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Recovery, desistance and coerced drug treatment Tim McSweeney Senior Research Fellow Institute for Criminal Policy R

What I want to do. Offer some definitions of recovery, desistance and ?coerced' treatmentConsider 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 datepresent En

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Recovery, desistance and coerced drug treatment Tim McSweeney Senior Research Fellow Institute for Criminal Policy R

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    1. ‘Recovery, desistance and 'coerced' drug treatment’ Tim McSweeney Senior Research Fellow Institute for Criminal Policy Research

    2. 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

    3. 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)

    4. 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)

    5. 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).

    6. 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 Work’s 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

    7. 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)

    8. 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.

    9. 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).

    10. 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.

    11. 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 (n=66) only or in day care with a substitute prescription (n=60) (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.

    12. Those we interviewed (N=157) 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 (n=83) experienced serious depression and anxiety in the past month.

    13. Those we interviewed (N=157) ‘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 (n=111) previously treated for AOD dependency. No difference in previous exposure to treatment between people on DTTOs and ‘volunteers’.

    14. Those we interviewed (N=157) At intake, the English DTTO clients were: more likely to be male (p<0.001), more likely to be homeless (p<0.01) using a wider range of drugs (p<0.01) - including crack (p<0.001), injecting more frequently (p<0.01), spending more on drugs (p<0.001), and were more criminally active (p<0.001). Perhaps more to be gained if these people could be encouraged to stay and succeed in treatment? (cf. DTORS intake findings.)

    15. 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 people’s 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.

    16. 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

    18. Average number of reported days using drugs* during the last month

    19. Key UK findings Substantial reductions in reported expenditure on illicit drugs: from a median of £1200 in the 30 days before intake interview (n=156) to £30 (n=104) 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.

    20. Caveats and limitations Sampling and response bias: 52% of those offered treatment in the 10 sites were interviewed; most didn’t 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?

    21. 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.

    22. 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).

    23. 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

    24. Acknowledgements The European Commission for funding the study The University of Kent and the other partner countries and agencies involved in ‘QCT Europe’ Rowdy & Margaret for the opportunity to present Further details of the Institute for Criminal Policy Research are available at: www.kcl.ac.uk/icpr For more information about the ‘QCT Europe’ study visit: http://www.kent.ac.uk/eiss/projects/qcteurope/index.html

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