Programs for Offenders

Specific measures to prevent convicted impaired drivers from repeating the offence have become extremely widespread, not only in Canada but throughout North America. These measures, often referred to as tertiary prevention efforts, typically involve (1) court-imposed and administrative sanctions and (2) rehabilitation programs. Section 3 outlined the range of judicial and administrative procedures for dealing with DWI offenders in each jurisdiction in Canada, including the types of programs available. This section examines rehabilitation programs in greater detail. It begins with an overview of rehabilitation programs, outlining the three major types of programs -- i.e., education, treatment and assessment. This is followed by examples of each type of program presently available in Canada plus a discussion of other types of programs that are not readily classified into one of the major groups. The section concludes with a discussion of a model rehabilitation program. The complete inventory of programs is contained in Section 5.0.

4.1 Background

During the past two decades, rehabilitation programs for impaired drivers have received increased attention and the range of programs available has expanded steadily. The rationale for this approach is founded on the belief that impaired driving could be best resolved by addressing the underlying problems that give rise to the behaviour -- most often problem drinking. Although there exists substantial overlap among rehabilitation approaches, for purposes of this section three general categories of programs have been distinguished -- education, treatment, and assessment. The rationale and purpose of each approach are outlined below along with a brief discussion of their effectiveness.

4.1.1 Education. The most common rehabilitation programs for impaired drivers are those with a primarily educational focus. While there is a wide variety of formats and methods being used, educational programs typically involve the presentation of information to participants about alcohol, its effects on behaviour, the effects of alcohol on driving ability, and the role of alcohol in motor vehicle crashes. While the curriculum may contain information pertaining to problem drinking, the modification of drinking patterns is not generally considered a direct focus of the program.

Educational programs have become increasingly popular as a sentencing alternative for convicted impaired drivers. Underlying the educational approach to the rehabilitation of drinking drivers is the assumption that convicted offenders do not possess the knowledge or skills necessary to avoid subsequent offences. Providing offenders with knowledge about alcohol, its effects on behaviour, the relationship between amount consumed and blood alcohol levels, and information about the law concerning alcohol and driving would presumably correct the situation and reduce the incidence of repeat offences. Although intuitively compelling, a major obstacle of this approach lies in the ability to link, either conceptually or empirically, knowledge about alcohol and drinking-driving behaviour.

The first large-scale educational program for drinking drivers was developed in Phoenix in the early 1970s (Stewart and Malfetti, 1970). This program consisted of four, two and one-half hour sessions in which participants were provided with information pertaining to alcohol and its effects in relation to driving. This program, with its initial positive results, provided a model for over 400 similar educational programs in North America (Malfetti, 1975). The content and duration of courses based on the Phoenix model, however, vary considerably. Some programs are conducted in a single session whereas others are spread over thirteen or more sessions.

Although the ultimate objective of educational programs is to reduce the incidence of recidivism among offenders, a more immediate goal is to increase participants’ level of knowledge about alcohol and its influence on driving. Studies of educational programs have examined their efficacy in terms of several different criteria or outcome measures including knowledge, attitudes, lifestyle, subsequent accidents, traffic violations, and drinking-driving convictions. Most often studies rely on indices of knowledge and attitude change as outcome measures. While such measures may be valid indicators of immediate program goals, they are indirect indicators of overall program effectiveness in terms of drinking-driving behaviour. Direct measures of traffic safety variables need to be considered in conjunction with other measures to provide a comprehensive assessment of program effectiveness.

In a review of published studies between 1970 and 1982, Mann et al. (1983) found the evidence on the effectiveness of educational programs for drinking drivers to be equivocal. In a later review of studies evaluating educational programs for drinking drivers, Foon (1988) concluded that while some programs have had modest success among lighter drinkers, in general, the effectiveness of such programs is questionable. Some programs report beneficial pre-post changes in knowledge and attitudes towards drinking-driving but little change is evident in personal drinking patterns. In terms of reconviction for a drinking-driving offence and other traffic safety measures, some less rigorously controlled studies have demonstrated beneficial impacts of educational programs, whereas more rigorously studies have not consistently demonstrated strong positive results.

In a rather unique long-term follow-up study, Mann et al., (1993) examined mortality among a group of second offenders 7 to 13 years after being assigned to either a brief educational program or a control condition. Overall, the group of offenders had a higher incidence of mortality than would be expected in the general population. Although the highest number of deaths was among those age 55 to 79 years, the risk of premature death was highest among offenders in the 15 to 34 year age group. When the cause of death was examined, offenders experienced a greater than expected incidence of death due to cerebrovascular disease, liver disease, accidental and violent deaths, and alcohol dependence syndrome.

The comparison of mortality rates between those who attended the educational program and those in the control condition demonstrates the long-term benefits of educational programs. Those who attended the educational program had a significantly lower overall mortality rate and lower mortality from accidental and violent causes than those in the no treatment control condition. There was, however, no difference between the treatment and control groups in terms of deaths due to cirrhosis and alcohol dependence syndrome. The observed differences in causes of death between the groups suggest that educational programs are more beneficial for episodic or early-stage problem drinkers in reducing mortality risk from accidents and violence but that such programs may be of limited value in reducing mortality risk from cirrhosis or alcohol dependence syndrome among those who have a well-established pattern of chronic, heavy alcohol consumption.

The available evidence indicates that the effectiveness of educational programs for convicted impaired drivers is undoubtedly diminished by the heterogeneous mix of the participant population. Many programs are attended by persons convicted of two or more offences, whereas the material presented may be more appropriate for first offenders. Foon (1988) suggests that many course participants may not be suitable intellectually, cognitively, or socially for the nature of the program and will, therefore, fail to derive significant benefit from it. A more efficient and cost-effective approach might be to devise a means of selecting participants for educational programs by matching individual characteristics with the demands and objectives of a particular program.

4.1.2 Alcohol treatment programs. Alcohol treatment programs exemplify the cooperative health-legal approach to dealing with the problem of impaired driving. The general rationale for having offenders attend treatment is based on the belief that an impaired driving conviction is a manifestation of a drinking problem or at least an early warning of an impending problem. Alcohol abuse might very well pervade all aspects of the individual’s life but has only come to public attention as a result of a conviction for impaired driving. From a public health perspective, arrests for impaired driving could serve as a mechanism for the early identification of problem drinkers. Offenders could then be directed into the health care system for treatment. From a legal perspective, reducing the extent of problem drinking and/or the alcohol problem through treatment should decrease the incidence of recidivism by reducing the likelihood of drinking to excess.

Approaches to the treatment of alcohol abuse are numerous and vary greatly both conceptually and in practice. No one approach seems to have emerged as the most efficient or effective for all types of problem drinkers. Alcohol treatment programs for convicted DWI offenders are generally modelled after or are part of those developed for problem drinkers from the general population. They can include individual and group counselling, inpatient treatment, Alcoholics Anonymous, disulfiram therapy, behaviour modification, as well as social-cognitive approaches. The length of treatment can also range from a few sessions to several months to a year or more.

In general, the evaluation of alcohol rehabilitation programs for impaired drivers is constrained to the same extent and by the same factors as the evaluation of treatment for alcohol dependence. The assessment and diagnosis of the extent of alcohol abuse, follow-up measures, and outcome criteria remain significant problems. In general, treatment programs for alcohol abuse have limited success. This is not to suggest that treatment is not effective. Indeed, in a recent review of the literature, Eliany and Rush (1992) indicate that 50-65% of individuals receiving treatment show some evidence of improvement at follow-up. About half of those who are improved will be abstinent or will have substantially reduced their consumption. Nevertheless, a large proportion of those who enter treatment suffer a relapse at some point and return to their previous patterns of consumption. While relapses may have little bearing on the long-term success rate of a treatment program, such relapses may contribute substantially to DWI recidivism, thereby reducing the apparent effectiveness of treatment for offenders. In the long term, however, the individual and societal benefits of treatment programs are significant.

The selection of drinking drivers for participation in alcohol rehabilitation programs continues to be a difficult and often contentious issue. Typically, only those offenders who appear to present the most severe problems associated with alcohol abuse are referred for treatment. Significant differences between treatment and comparison groups prior to intervention often render interpretation of findings tentative and inconclusive (e.g., Salzberg and Klingberg, 1982). Moreover, where an assessment of the extent of alcohol problems is required, the classification into problem versus non-problem groups is often performed by personnel untrained in clinical assessment and diagnosis procedures using instruments with questionable predictive and concurrent validity (Mann et al., 1983).

The ultimate objective of alcohol treatment programs is often to eliminate the dependence on alcohol. The harm reduction approach to alcohol problems, however, embodies a recognition that full abandonment of alcohol use is often too lofty a goal for the majority of clients who are not ready for treatment, and that short of abstinence, public health goals can be significantly advanced by minimizing aspects of risk. This approach has particular relevance for the population of DWI offenders who are at risk of repeating the offence and possibly becoming involved in a crash should they continue to drink to excess and drive afterwards. An intermediate goal of treatment for this population that is consistent with the harm reduction approach is a reduction in the incidence of recidivism and alcohol-related crash involvement. Changes in patterns of alcohol consumption as well as improvements in attitude and lifestyle measures might be considered as longer term goals of treatment. Traffic safety measures, including alcohol-related indices, are one step removed from the ultimate goals of alcohol treatment but are nevertheless important objectives of such programs for DWI offenders.

In their respective reviews of alcohol treatment programs for convicted impaired drivers, both Foon (1988) and Mann et al. (1983) concluded that alcohol treatment programs for DWI offenders have not provided definitive evidence of their effectiveness. Although many studies showed that knowledge and attitude measures were often beneficially influenced by treatment, alcohol consumption and related lifestyle behaviours proved difficult to change, especially in the short term. Traffic safety measures, including drinking-driving convictions, however, showed "sufficient positive changes among participants in treatment to warrant further study" (Mann et al., 1983 p. 457).

As noted earlier, offenders directed to an alcohol treatment program are typically those repeat offenders who display the most severe signs of dependence. Greater success in treatment may be afforded those with less severe problems. The matching of different types of treatment with specific subtypes of offenders may be the most efficient and effective approach.

4.1.3 Assessment Programs. The effectiveness of rehabilitation programs for DWI offenders is undoubtedly diminished by the heterogeneous mix of the participant population. Not all offenders exhibit the same types of problems or necessarily to the same degree. Assignment to programs is often based on a priori assumptions about clients and treatments. Although in certain cases some attempt is made to match clients’ needs with program objectives, routine assessment of offenders prior to assignment to rehabilitation is still the exception rather than the norm.

Assessment programs seek to identify the type and severity of problems experienced by DWI offenders and to use this information to assign participants to rehabilitation programs. The assessment process may involve the completion of standardized questionnaires, interviews, clinical opinion and/or medical tests. These procedures typically focus on the participant’s involvement with alcohol and or drugs. Recent research, however, suggests that such assessments should be more comprehensive and include other areas such as depression, thrill-seeking, hostility, aggression, and social/personal problems (e.g. Donovan et al., 1988; Wilson, 1991). Ideally, such assessments should be performed by well-trained, experienced professionals using valid and reliable assessment instruments and techniques.

On the basis of the results of the assessment, offenders should be directed to the rehabilitation program(s) that most directly match the type and severity of their problem(s). This requires a variety of rehabilitation programs be available and that there exists a means to ensure that offenders access the resources to which they have been directed.

4.1.4 Summary and conclusion. There have been a great number of studies that have examined the effectiveness of rehabilitation programs for DWI offenders. Unfortunately, the research in this area precludes strong statements regarding the efficacy of these programs. Nevertheless, the repeated demonstration of small positive benefits of countermeasure programs warrants continued efforts. And, while the magnitude of the effect of rehabilitation programs --typically 10-15% improvement -- may not match our expectations, it is nonetheless substantial and important. Effects of this magnitude in the field of traffic safety can yield significant benefits when translated into reduced crashes, deaths and injuries.

Studies examining the effectiveness of rehabilitation programs for DWI offenders undoubtedly underestimate the beneficial effects. For example, programs that are attended by a very heterogeneous offender population may show very small or no overall improvement. The true effect of the program might well be reduced by the fact that it is inappropriate for certain types of offenders. Selective matching of offenders to treatments would provide a more direct demonstration of the beneficial effects of programs. This, however, requires a systematic program of assessment for all offenders.