Every impaired driver who enters the criminal justice system should be screened and assessed to determine whether treatment is needed to address the underlying causes of their actions. A significant percentage of offenders have severe substance use disorders and co-occurring mental health disorders. The prevalence of these issues is high among high-risk and repeat offenders. Protecting society, therefore, means matching these individuals with treatment interventions that are tailored for risk, needs, and responsivity. 

Individual and group counseling along with more intensive psychotherapy are common approaches used with impaired drivers. Other common approaches include brief interventions, motivational interviewing, cognitive behavioral therapy, self-help and 12-step groups. 

To achieve reductions in recidivism, treatment, rehabilitation, and behavior change must be prioritized and offered in a way that produces maximum benefits for each individual client. Overly prescriptive or generic programming will lead to poor outcomes. Tailored interventions are far more likely to facilitate sustained behavior change. 

Treatment: Goals and barriers to entry 

When treating substance abuse or mental health disorders, the first step is to identify the nature and severity of the disorder(s) and then determine the best course of action to alleviate and manage symptoms and then in the case of substance abuse, interrupt addictive behaviors and patterns. 

Goals. DUI offenders have high rates of addiction and mental health disorders. Treatment is designed to lessen and prevent negative consequences associated with substance abuse, such as impaired driving or other criminal behavior. In addition to creating long-term behavior change and improving quality of life, a goal of any treatment program should be to reduce recidivism. Other goals include ceasing substance use, eliminating access to illicit substances, identifying and treating co-occurring mental health disorders, developing techniques to manage stress and anxiety, creating support networks, and developing strategies to prevent or manage relapse. 

Barriers. While society has made great strides to lessen the stigma associated with addiction and mental health, feelings of shame and humiliation remain one of the primary barriers to treatment entry. There tends to be a general lack of empathy for individuals with substance use disorders because a prevailing view is that they chose to consume alcohol or drugs and therefore, they are responsible for their own predicament. If these individuals are also justice-involved, then the likelihood that others will have empathy for their current situation is very low. More education is needed to raise awareness in society that these conditions are not reflective of moral failings but rather brain chemistry, genetics, and lapses in judgment. 

There may be other reasons why individuals fail to enter treatment, but several common themes include the following:

In the case of justice-involved individuals, some of these barriers can be overcome simply because completion of treatment is a requirement of the sentence or supervision and the only options available are to either complete the program or face incarceration. Most will at least enter treatment, though they may be reluctant to engage. 

Addiction and serious mental illness: Definitions and prevalence

The American Society of Addiction Medicine (ASAM) defines addiction as “a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors…. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”

Addiction and mental health disorders are diagnosed using a set of criteria published by the American Psychiatric Association (APA). Most practitioners rely on the Diagnostic and Statistical Manual of Mental Disorders (DSM) as the principal authority for psychiatric diagnoses. Practitioners may use either the fifth or fourth edition of the DSM, and there are some differences between DSM-IV and DSM-V in diagnosing addiction.

Figure: Comparison of DSM-IV and DSM-5 criteria for diagnosing alcohol abuse and alcohol dependence vs. alcohol use disorder (Source: NIAAA)

In addition to substance use issues, the DSM is also used to diagnose other psychiatric disorders commonly referred to as mental health disorders or serious mental illness. Examples of serious mental illness include schizophrenia, major depression, manic depressive disorder, bipolar disorder, panic disorder, obsessive compulsive disorder, etc. 

Co-occurring disorders (also referred to as psychiatric comorbidity or dual diagnosis) are the presence of a substance use disorder and a mental health disorder. Research has shown that individuals with mental health disorders are more likely to also experience alcohol or drug dependency within their lifetime. It can also be difficult to identify and diagnose co-occurring disorders as the severity of the disorders varies and symptoms can overlap. For example, practitioners may identify signs of substance abuse but fail to identify the post-traumatic stress disorder that leads to alcohol or drug consumption as a way to self-medicate.

Individuals who suffer from multiple disorders may not always receive a complete diagnosis. While they receive treatment for one substance use disorder or mental health condition, their other disorder(s) will go undiagnosed, and, subsequently, untreated. 

The prevalence of addiction and mental health disorders is common among the general public:

Overall, 56.8 million adults are affected by either a mental health disorder or substance use disorder. A significant percentage of these individuals will not seek or receive proper treatment for their disorders. Ninety-two percent (92%) of individuals age 18 and over diagnosed with a co-occurring disorder will not receive treatment for both issues. 

Rates of substance use disorders, mental health disorders, and co-occurring disorders are high among DUI populations, particularly repeat offenders.

The failure to identify mental health disorders can have negative consequences within the justice system. It misses an opportunity to intervene and treat individuals in an effective way. Many treatment programs, some of which are mandatory, only focus on substance use and fail to take into consideration the mental health issues that may be the cause of the alcohol and/or drug abuse. 

The use of comprehensive screening and assessment in the criminal justice setting is therefore necessary to identify co-occurring disorders among DUI offenders. 

Screening and assessment in a treatment context

The focus of screening and assessment within a treatment environment is slightly different than the process used in the criminal justice system. 

Screening is the first step in the process of determining whether DUI offenders should be referred for treatment. At this stage, offenders who do not have substance use or mental health issues are identified and those who may have issues can be sent for a more in-depth assessment. 

In recent years, there has been some blurring between the use of screening and assessment. In a high-volume system with multiple offenders processed daily, practitioners do not always have the time available to perform lengthier assessments. As a result, a screening may be all that occurs, and the information obtained from that screener is all that is available to guide decision-making. 

Depending on the screener used, clients may complete their own screening and have practitioners score the results. The process can take anywhere from 5 to 45 minutes to complete. The information obtained from screening is valuable for prosecutors, judges, defendants and defense counsel, pre-trial services, probation officers, and clinicians. 

Assessment occurs after the screening process is complete. Offenders who show signs of substance use disorders or mental health issues are commonly referred for further testing to determine whether they meet the diagnostic criteria for specific disorders. Assessments are more formal than screening tools and these instruments are standardized, comprehensive, and explore individual issues in-depth. A formal assessment takes up to several hours and is typically administered by a trained clinician or professional. 

Assessments should be validated for specific populations to ensure accurate results. Treatment providers who work with DUI populations are likely to select assessment instruments that provide detailed information about substance use disorders. These providers should also assess for mental health disorders and trauma in addition to alcohol and drug use disorders. Unfortunately, many treatment providers who handle DUI clients lack training and expertise in the area of mental health. There must be a more concerted effort to refer DUI clients to providers who have the ability to assess and treat clients with a range of disorders. 

Assessments are used to inform treatment plans for individual DUI clients or referrals to other services. Even if DUI clients are screened/assessed during other phases of their involvement in the system, treatment providers almost always perform their own screening and assessment to ascertain clinical information. 

Once screening and assessment are complete, treatment providers make recommendations for interventions based on outcomes. If they do not offer services that are tailored to the needs of individual clients, it is incumbent on providers to match these clients with other treatment programs. In every jurisdiction, there should be a network of treatment options that all providers should be familiar with to facilitate the referral process. Providers might also report back to the court or supervision authority with their recommendations and then probation might assume responsibility for making necessary referrals to programs and interventions.

Extra consideration should be given to female clients or individuals from different ethnic backgrounds as research has shown that gender-sensitive or specific approaches as well as culturally sensitive programs produce better outcomes by creating safer spaces for discussion and sharing. Trauma-informed approaches and treatment for traumatic events and post-traumatic stress disorder should also be considered for clients.

Principles of effective treatment 

According to the National Institute on Drug Abuse (NIDA), there are 13 fundamental and evidence-based principles that treatment programs should embrace to promote effective client care:

Developing the treatment plan

Practitioners should have open dialogue with clients and discuss available treatment options including the strengths and limitations as well as the benefits and risks of various approaches. 

Practitioners recommend that all treatment objectives be SMART: specific, measurable, attainable, realistic, and timely to ensure that clients remain engaged in the process. Common patient responsibilities that are outlined in the treatment plan include the following:

Once the plan is created, it is common practice for clinicians and clients to each sign an agreement about the expectations of each party during treatment. The treatment plan should be considered a dynamic document that is subject to periodic review and modifications based on client experience and progress.  

Clients and clinicians should explore the creation of a strong support network. This network should consist of pro-social peers who support client abstinence and behavior change. Family and friends should participate in the recovery process if they can offer support and do not trigger clients. 

Level of care

One of the first decisions that counselors must make is identifying the appropriate level of service required to address client needs. The American Society of Addiction Medicine (ASAM) has identified five different levels of care with a variety of treatment options available along the continuum. The availability of each of these services may vary depending on the level of resources within individual communities. When clinicians make decisions about client level of care, they often rely on ASAM criteria to determine the most appropriate placement for clients. 

Figure: ASAM Continuum of Care and Treatment Placement Options

Source: ASAM, 2015.

Detailed descriptions about each levels of care, the types of services offered to patients, and how to identify individuals who would most likely benefit from these services are outlined in the ASAM Criteria. 

The most common types of care ordered for DUI offenders include the following:

Regardless of the approach, the process should always involve the completion of a psychosocial needs assessment, supportive counseling, establishment of a strong support network to facilitate recovery, and referrals to community services to address other foundational needs. 

Treatment planning should include collaboration with licensed behavioral health care providers to determine the optimal type and intensity of psychosocial treatment. These providers should also be consulted when clients fail to adhere to the conditions set forth in the treatment plan or do not follow through with recommendations. 

Treatment is even more individualized than supervision, and approaches that lead to success with one DUI client may not produce positive outcomes with others. Informed decision-making, weighing options, and obtaining client feedback and input are important to arriving at the best possible treatment placements and plans. 

Common treatment approaches

Several treatment approaches are commonly used among impaired driving clients. 

Brief interventions. Brief interventions are designed to identify an individual’s current or potential alcohol problem and motivate him or her to do something about it. It typically consists of a short counseling session (approx. 5-10 minutes), in which a health care provider discusses alcohol consumption and associated consequences with the patient. A behavior change plan is then negotiated. For patients with less severe alcohol problems, a brief intervention may be the only treatment needed to facilitate a change in their drinking behavior. For those who are dependent on alcohol, a brief intervention should be coupled with specialized treatment for chemical dependency. 

Motivational interviewing. Motivational interviewing is one form of brief intervention that is frequently used by community supervision officials. MI involves one-on-one, patient-centered, non-confrontational counseling sessions and may be used at different stages of an offender’s processing. The idea is to encourage the offender to acknowledge and accept substance use problem(s), understand the benefits of behavior change and treatment, and access necessary services that will assist the client in overcoming substance use. The premise is to enable professional staff to build a rapport with offenders and empower them to change on their own.

Cognitive-behavioral therapy. CBT is a form of psychosocial therapy with an action-oriented perspective. CBT encompasses a range of cost-effective psychotherapeutic approaches that deal with thoughts and beliefs as a means to reduce problematic behavior such as substance abuse. The objective is to identify thoughts, assumptions, beliefs, and behaviors that are related to negative emotions and underlying dysfunction (e.g., drinking problems) and to replace these thoughts and behaviors with more realistic, pro-social, and functional patterns and behaviors. 

Medication-assisted treatment. Pharmacotherapy involves the use of prescribed medications to help patients stabilize and control or eliminate the use of particular substances. There are two main types of pharmacological agents: substitution drugs, which are pharmacologically related to the drug producing the dependence; and blocking agents, which do not have any psychotropic effects and block the effects of the substance(s) producing dependence. These medications act on neurotransmitter receptor sites and produce decreases in cravings and, as such, can lead to better treatment and recovery outcomes. 

While MAT is not a substitute for cognitive-behavioral therapy or other forms of counseling, it is another tool to address substance use disorders. 

There are several commonly used medications to treat alcohol use disorder and drug use disorder:

Medication for addiction works best in the context of psychosocial treatment. Evidence is accumulating that weekly or bi-weekly brief counseling combined with medication is an effective treatment for many patients. The opioid and heroin epidemic has led to greater acceptance of MATs, although pharmacotherapies remain underutilized among the impaired driving population. 

Many of these medications can be taken safely for years and there is no recommended length of time for the use of medication in addiction treatment. While medications can be used as a stabilizing force and safety net, some clients may eventually choose to taper dosages or cease the use of MAT entirely. 

Self-help and 12-step recovery programs. While these are not formal treatment modalities, 12-step programs and support groups are some of the most common approaches utilized to address substance use disorders. Participation in these groups may be required as a condition of supervision or recommended as a supplement to individualized counseling or psychotherapy. Alcoholics Anonymous and Narcotics Anonymous remain the most popular iterations of self-help groups and have proven to be effective in helping individuals enter into and maintain recovery. Groups like AA and NA can be instrumental in building strong networks of recovery support within the community although these programs and their reliance on faith-based tenants do not work well for every individual. Clients should be encouraged to engage in programs that resonate with them, and if other step-based programs prove to be a better fit than traditional AA, clients should pursue these options instead. 

Challenges: Access and capacity issues 

Unfortunately, access to treatment is limited and the need for treatment services greatly exceeds availability, especially in rural areas. In addition to general capacity issues, common barriers to the delivery of treatment include 

Maximizing responsivity and treatment effectiveness

To enhance the quality and delivery of treatment services, agencies and practitioners should consider the following strategies: