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Iv. Rehabilitation options for offenders sentenced to treatment

Treatment Programs

Recent research on the effectiveness of screening and brief interventions in medical settings is promising. However, most of these interventions are accomplished before drivers are arrested or charged with DWI. Counseling by medical professionals of drinking drivers injured in crashes and treated at hospitals has been shown to reduce future alcohol-related episodes (Gentilello et al., 1999; Longabaugh et al., 2001; Wells-Parker and Williams, 2002). In addition to brief intervention programs (such as where an offender who has been injured in a crash is identified by hospital professionals for a quick, on-site, screening and discussion), offenders evaluated as problem drinkers or alcohol-dependent require a more intensive and longer treatment program than DWI education alone (Wells-Parker et al., 1990; Mayhew and Simpson, 1991). Such rehabilitation may be conducted on an outpatient or inpatient basis. The option of inpatient treatment provides for:

  • Incapacitation;
  • More intense, broader-spectrum treatment than many outpatient programs; and
  • The opportunity to closely monitor the offender’s compliance with the treatment regimen (Nace, 1993; Transportation Research Board, 1995).

Intensive inpatient or outpatient alcohol dependent treatment can take several approaches. An example is cognitive-behavioral therapy (CBT), which provides training in ways to confront or avoid everyday situations that might lead to drinking and works to strengthen behaviors that help maintain long-term sobriety (Kadden, 1994; Miller, 1993). Other popular approaches include motivational enhancement therapy (MET) (Miller, Zweben, DiClemente, and Rychtarik, 1992) and 12-step facilitation therapy (TSF) (Nowinski, Baker, and Carroll, 1992). In the largest, most statistically powerful psychotherapy trial ever conducted, the Project MATCH Research Group (1997) essentially found each approach to be equally effective on alcohol-dependent clients in reducing their alcohol abuse post-treatment.

Limited available evidence suggests that recidivism may be reduced if DWI offenders who are problem drinkers are required to participate in an intensive treatment program for at least 1 year. This conclusion was based, in part, on a program that included therapy sessions once a week and an individual interview with either a therapist or probation official every other week (NHTSA, 1986).

Combination treatment and education programs tailored to the number of prior DWI convictions held by an offender have been found to reduce recidivism. In California, for example, first offender programs lasted three months and were comprised of a minimum of 10 hours of alcohol education, 10 hours of counseling, 10 hours of education and counseling combined, and regular face-to-face interviews with program staff (DeYoung, 1997). Second offenders were sentenced to an 18-month program (at least 12 hours of alcohol education, 52 hours counseling and face-to-face interviews twice a week). Third and higher offenders were sentenced to a 30-month program (18 hours of education, 117 hours of counseling, 120-300 hours of community service, and more frequent face-to-face interviews). DeYoung (1997) found that repeat offenders with one prior (i.e., second offenders), were 1.5 times less likely to recidivate in the combination program than those offenders who received only license revocation. For repeat offenders with three or more priors, those who participated in the program were 1.7 times less likely to recidivate compared to those offenders who only had their licenses revoked. In other words, increasingly intense treatment, depending on the number of prior DWIs of the offender, had pronounced positive effects on recidivism rates in this California study.

Use of Medications

For DWI offenders diagnosed with alcoholism, medications to prevent drinking, such as disulfiram (Antabuse), are most likely to succeed in environments in which medication compliance can be closely monitored (Chick et al., 1992). More recently, naltraxone has come into use in the treatment of alcohol-dependent DWI offenders. The effectiveness of naltraxone with DWI offenders is unknown at this time. However, how closely offenders comply with the prescribed dose regimen is obviously an important element for any medication to be effective. In some cases, it may only work when medication is taken under direct professional supervision.

Diversion Programs

Diversion programs generally allow an offender to complete an education, treatment, and/or community service program and then dismiss the DWI charge. This results in no conviction on the driver record of the offender and means that some repeat offenders continue to be treated as first-time offenders. Programs allowing charge dismissal after completion of treatment generally do not appear to reduce recidivism (Jones and Lacey, 1991; Harding, 1989b; Rauch et al., 2002a). However, one study found that deferring prosecution for 2 years while offenders participated in various forms of treatment decreased DWI recidivism during the deferral period and, in some cases, beyond (Baxter, Salzberg, and Kleyn, 1993). NHTSA has recommended that States eliminate diversion programs (NHTSA, 2003b).

Alcoholics Anonymous

AA has been the primary aid to recovery for many alcohol-dependent offenders. For DWI offenders, AA may be most effective in hospital or correctional settings in which attendance can be monitored (McCrady and Miller, 1993). Researchers have questioned the wisdom of requiring all offenders to attend AA and to make it the core component of offenders’ aftercare (Emrick, Tonigan, Montgomery, and Little, 1993) for the following reasons:

  • As with any other form of rehabilitation, AA works better for some people than for others (McCrady and Miller, 1993).
  • AA spokespersons have expressed concern that court-mandated AA attendance may overwhelm meetings with people who do not want to be there and who are often hostile and disruptive (Speiglman, Witbrodt, and Many, 1992).
  • AA is a spiritual, not religion-based, program and may not be appropriate for some offenders.

Summary

In summary, the George Washington University Medical Center (2003) has identified several components of effective alcohol treatment:

  • Early detection, including screening and brief interventions (for nondependent problem drinkers)
  • Comprehensive assessment and individualized treatment plan
  • Care management
  • Individually delivered, proven professional interventions
  • Contracting with patients in order to ensure compliance
  • Social skills training
  • Medications
  • Specialized services for medical, psychiatric, employment, or family problems
  • Continuing care
  • Strong bond with therapist or counselor
  • Longer duration of treatment for alcohol dependent persons
  • Participation in support groups
  • Strong patient motivation

(Sources: McLellan, 2002; Miller and Wilbourne, 2002; National Institute on Drug Abuse, 1999; Project MATCH Research Group, 1997).

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