Recovery, desistance and 'coerced' drug treatment Tim McSweeney Senior Research Fellow Institute for

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Recovery, desistance and 'coerced' drug
treatmentTim McSweeneySenior Research
FellowInstitute for Criminal Policy Research
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What I want to do

• Offer some definitions of recovery, desistance
  and coerced treatment
• Consider why these issues are important?
• Assess extent to which one form of coerced
  treatment in Britain contributes to these goals
  (relative to voluntary forms)?
• overview use of DTTOs to date
• present English evidence from a recent European
  study
• Identify barriers that inhibit recovery and
  desistance

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Definitions

• No standard or universally agreed definitions
• Coerced treatment - motivated, ordered or
  supervised by the CJS (Stevens et al., 2005)
• Primary desistance (the achievement of a
  significant lull or cessation in offending) and
  
• secondary desistance (an underlying change in
  self-identity wherein the ex-offender labels him
  or herself as such) Burnett and McNeill (2005)

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Definitions

• Recovery - special issue J Sub Abuse Treatment 33
  (3) 2007
• sustained cessation or reduction in the
  frequency, quantity, and (high risk)
  circumstances of AOD use following a sustained
  period of harmful use or dependence
• absence of, or progressive reduction in, the
  number and intensity of AOD-related problems and
  
• evidence of enhanced global (physical, emotional,
  relational, educational/occupational) health
  (White, 2007)

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Why are these issues important?

• For theoretical, ethical and practical reasons
• the factors associated with giving up drugs
  could be related to those associated with giving
  up crime (Gossop et al., 2005)
• increasing shift from coercion (constrained
  choice) to outright compulsion (e.g. with testing
  on arrest) with allied concerns about
  net-widening, proportionality and effectiveness
  and
• rapid expansion in range of CJ options targeting
  DUOs since 1997 (at considerable public expense -
  330m in 06/07).

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How can coerced treatment contribute to these
goals?

• Maguire Raynor (2006) state by acknowledging
  that
• Recovery and desistance are processes not events
• Access to timely appropriate support is key
• Works required to develop motivation,
  opportunities and capacity to change
• Agency is important in promoting/inhibiting
  change (thinking, attitudes, perceptions,
  identities, narratives, roles and
  responsibilities)
• Tackling social problems and integration
  important too (housing, relationships,
  employability)
• We need to provide opportunities to use new
  skills and roles

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Does coerced treatment contribute to these
goals?

• Focus here to DTTOs (suitable for north/south
  comparison)
• 60,000 imposed in Britain since late 1990s
• Incidence per 10,000 of the adult (16)
  population during 2006/07 was 1.7 in Scotland and
  3.6 in England and Wales
• Between 2002-2005 in England and Wales
• DTTO completion rates rose from 25 to 39 (now
  broadly consistent with Scottish orders and
  mainstream treatment)
• 1-year reconviction rates for DTTOs fell from 79
  to 70 (reductions in frequency of offending too)
  (MoJ 2007 2008)

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Does coerced treatment contribute to these
goals?

• In British pilots those completing DTTOs
  significantly less likely to be reconvicted than
  those not (Hough et al., 2003 McIvor, 2004)
• England 53 completers vs 91 non-completers
• Scotland 52 completers vs 79 non-completers
• Still marked regional variation in performance
  (in 2004/05)
• 14 in Staffordshire and 15 in North Yorkshire
• 53 in South London and 51 in Dorset.

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Does coerced treatment contribute to these
goals?

• Variations likely to be explained by
• area-level differences in profile of those being
  sentenced
• length of sentences being imposed (e.g. Dorset
  has tended to impose 6 month orders others also
  encouraged with DRRs)
• treatment quality, availability and delivery
  (NAPO survey)
• setting (whether community-based or residential)
• treatment orientation (abstinence-based or
  controlled use)
• responsiveness of interventions (e.g. to the
  needs of crack cocaine users) and
• enforcement/breach practices (more flexibility in
  Scotland).

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Recent evidence QCT Europe

• Parallel studies in Austria, England, Germany,
  Italy and Switzerland. Also considered Dutch SOV
  pilots.
• Sampled from 65 purposively selected treatment
  centres between June 2003 and May 2004 (mix of
  community-based and in-patient).
• 845 people questioned using EuropASI at 4
  intervals.
• 84 health and criminal justice professionals.
• In-depth interviews with 138 subject to QCT.

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QCT Europe English sample

• 157 people recruited between June 2003 and
  January 2004.
• Sampled from 10 purposively selected
  community-based treatment services in London and
  Kent.
• Four-fifths in either day care (n66) only or
  in day care with a substitute prescription (n60)
  (only 4 of DTTO cases in England accessed rehab
  during this time).
• 38 health and criminal justice professionals
  interviewed.
• 57 in-depth interviews from quantitative sample
  serving a DTTO.

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Those we interviewed (N157)

• 89 (57) were in treatment as part of a DTTO.
• Most (120) were male - average age 31 years.
• 80 (125) described themselves as White.
• 53 (82) left school before the age of 16.
• 75 had neither worked nor studied in the 3 years
  prior to intake.
• More than half (n83) experienced serious
  depression and anxiety in the past month.

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Those we interviewed (N157)

• Volunteers tended to report worse mental health
  problems.
• 75 used heroin in month before intake 62
  crack 86 used heroin and crack.
• 51 were injectors (last 6 months) 33 shared
  equipment
• Nearly three-quarters (n111) previously treated
  for AOD dependency.
• No difference in previous exposure to treatment
  between people on DTTOs and volunteers.

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Those we interviewed (N157)

• At intake, the English DTTO clients were
• more likely to be male (plt0.001),
• more likely to be homeless (plt0.01)
• using a wider range of drugs (plt0.01) - including
  crack (plt0.001),
• injecting more frequently (plt0.01),
• spending more on drugs (plt0.001), and
• were more criminally active (plt0.001).
• Perhaps more to be gained if these people could
  be encouraged to stay and succeed in treatment?
  (cf. DTORS intake findings.)

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The role of coercion

• Across the entire QCT Europe sample of 845
  respondents
• 65 of the volunteers reported some external
  pressure or duress to enter treatment
• 22 of the QCT group reported experiencing no
  such pressures.
• Link between legal status and perceived pressure
  but this does not reduce peoples motivation to
  change (Stevens et al., 2006). Again, supported
  by more recent DTORS intake findings.
• People reported feeling less coercion during
  follow-up than at intake.

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Key UK findings

• Significant and sustained reductions in
  self-reported illicit drug use and offending
  behaviours over an 18-month follow-up period for
  both groups.

17
Average number of reported days involved in crime
during the last month
plt0.001
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Average number of reported days using drugs
during the last month
excluding alcohol, cannabis and methadone
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Key UK findings

• Substantial reductions in reported expenditure on
  illicit drugs from a median of 1200 in the 30
  days before intake interview (n156) to 30
  (n104) at 6-month follow-up.
• Modest improvements in mental health.
• Reductions in reported risk behaviours (e.g.
  sharing injecting equipment).
• Improvements in housing and personal
  relationships.
• No change in (very high) rates of unemployment
  (78).
• No significant differences between those
  coerced into drug treatment and the comparison
  group of volunteers in retention rates and
  other outcomes.

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Caveats and limitations

• Sampling and response bias
• 52 of those offered treatment in the 10 sites
  were interviewed most didnt show or stay long
  enough
• Attrition ranged from 68 (t2), 64 (t3) to 61
  (t4)
• But 82 were re-interviewed at least once
  post-admission
• Reductions maintained when adjustments made for
  missing data and time at reduced risk (e.g.
  imprisonment).
• Relies on self-reports of behaviour
• But shown to be reliable in other studies
  involving offenders (Farrell 2005) and drug users
  (Gossop et al 2006)
• The possibility of a spontaneous improvement
  effect
• How much of the change is attributable to
  treatment/formal intervention and how much
  self-change processes?

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Conclusions

• Coerced treatment can have comparable retention
  rates and outcomes to drug treatment entered
  through non-criminal justice routes.
• The English results replicate those from the
  other four partner countries involved in the QCT
  Europe study.
• The approach could be considered a viable
  alternative to imprisonment and a vehicle for
  initiating recovery and desistance processes
• most problem drug users fail to sustain behaviour
  changes made while in custody (75 relapse rate
  in one recent UK study) and
• non-custodial treatment alternatives are likely
  to be a more cost effective approach and have
  fewer detrimental effects.

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Conclusions - Barriers to facilitating recovery
and desistance (in Britain)

• Scope for improving methods of delivery
• Refining referral and assessment processes
• difficulties assessing motivation and identifying
  those likely to do well
• exacerbated by pressure of targets and
  performance management culture.
• Providing appropriate, responsive treatment
  options in a timely manner (more focus on
  stimulant users - who are over-represented in CJ
  caseloads, women, young people and BME groups).

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Conclusions - Barriers to facilitating recovery
and desistance (in Britain)

• Offering consistency around procedures for drug
  testing, court/status reviews and enforcing
  coerced conditions
• aims rationale for frequency of testing,
  consequences of
• failed tests and how tests compliment care
  plans
• continuity, style and quality of interaction
  during reviews
• limited scope for discretion in responding to
  non-compliance.
• Ensuring effective arrangements for aftercare and
  reintegration are in place. Too often just an
  afterthought.
• Limited capacity to tackle wider social
  environmental factors

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AcknowledgementsThe European Commission for
funding the studyThe University of Kent and the
other partner countries and agencies involved in
QCT Europe Rowdy Margaret for the
opportunity to presentFurther details of the
Institute for Criminal Policy Research are
available at www.kcl.ac.uk/icprFor more
information about the QCT Europe study
visithttp//www.kent.ac.uk/eiss/projects/qcteuro
pe/index.html