Practice note: Building recovery, reducing crime
Chief Executive, CareNZ
Kathryn has extensive experience in health and criminal justice, including the early development of UK prison drug treatment, and community criminal justice based interventions. She has co-authored a number of programmes and practice guides including those for HM Prison Service (UK) and Best Practice Guide to providing Drug Services in Prison (UNODC). She has been a social work and business studies lecturer and a consultant and trainer for EU and UNODC programmes across Eastern Europe and Central Asia. Kathryn was appointed Chief Executive of CareNZ in 2013.
It is well established that problematic drug and alcohol use is a major driver of crime.
The relationship between substance use and offending is complex and may be related to the following factors or any combination of these:
- Offending to support/fund drug and alcohol dependency
- Offending when under the influence of drugs and alcohol
- Using drugs and alcohol to facilitate offending and/or manage emotions about offending
- Supply of drugs and alcohol
- Combining an activity that would otherwise be legal (e.g. driving) and alcohol/drugs.
In New Zealand it is estimated that two thirds of prisoners have problems with drugs and/or alcohol. This figure correlates with international studies which indicate a prevalence of between 40 and 80 percent. Figures for offenders in the community are not dissimilar.
Problematic drug and alcohol use is a risk factor for offending. Addressing alcohol and drug dependency has a critical role to play in reducing re-offending and in reaching the Better Public Services goal of a 25 percent reduction in re-offending by 2017.
Working within the criminal justice setting has not always been a comfortable environment for alcohol and drug practitioners. Over the years concern has been expressed about the ethics and efficacy of entering treatment under coercion, for example court mandated. However, as a sector we have come to understand more about the role that interventions and practitioners play in building participant motivation. Motivation can no longer be viewed as a personality trait or something one has but rather as something one does. Contrary to long held beliefs, the client’s motivation on first presentation is not a predeterminant of success. We now understand the role of programmes and workers in building motivation. Indeed, research on ‘motivated clients’ has more to say about the worker than the client themselves. Motivated clients have workers who are empathic, able to build rapport quickly and believe in the possibility of change for the client and likelihood of a positive outcome. Services have needed to recognise that people do not present for treatment because of their alcohol or other drug (AOD) use per se but because of the problems it is causing them. These external motivators need to be internalised if dependency issues are to be successfully addressed. In this way court motivated treatment and treatment to meet sentence plan or parole targets is no different from the threat of a partner leaving, loss of job or Child Youth and Family taking the children into care. A crucial first phase of treatment is to support the client building on and internalising their motivation so that if external motivators change the client continues with the treatment and does not drop out of the service.
Given the correlation between alcohol and drug use and offending, supporting offenders to address and maintain changes in their drug and alcohol use will arguably support them in building offence free lives. There is evidence to support both prison and community based interventions’ role in reducing re-offending (Holloway, Bennett & Farrington, 2005). But addressing problematic drug and alcohol use isn’t easy and success rates for treatment have not always been positive. Addiction has been described as a chronic relapsing condition and research would suggest that the most likely first outcome of treatment is relapse.
However, the evidence base regarding the efficacy of interventions is growing and there have been significant developments over the last 10 to 15 years. There is greater understanding of what works well and what is not as effective. For a long time the sector has known that the therapeutic relationship itself and the support of peers are important; the research now concurs. Other evidence has forced the sector to rethink and approach some things differently e.g. motivation. At the same time we are also learning more about neuroscience and change as an ongoing process. These are important if we are to be more effective in helping clients build individual resilience, address their substance use and live crime free lives.
The sector is broadening its understanding of what constitutes treatment. There is increasing recognition that it is not just group or individual therapy. A range of additional activities such as learning to cook, budget, eat a healthy diet, reduce caffeine and nicotine use, physical activity, peer support, mindfulness and positive alcohol/drug free social interactions play a critical part. These support and influence therapeutic interventions and form a critical part of clinical work. For example regular physical activity combined with mindfulness training lowers stress reactivity and enables people to learn to tolerate sensations and emotions which in the past may have acted as triggers for using.
In the New Zealand context ensuring the cultural appropriateness of interventions is essential. This is about more than observing protocol. Interventions need to reflect Mäori health frameworks, which characteristically integrate mind, body and spirit within the context of social collectivity. The importance of whänau, iwi and rebuilding cultural connections is critical.
Working with diversity and ensuring that services are accessible, relevant and perceived as such is also important. We cannot address alcohol and drug dependency effectively if we ignore, for example the impact of gender, culture, age, faith, sexual orientation, literacy or disability on the client’s using experience or potential recovery.
Research consistently shows that the therapeutic relationship is the critical factor rather than the modality. Abstinence and 12 Step programmes, therapeutic communities and cognitive behavioural programmes have all been effective.
Any treatment model needs to target changeable risk factors. These are well documented and evidenced. There is a lot of similarity between the risk factors for addressing offending/anti-social behaviour and alcohol/drug dependency. It is the targeting, focus and sequencing of interventions to these risk factors that effects behaviour change. Done too quickly or without adequate practice, new skills and abilities are not sufficiently internalised. Structured treatment builds individual capability and capacity to support a life free from problem drug and alcohol use. It reduces the risk of lapse and relapse and therefore ultimately supports and sustains behaviour change.
We are seeing a shift in treatment from the role of practitioner as expert to the client as their own expert with the resources and capabilities for change. This is important in building self-efficacy. It is essential that the work of treatment helps participants to take responsibility for the changes they are making. In prison it may not feel like much of a choice, but each day in a prison-based Drug Treatment Unit, prisoners choose to go to group. In the same way, turning up to an AOD appointment as part of a community sentence is a choice. We can always choose not to even though there will be consequences to be faced as a result. If we can help offenders recognise these choices and the action they have taken, it not only seeds momentum for change but they can also take the credit later on.
In the past, the focus has been on building the individual’s self-worth and self-esteem. However, how I feel about myself is not the same as my belief in my ability to make and sustain change. Thus identifying any positive movement and recognising achievement is central in building recovery. Interestingly a well-known saying often used in treatment perspective taking reflects this: ‘is the glass half full or half empty?’. Are we looking at what we are doing rather than what we haven’t yet achieved and can we begin to understand that the glass is both half full and half empty? Similarly, sobriety countdowns and daily awhi (acknowledgements) in therapeutic community meetings are a critical component in building self-efficacy.
If you have always lived your life as an adult using drugs and alcohol for socialising, communicating, coping with emotions, and managing intimate relationships – life alcohol and drug free can be scary. Temptations are many. Long term change requires that clients are able to navigate the natural experiences of daily life and live ‘life on life’s terms’. Alcoholics Anonymous members will talk about AA being a bridge to normal living. Effective treatment helps clients to access and build that bridge and ultimately cross over to the other side.
It can be easy to overcomplicate treatment. Whilst therapy and addressing unresolved issues may be part of the process, practical support and life skills are important in ensuring clients can sustain contact and engagement with a programme; that they can access services and implement changes in their life. Practical help with sleep difficulties, panic attacks, urge surfing and strategies to stay safe can be easily overlooked. Alongside the talking therapy, one of my most effective pieces of work was with an offender in a bail hostel. As part of his relapse prevention plan he needed to get to his first AA meeting. He believed that if he could make it sober to his first AA meeting, he could stay sober for the day. So we plotted his route without passing where he used to drink and use, or could buy alcohol or drugs.
Access to housing, employment and training, and prosocial and non-using peers cannot be overlooked. Having a place to live, an income, a purpose to your day and supportive relationships undoubtedly makes addressing drug and alcohol issues easier. Treatment cannot stop at the counselling room door, group session or residential unit. We need to find ways to incorporate these into the treatment. Aftercare and throughcare post programme are critically important. This is still an area for potential development within the sector and within the criminal justice context. However, we are increasingly seeing new low-threshold initiatives emerge. These services work with people where they are at, providing information and advice and reducing barriers to engagement. Post programme follow up and support following reintegration into the community are also increasingly gaining momentum. Similarly, mentors and peer supporters bring the power of role modelling, real life demonstration and evidence for the potential and possibility of change. This can be very empowering for clients.
Success or desistance involves building resilience and protective factors, creating an insurance policy and investing in recovery.
The use of the term ‘recovery’ is not without controversy in the sector. Historically recovery was linked with the 12 step fellowships. The concept of recovery from the disease theory of addiction came through abstinence. More recently the term is being used much more broadly with a focus on recovery as being about wellness including the principles of health, a place to live, purpose in life and sense of community. In New Zealand, Te Pou recently published Equally Well which highlighted the health inequalities for people with mental health and addiction issues (Te Pou, 2014).
Overseas, in the last few years, the concept of ‘recovery capital’ has gained increasing traction. Definitions (UK Drug Policy Commission , 2008) of recovery in this context involve three components: wellbeing and quality of life, community engagement or citizenship, and addressing substance use. Becoming a fully participating member of society involves living in accordance with the laws of the land and therefore by implication, offence free.
Clearly we are heading in the right direction. However, we need to continue to develop referral pathways into services including low threshold advice and information interventions (including initiatives such as the Department of Corrections led Out of Gate) as well as peer support, through and aftercare programmes. At the same time structured treatment must address changeable risk factors and build resilience if we are to ensure we fully realise the potential for building recovery and reducing crime.
- Holloway, Bennett & Farrington (2005) Effectiveness of drug treatment in reducing drug-related crime: a systematic review, London, Home Office Online Report 26/05.
- Te Pou (2014) The physical health of people with a serious mental illness and/or addiction: An evidence review, Auckland www.tepou.co.nz
- UK Drug Policy Commission, (2008) Recovery Consensus Statement, www.ukdpc.org.uk/Recovery_Consensus_Statement.shtml