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Court-Mandated Treatment for Convicted Drinking Drivers

Part 1/Part 2

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).

A DUI EVENT AS A WINDOW OF OPPORTUNITY TO ENCOURAGE BEHAVIOR CHANGE

Recent studies suggest that levels of motivation and readiness to change are critical to the success of mandated treatment, and assessment and treatment should include components which target these issues (Farabee et al. 1998). A DUI arrest and conviction may represent an opportunity to increase motivation by helping an offender recognize his or her problem with drinking and its consequences. For example, most first-time offenders who entered a DUI program acknowledged that they needed to change both their drinking and their drinking-and-driving behavior, and indicated that they were trying to do so (Wells-Parker and Williams 2002). To take advantage of the window of opportunity that may be created by the DUI event, strategies designed to be nonconfrontational and to support motivation to change and the development of realistic change plans may be especially useful as components of DUI programs. These strategies also may be useful in increasing motivation for additional treatment when problems are severe.

BRIEF INTERVENTIONS WITH DUI OFFENDERS OUTSIDE OF THE MANDATED TREATMENT SYSTEM

Many people who drink, drive, and are involved in traffic crashes are treated for injuries but do not enter the criminal justice system (Dill et al. 2004). A crash, therefore, especially one resulting in injuries, may offer another opportunity to motivate change. Recent efforts have focused on intervening with alcohol-positive drivers who are injured in crashes and are treated for those injuries in medical settings such as emergency departments or trauma centers (Dill et al. 2004).

Brief interventions often consist of only one or two short sessions, which are compatible with busy medical settings. These interventions generally have several components, including individualized feedback from a short screening, brief advice, and specially adapted counseling strategies appropriate for short sessions. These types of interventions have been offered to alcohol-positive drivers treated in emergency departments and trauma settings and have been found effective in reducing drinking and driving and other harmful behaviors (Dill et al. 2004), as well as mortality (Cuijpers et al. 2004). Brief interventions can be offered in a broad range of settings, are cost-effective, and may be used along with other rehabilitative modalities to enhance the motivation and self-confidence to change drinking-and-driving behavior.

TREATMENT: COST-EFFECTIVENESS AND ACCESS

Research has not specifically examined the cost-effectiveness of mandated treatment for drinking and driving. However, considering that alcohol was a factor in 41 percent of U.S. traffic deaths in 2002 (Hingson and Winter 2003), and that the U.S. economic costs related to alcohol use problems (not counting the costs of prevention and treatment) were about $177 billion in 1998 (NIAAA 2000), cost-effective treatments are imperative.

It should be noted that the degree of cost-effectiveness depends on the treatment outcome considered-such as reduced health care costs, legal costs, or work-related costs (NIAAA 2000; Sindelar et al. 2004). When considering reduced health care costs, studies of the cost-effectiveness of alcoholism treatment in general suggest that many treatment modalities are cost-effective; however, more expensive treatments do not necessarily yield better outcomes (NIAAA 2000). Outpatient treatment, when appropriate, is considered the most cost-effective measure, but people with heavy alcohol dependence may require inpatient services to reap the most benefit relative to cost. In addition, studies have found that reducing inpatient treatment from 28 days to 21 days yields similar outcomes at a more cost-effective rate (NIAAA 2000).

Research is needed to determine the cost-effectiveness of mandated treatment. Overall treatment effectiveness may be influenced by offenders’ levels of motivation and by hostility resulting from coercion. Certain types of treatment, such as motivational enhancement therapy, may prove to be more cost-effective in these involuntary circumstances, as demonstrated with findings from Project MATCH (NIAAA 2000).

Treatment Costs and Insurance Reimbursement

Compared with the previously mentioned $177 billion that alcohol use problems cost the U.S. economy in 1998, this country spent only $7.5 billion on treatment (NIAAA 2000). Thus, the development of cost-effective alcoholism intervention and treatment may represent an unrealized opportunity to lessen the negative consequences of alcohol problems nationwide. However, third-party payers are allowed by law to refuse coverage for court-ordered treatment (Wing 2004). Often, even if coverage is available, it is insufficient for a clinically meaningful length and intensity of treatment (Wing 2004). Clearly, current policy deters potential third-party coverage for mandated treatment, although such coverage may be available if entry into treatment was voluntary.

FUTURE RESEARCH NEEDS

As noted in this review, many questions concerning mandated treatment remain unanswered. Emerging issues related to changing DUI offender populations, multidrug use by impaired drivers, and new technologies for monitoring DUI offenders require rigorous study to determine how to provide more effective court-referred treatments.

About the Author

Patricia L. Dill, Ph.D., is an assistant research professor, and Elisabeth Wells-Parker, Ph.D., is a professor, both at the Social Science Research Center, Mississippi State University, Mississippi State, Mississippi. This research was supported in part by a grant from the Mississippi Alcohol Safety Education Program. The article’s contents are solely the responsibility of the authors and do not necessarily represent the official views of the Social Science Research Center.