Best Practices - Treatment and Rehabilitation for Driving While Impaired Offenders

3. Current Treatment Practice Issues (continued)

3.2 Effectiveness of different types of treatment interventions for different types of impaired drivers

Key Points

• The literature supports the need for all remedial interventions to include, at a minimum, education regarding alcohol and traffic safety, an examination of one's substance use and driving behaviour, and strategies to avoid driving while impaired.
• For offenders at higher risk, additional components with greater emphasis on therapeutic interventions are required.

3.2.1 Indications from the literature

Many jurisdictions with remedial programs for DWI offenders have two or more levels of interventions for those judged to have more or less serious substance use problems. Those judged to have less serious problems often receive education, while others may receive both education and some type of therapy designed, for example, to increase motivation for reducing excessive alcohol or drug use, to help offenders to identify and plan for high-risk situations, and to promote lifestyle changes.

Some of the studies noted in the first section considered the relative effectiveness of different types of interventions and outcomes for different types of offenders, particularly first-time or repeat offenders. In general, first-time offenders seem to benefit more from education and treatment than multiple offenders, but it is also possible that other sub-types of offenders may benefit more from particular types of education or treatment.

Manitoba has had a province-wide program for persons convicted of a first or subsequent DWI offence since 1986 (Health Canada, 1997). In 1986, the current Impaired Drivers Program was established. The program is mandatory for first and subsequent impaired driving offenders prior to reinstatement of their driving privileges. Offenders are placed into one of the following four interventions on the basis of an assessment involving the Substance Abuse/Life Circumstances Evaluation (SALCE) (see Table 2) and a structured interview by a trained addictions counsellor:

1. No intervention

No intervention occurs when cases are assessed as having no apparent substance use problem requiring further services and are deemed not to be at risk of re-offending. They are judged to be taking responsibility for the offence committed and have viable alternative plans to prevent further offences. They may have already made lifestyle changes prior to accessing the program. No further action is taken to provide education or treatment to this group.

2. Presumptive problem

These offenders are judged to be using alcohol or other drugs in a high-risk manner. There are two possible referral options:

(i) Educational workshop

This is a one-day workshop that aims to help participants to develop alternative plans to drinking and driving. The workshop provides accurate information on alcohol and drugs, and their effects on driving. It emphasizes the need to keep drinking behaviours separate from driving. The workshop is also designed to be interaction-oriented, with groups of 10 to 12.

Those referred to the workshop are considered to be at risk of re-offending, due mainly to a combination of not taking responsibility for the offence; not having viable options to prevent further incidents of impaired driving; engaging in high-risk behaviours as identified through their driving abstract or lifestyle (e.g. not considering the potential consequences to their employment when it is dependent on a driver's licence); and/or not being able to gain insights easily into the need to make lifestyle changes.

(ii) High-risk program

The program spans an average of three to six months, including an average of nine hours of contact with program staff. It is delivered through a series of individual and group sessions, involving a minimum of three individual sessions and a maximum of six group sessions. During the initial phase of involvement, the agreement calls for total abstinence. In the latter half of the program, the participant and counsellor negotiate whether abstinence or moderate drinking will be the behaviour adopted.

Throughout the program, participants are encouraged to discuss any problems they have with abstinence or moderate drinking. If the problems are great, then it may be viewed as indicative of a possible substance dependence, and a referral to a treatment program is considered.

Criteria used to select offenders for this program include some combination of (a) periods of over-using substances, which may also include episodic reduction in consumption or abstinence; (b) inability to link his/her behaviour with subsequent consequences; (c) no obvious signs of substance dependence; (d) previous involvement with the impaired drivers program; (e) demonstrable risks in lifestyle as evidenced by substance use that compromises personal health; (f) lifestyle centred around heavy consumption; (g) family/work concerns related to alcohol/drug use, or (h) the need for a more in-depth program to gain insights into the need to make lifestyle changes.

3. Specialized abstinence-based residential or non-residential addictions treatment program

Offenders referred to these programs are currently experiencing the signs and symptoms of a substance dependence. They are referred to a particular program depending on their needs.

4. Referral to resources previously found to be helpful

Those who have a substance dependence and are in recovery with a lifestyle that supports abstinence are required to maintain abstinence and are referred to the resources that they have found helpful in the past. An associated person is contacted periodically over a two-year period to verify self-reported abstinence.

A report prepared for Health Canada (1997) indicates that the Manitoba program is well regarded across the country and appears to have a positive impact on some offenders. However, it has not been evaluated using an experimental or quasi-experimental design due to ethical considerations involved in mandatory programs.

One of the few studies to empirically examine "offender by intervention" interactions in a DWI offender population found interactions involving several demographic characteristics and supportive counselling (Wells-Parker et al., 1988). For this study, DWI offenders were randomly assigned to a variety of interventions, including supportive monthly counselling in a year-long probation context and licence suspension only. The probation-based supportive counselling was found to be especially effective for younger (under 30) minority group offenders (primarily African American). Programs combining traditional short-term DWI interventions with supportive counselling and probation were most effective for this group. The study also suggested that women might be more responsive to all interventions than men, but the numbers were too small to draw firm conclusions.

Another more recent study (Wells-Parker and Williams, 2002) considered possible interactions between different types of treatment and selected characteristics (age, gender, minority group membership and depression). In this study, first-time DWI offenders (N=4,074) were randomly assigned to a standard first-offender program or an enhanced standard program that included two short individual sessions and a brief follow-up session. Over a 28 to 55 month follow-up interval, offenders classified as suffering from depression who were assigned to the enhanced program were 35% less likely to recidivate than those assigned to the standard program. However, no significant interaction effects were found between program type and age, minority status or gender. The authors concluded that a combination of a standard first-offender program with brief individual counselling can be effective for DWI offenders who report depressed moods and who are at high risk for recidivism.

Only one other study (Ball et al., 2000) has considered the benefits of matching different types of DWI offenders to different treatments. However, this study did not use post-treatment DWI offences as an outcome measure.

Despite the limited evidence in favour of matching, some researchers believe that there is still much to be learned and many attempts have been made to develop typologies of DWI offenders to guide research and to inform clinical practice. Attempts to identify sub-types of DWI offenders using cluster analysis or other statistical methods have found a substantial minority (40% or more) with few risk factors for recidivism, and others with various types of risks, including alcohol use problems, bad driving habits, psychiatric problems, social instability, impulsiveness, sensation seeking, hostility, depression and anti-social attitudes (Donovan and Marlatt, 1992; Donovan, Umlauf and Slazberg, 1988; Macdonald and Mann, 1996; Wieczorek and Miller, 1992; and Wilson, 1991).

McMillen et al. (1992) found first-time and multiple DWI offenders differed significantly with respect to personality traits, drinking behaviour and problems, and driving behaviours. More specifically, multiple offenders had higher scores on measures of hostility, sensation seeking, psychopathic deviance, mania and depression than first offenders. Multiple offenders were also significantly lower in emotional adjustment and assertiveness and had more non-traffic arrests, accidents and traffic tickets than first offenders. They also consumed significantly more alcohol, evidenced more alcohol use problems and had higher BACs at the time of arrest than first offenders.

Wells-Parker, Cosby and Landrum (1986) also found that DWI offenders could be grouped on the basis of their previous traffic and criminal records. Five groups were identified using cluster analysis. The largest group encompassed offenders with few previous offences. Other groups comprised offenders who mainly had traffic offences, licence and equipment offences, public drunkenness offences or a mixture of offences.

One recent study (Chang, Lapham and Wanberg, 2001) used scores from the Alcohol Use Inventory (AUI) (Horn, Wanberg and Foster, 1987) to develop a typology of first-time DWI offenders and to determine if some types were more likely to re-offend than others. Six types were identified using cluster analysis. The largest encompassed 50% of all cases and members had low scores on all AUI scales. Other types were variously distinguished with respect to scores on measures of alcohol preoccupation, anxiety and the enhancing or disruptive effects of drinking. Predictors of recidivism included male gender, young age, less education, high arrest BAC and presenting high scores on disruptive and/or enhancing effects of alcohol scales.

Another multi-dimensional classification scheme with implications for treatment planning has been proposed by Cavaiola and Wuth (2002). This was used at one of the largest DWI programs in the United States (in Cook County, Illinois). This scheme is based on the results of self-administered questionnaires, face-to-face interviews with offenders and significant others, and objective data such as previous convictions. Offenders are assigned to one of six "level of risk" categories:

• Minimal: No prior convictions or court-ordered supervision for DUI; no prior statutory summary suspension; no prior reckless driving invocations reduced from DUI; a BAC of less than .15g/dl at the time of the arrest for DUI; and no symptoms of substance abuse or dependence.
• Moderate: No prior conviction or court-ordered supervision for DUI; no prior statutory summary suspension; no prior reckless driving conviction reduced from DUI; a BAC of .15 to .19 or a refusal of chemical testing at the time of the current DUI arrest; and no other symptoms of substance abuse or dependence.
• Significant: One prior conviction or court-ordered supervision for DUI, one prior statutory summary suspension, or one prior reckless driving conviction reduced from DUI; and/or a BAC of .20g/dl or higher at the time of the most current arrest for DUI and/or other symptoms of substance abuse.
• High: Symptoms of substance dependence, no prior arrest.
• High +: Two prior convictions or court-ordered supervisions for DUI, two prior statutory summary suspensions, or two prior reckless driving convictions reduced from DUI within a ten-year period from the date of the most current (third) arrest.
• High ++: Symptoms of substance dependence and two prior convictions or court-ordered supervisions for DUI, or two prior statutory summary suspensions, or two prior reckless driving convictions reduced from DUI within a ten-year period from the date of the most current (third) arrest. (Cavaiola and Wuth, 2002, pgs. 165 - 166)
• To return to the issue of matching, it is of note that the broader literature on substance abuse treatment includes some studies indicating the benefits of matching clients to treatment, but it cannot be assumed that the results can be generalized to DWI populations. There is, however, a consensus among service providers that a variety of flexible and individualized services are needed to address the variety of problems presented by clients of specialized substance abuse services. As stated in a Health Canada report:

Some clients need services for mental health problems, others require help with employment and other social problems, and some will need temporary or longer-term shelter. Attention to these problems is essential if those involved are to achieve and maintain improvements in substance use behaviours.

These points have been further elaborated with respect to treatment for alcohol-impaired drivers by a committee of experts convened by the US Century Council (1997), and there are no good reasons to believe that the issues differ for drivers impaired by other drugs. The Century Council recommends that treatment for DWI offenders should be:

• based on a personalized assessment process that is needed to evaluate an individual's use of, or dependence on, alcohol;
• individualized to meet the needs of each offender;
• based on a combination of strategies, such as education with therapy, plus follow-up; and
• provided over a sufficient period of time for meaningful behaviour changes to occur, and be monitored.
  
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The Century Council's expert committee also indicated that treatment should not be a substitute for other sanctions, especially licence suspensions. It noted that treatment has its largest impact on recidivism when it is combined with sanctions such as licence suspensions and interlock requirements.

Mann et al. (1997) reviewed the DWI treatment literature, the broader literature on substance abuse treatment and the literature on the treatment of offenders to identify the most important elements for comprehensive remedial programs for DWI offenders. They proposed the following components for programs intending to address a diversity of needs:

• alcohol and traffic safety education;
• motivational enhancement to cut down excessive drinking;
• consciousness raising concerning the individual's quantity, frequency and pattern of drinking;
• identification of high-risk situations, and planning;
• rehearsal of alternative coping skills;
• promotion of lifestyle changes;
• social support for reduced drinking or abstinence;
• information on further treatment options; and
• the opportunity to choose abstinence or moderate drinking as a program goal.

Mann et al. (1997) also noted that the literature shows the importance of dealing with clients in a non-judgmental manner.

The literature supports the need for all remedial interventions (including those for offenders at no or low risk of recidivism) to include, at a minimum, education regarding alcohol and traffic safety, and an opportunity to examine their substance use and driving behaviour and to develop strategies to avoid driving while impaired in the future. These objectives are best met through participatory instructional strategies, based on sound adult education practice. For offenders at higher risk, additional components with greater emphasis on therapeutic interventions are required (Century Council, 1997; Mann et al., 1997).

3.2.2 Key informant interviews

Key informants supported the need for multiple levels of intervention to ensure that offenders were not over-treated or under-treated, and for interventions that were client-centred and tailored to each client's strengths and problem areas as identified in the screening/assessment process. "One size does not fit all" was expressed by a number of key informants. Based on current practice across the country, these different levels of intervention would address the needs of those who require education regarding the effects of alcohol (BAC) and DWI legislation; are considered higher risk because of their attitudes and behaviours regarding drinking and driving and/or are at an early stage of a substance use problem; and have a serious substance use problem. A group format was considered the most cost-effective intervention modality for DWI offenders. Though it was generally felt that educational interventions were appropriate for many first offenders, key informants also cautioned that assignment should be in the context of the results from screening/assessment.

Several key informants recommended that offenders, particularly repeat offenders, be regularly monitored for periods that would be determined by relapse pattern and rating of risk. Key informants were particularly concerned about offenders who they felt continued to pose a risk for drinking and driving and that they should continue to be monitored following licence reinstatement.

3.2.3 Best practices

It is widely assumed that two or three levels of intervention are needed: (1) education for those at a lower risk for relapse, (2) outpatient treatment and (3) more intensive treatment for those at higher risk due to the severity of their substance use problem. This assumption is reflected in the practices of many jurisdictions. Although the empirical support for such arrangements is limited, clinical experience supports the value of having two or three levels of intervention.

Best Practice 3
Comprehensive remedial programs for convicted impaired drivers should incorporate at least two levels of intervention for individuals with differing levels of substance use and related problems.

Available research identifies effective components that can be incorporated into all programs, regardless of length. Programs that rely solely on a didactic approach, or on an attempt to confront clients with the consequences of their actions, appear to be less effective than programs that incorporate both educational and therapeutic activities, regardless of the length or intensity of the program.

Best Practice 4
All programs for convicted DWI offenders should incorporate both educational and therapeutic activities, regardless of program length.

Follow-up is widely considered to be a central aspect of effective substance use treatment and programs for convicted impaired drivers. With convicted impaired drivers, follow-up can serve several important purposes: it can be as an additional therapeutic contact; it extends the period during which clients are under therapeutic supervision; it aids in the consolidation of the positive behavioural and attitudinal changes made in remedial programs; and it is also a check on the success of the client in maintaining those gains.

Best Practice 5
Mandatory clinical follow-up after licence reinstatement should be required for all DWI offenders sent to remedial programs.