attempts to enhance treatment engagement with (2) traditional jail sanctions. Their report also compares in-home confinement and electronic monitoring with traditional jail sanctions (beyond the scope of this report).

The treatment group (N=506) were repeat offenders who, after arrest, were offered (but not guaranteed) a reduced jail sentence if they participated in the program. The program aimed to reduce impaired driving by addressing drinking habits and drinking problems among those involved. It featured at least bi-weekly contact with probation officers for four to five months. These officers monitored their clients' progress and needs and, where indicated, made referrals to appropriate treatment agencies.

The comparison group (N=1,452) were repeat offenders who were not offered or who did not accept assignment to intensive probation and treatment. Instead, they went to jail followed by probation. Assignment to the new program was based on multiple considerations, including motivation.

Survival analysis was used to compare recidivism rates over a maximum of 20 months for the two groups. The analysis controlled for age, sex, ethnicity, marital status and number of prior convictions. After adjusting for these variable, the one-year recidivism rate for the experimental group was 5.6%, and 10.7% for the control group. This difference was highly significant statistically and would occur by chance less than two times in 10,000 if the intervention studied had no effect. There were also cost savings associated with the new program, principally associated with reduced time in jail for those given intensive community supervision.

Jones and Lacey (1999) reported a comparison group study involving DWI offenders assigned to a Day Reporting Centre (DC) or to a standard probation program. Both groups involved offenders who had been charged and convicted of serious DWI offences and had initially been sentenced to at least four months in prison. Both groups received some form of treatment or counselling (not specified) and visits with a probation officer four times a year for four years. However, the treatment for those in the DC group was based to a greater extent on assessment and appropriate placement in programs.

Those in the DC group were also assessed for job skills and educational needs and then placed into specific programs as appropriate. While in the program, the offenders had at least two contacts per week with probation officers and had to seek employment. Participation lasted for one to two months in lieu of a similar period of incarceration and was followed by standard probation. Assignment to the DC program was not random but based on multiple considerations, including motivation.

Post-assignment data on DWI convictions were reported for 176 cases in the DC program and 2,765 given standard probation. Survival analysis was used to compare recidivism over a maximum of 80 months for the two groups. Covariates include age, sex, ethnicity, education, alcohol abuses (yes/no) and variables concerning previous convictions. The results showed that the DC program was no more effective than standard probation in reducing recidivism. However, it was more cost-effective because it reduced time in prison.

Tornos (1994) reported on an evaluation of an educational program for incarcerated impaired drivers in Sweden. The program was voluntary and generally involved daily lectures for five days each week, over a four-week period. The aim was to educate participants about the risks of drinking by providing information on topics such as the physiological and psychological effects of alcohol, effects on driving and traffic safety and impaired driving legislation. Lectures were given by prison staff, AA members, psychologists, doctors and lawyers.

For first offenders, the recidivism rate within four years was 12.5% for participants and 19.5% for a control sample whose members were individually matched on age, gender, criminality, main offences, and months of imprisonment. For similarly matched repeat offenders, the recidivism rates were very similar (about 43%).

Davies et al. (no date) examined re-conviction rates over three years for more than 20,000 drinking-driving offenders in the United Kingdom, of whom 9,000 (45%) had attended mandatory education courses. However, offenders did not have to accept a referral to the education course. Those who completed the course could earn a reduced period of licence suspension. There was considerable variation in the proportion of offenders assigned to education in different jurisdictions and this was used as a control for the effects of subject selection bias. The authors interpreted their results as showing that the drinking-driver rehabilitation courses reduced re-conviction rates by slightly more than 50%. Some further analysis suggested offenders aged 30 to 39 may have benefited from the courses more than others and that men may have benefited more than women. However, the differences were small and no analyses that controlled for other offender characteristics were undertaken.

Lucker and Osti (1997) reported on an evaluation of pre-trial intervention (PTI) for DWI offenders, which was available for some DWI offenders at the time of their arrest. This involved 3 to12 months of supervision and supportive counselling from a probation officer and was an option for offenders who were legal US residents with no criminal records who had not previously received a PTI and whose current offence did not involve violence, drugs or serious property damage. Those choosing the PTI option could avoid the usual criminal court procedures and have all charges dismissed if they completed the program. However, they were also required to attend a 12-hour state-certified DWI course where they were given factual information about the effects of alcohol and encouraged to become aware of their own substance use and driving habits, and to develop plans to reduce future DWI occurrences. Those who did not choose the pre-trial intervention or who were ineligible for it were also required to attend this course.

Survival analysis was used to compare the risk of re-arrest for up to10 years for 3,994 first-time DWI offenders who either: (1) chose a PTI program, or (2) were convicted of DWI and sentenced to DWI education classes and probation. The results indicated that those convicted of DWI and put on probation had a 47% greater risk of a re-arrest for DWI than those who completed the PTI program.

The authors concluded that the PTI reduced recidivism and costs to the publicly financed criminal justice system. This conclusion may not, however, be warranted because no attempts were made to show that those who completed the PTI program had the same base-line characteristics as those who either failed to choose this option or were ineligible to receive it. The selection process suggests that these differences may have been quite significant and likely to lead to different outcomes independent of the influence of the PTI.

Kooler and Bruvold (1992) evaluated an educational intervention for juveniles found guilty of DWI. Over 700 juveniles convicted of DWI formed the study group and, of these, 100 had been referred to an 18-hour educational program by their probation officers. About 60% of non-referrals were from a time before the education program was available; however, the report does not indicate why some were or were not referred once the program started.

Pre-post measures of those participating in the program indicated increased knowledge, stronger attitudes against driving while impaired and less self-reported alcohol use and risky automobile-related behaviours. County juvenile records of offences committed prior to age 18 were also examined and class participants were found to have significantly fewer repeat offences compared with non-participants. According to the authors, this could not be explained by race, offence severity, age or gender.

This study does, however, have significant limitations. Forty-two percent of those involved in the study were within six months of their 18th birthday on referral to the education program and thus had only a short time to re-offend.

Discussion

As with the earlier studies reviewed by Wells-Parker et al. (1995), these more recent studies vary in methodological rigour. As with earlier studies, most of those that are methodologically weak (Davies et al., undated; Jones, Wiliszowski and Lacey, 1996; Kooler and Bruvold, 1992; Lucker and Osti, 1997; Tornos, 1994) support the remediations evaluated. However, with the exception of the study by Peck, Arnstein-Kerslake and Helander, (1994), the methodologically more robust studies also indicate that remediation (but not victim impact panels) can reduce the risk of DWI recidivism, especially in combination with legal sanctions (DeYoung, 1997).

Overall then, the literature supports education and treatment for DWI offenders. Several well-designed studies with large samples and long-term follow-up intervals have produced positive results and, on balance, the degree of support for DWI remediation is as strong as that for remediations that target other populations with alcohol use problems.

As previously noted, the Wells-Parker et al. (1995) meta-analysis indicated that treatment strategies that combined education, psychotherapy with follow-up and aftercare were most effective for multiple and first offenders. However, some reports provided few details of the kinds of treatments considered. This is also the case for many of the new reports reviewed above. Exceptions are the reports by Nickel (1990a,b). These include fairly detailed descriptions of the program studied and involved a variety of components, including education, self-monitoring, dynamic group work and follow-up.

No studies of the impact of a remedial program for individuals convicted of driving while impaired by drugs other than alcohol were located. However, studies that evaluate the effects of treatment for drug use problems on driving measures have begun to appear. Mann et al. (1995) examined driver records of 137 males between the ages of 21 and 40 before and after treatment. About one third of the sample had a problem with alcohol use only, one third had a problem with alcohol plus one other substance, and one third had a problem with the use of one or two substances other than alcohol. Overall, significant post-treatment reductions were found in moving violations, DWI convictions and total collisions, and no differences in outcome between drugs were observed, suggesting that treatment for drugs other than alcohol can positively affect driving behaviours.

Macdonald et al. (2002) examined the driving records of patients admitted to substance abuse treatment in 1994 for a primary problem of alcohol (N=128), cannabis (N=80) or cocaine (N=150). A comparison group of 507 licensed drivers matched by age, sex and place of residence was randomly selected for comparison purposes. All three drug groups had significantly higher collision rates in the five years prior to treatment. In the five years after treatment, the collision rates for the alcohol and cocaine group did not differ from controls, while the collision rates of the cannabis group remained elevated. In a subsequent study, Macdonald et al. (2003) conducted telephone interviews with 110 clients treated in 1995 for a problem with alcohol (N=44), cannabis (N=37) or cocaine (N=29), and a randomly selected sample of 104 drivers from the general population, matched by age, sex and place of residence. Prior to treatment, the drug groups reported significantly higher collision rates, while after treatment no differences between the treatment and control groups were observed. As well, treatment subjects reported significant reductions in driving after the use of alcohol, cannabis and cocaine following treatment. Thus, there are indications in the literature that treatment for at least some forms of drug use problems are associated with decreases in DWI by drugs and associated collisions.

Some research on treatments for the general population of people with substance use problems suggests that those with low to moderate alcohol dependence may benefit more from programs where they are allowed to choose abstinence or reduced drinking as a goal than from programs that only have abstinence goals (Institute of Medicine, 1990). However, the impact of goal choice on drinking and driving has not been studied. Such a choice is, of course, often denied to DWI offenders by the courts and many treatment programs also require all clients to have a goal of complete abstinence. It is not known if programs that allow a choice of goals permit such a choice among DWI offenders who are ordered by the court to refrain from the use of alcohol or drugs.

3.1.2 Key informant interviews

Most, but not all, key informants recommended that both first and repeat offenders should have some type of remedial intervention and that this should occur as rapidly as possible following a DWI conviction. Offenders, whether in education or treatment, should be provided with information on the effects of alcohol and other drugs on driving, and the laws on drinking and driving in Canada.

Issues related to drug-impaired drivers were raised by a number of key informants. Issues identified included driving while impaired by psychoactive medication, the need to develop risk levels for drug-impaired drivers, and the need for police to have tools/methods to detect people driving while impaired by drugs other than alcohol. Key informants also endorsed screening/assessment for all substances.

There was no consensus regarding the involvement of family members in educational or treatment interventions. Some felt that successful treatment required family involvement, particularly for youth, while others were concerned that requiring family involvement could be seen as coercive or could possibly pose a risk to family members in situations of domestic violence.

The issue of effective ways to provide ongoing monitoring and support for DWI offenders was raised by a number of key informants, particularly for repeat offenders. Several key informants mentioned the restorative justice model (an approach to criminal justice that gives a balanced focus to the offender, victim and community) and the need to involve a wide range of people and systems in providing monitoring and support.

3.1.3 Best practices

Remedial programs for convicted drinking drivers have become increasingly used over the past decades. There is good empirical evidence that they can positively influence knowledge, beliefs, attitudes, alcohol use, recidivism, collisions and the health status of convicted DWI offenders.

Best Practice 1
Remedial programs should occupy an integral place in a comprehensive impaired driving countermeasure program. Participation in such programs should be a condition of licence reinstatement for all persons convicted of an impaired driving offence.

Less is known about other drugs and driving than about alcohol and driving. However, there are clear indications that the use of certain drugs (including medications) can impair the ability to operate a vehicle safely and increase the risk of fatal crash involvement. There is also preliminary evidence that treatment for drug abuse is associated with post-treatment reduction in motor vehicle collision rates.

Best Practice 2
Remedial programs should also be an integral part of comprehensive efforts to reduce driving while impaired by drugs other than alcohol. Participation in such programs should be a condition of licence reinstatement for all persons convicted of a drug-related driving offence.