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S Seminal studies K Key studies R Reviews G Guidance more Search for more studies
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K Daunting task of managing ‘wet’ day centres (2003). Analyses the set-up and management challenges faced by UK centres offering street drinkers a place where they can start to reverse years of deterioration – without having to stop drinking. Related study below. Discussion in bite’s Issues section.
K Management problems undermine hostel for drinkers (1999). In London’s East End a project to house rough sleepers unwilling to stop drinking curbed local nuisance but was at first undermined by unsuitable premises, staffing, and management. Related study above. Discussion in bite’s Issues section.
K Leadership affects adoption of evidence-based practices (2008). Leadership qualities including knowledge and experience and commitment to a rehabilitation focus predicted good substance use treatment practice in US criminal justice services.
K Motivational interviewing style clashes with criminal justice context (2001). After training in motivational interviewing the performance of US probation staff with real and simulated clients contradicted their glowing self-evaluations and promising exam-type responses, and the officers were rated as less ‘genuine’ than before training. Related discussion in cell B5’s bite.
K Risk-need-responsivity model really does help (2011). Training probation officers in the risk-need-responsivity model of offender supervision (intended to match interventions to the offender) reduced recidivism among probationers for whom substance use was a major issue. Discussion in bite’s Highlighted study and Issues sections.
R G Managing services for drink-drivers (Health Canada, 2004). On the basis of a research review and expert opinion, recommends education, treatment and rehabilitation approaches to alcohol/drug impaired driving, including training and organisational requirements.
R G Training for treatment in the criminal justice system (Australian Government, 2005). Based on research on substance use treatment in criminal justice and more generic literature and principles, draws lessons on training and its management. Discussion in bite’s Where should I start? and Issues sections.
R G Creating and maintaining ‘family sensitive’ treatment services ([Australian] National Centre for Education and Training on Addiction, 2010). Reviews generic and substance use-specific research as a basis for guidance on workforce development policies and practices to help ensure treatment services safeguard their clients’ children.
G Whole-family recovery advocated in Scotland (Scottish Government, 2013) Guidance specific to substance use intended for all child and adult services, including drug and alcohol services. What new patients should be asked about children and the role substance use services should play in a system which (Getting our Priorities Right is the title) prioritises child welfare.
G Developing and providing effective services for the children of problem drinkers (accessed 2017). Funded by the UK charity Comic Relief, a web resource to help managers, commissioners and practitioners develop and provide effective services for the children of problem-drinking parents.
G Capabilities needed for substance use treatment staff to work with male perpetrators of domestic violence (2015). Published by King’s College, London and developed from UK research. Helps substance use treatment services define and clarify key staff capabilities (knowledge, attitude and values, ethical practice, skills and reflection and professional development) for working with male substance users who perpetrate intimate partner violence. See also generic NICE quality standards ([UK] National Institute for Health and Care Excellence, 2016) for health and social care services on assessing and responding to domestic abuse.
G Good practice in responding to domestic and sexual violence involving substance use (2013). UK guidelines representing the culmination of a three-year government-funded project to improve responses to survivors and perpetrators of domestic and sexual violence also affected by substance use and/or mental health problems. Includes minimum standards of practice and guidance on policies and procedures. See also generic NICE quality standards ([UK] National Institute for Health and Care Excellence, 2016) for health and social care services on assessing and responding to domestic abuse.
G Substance abuse treatment and domestic violence ([US] Substance Abuse and Mental Health Services Administration, 1997). US consensus guidance on how treatment services can identify and work with both perpetrators and victims.
G Managing alcohol problems in prisoners (World Health Organization, 2012). Integrated model of best practice in care for problem-drinking prisoners based on UK experience.
G US consensus on substance use treatment in the criminal justice system ([US] Substance Abuse and Mental Health Services Administration, 2005). Consensus guidance endorsed by US experts; includes treatment interventions, matching these to the offender, and planning programmes.
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What is this cell about? Therapy and therapists matter of course, but so do the management functions of selecting, training and managing staff, and managing the intervention programme. In highly controlled studies, it may be possible to divorce the impact of interventions from the management of the service delivering them, but in everyday practice, whether interventions get adopted and adequately implemented, and whether staff are able to develop and maintain appropriate attitudes and knowledge, depend on management and supervision.
This cell is about the role played by these management functions in treatment organised and/or funded by criminal justice and other authorities, whose primary aim is to safeguard those in contact with the patient or the wider community. Typically in these contexts, treatment is offered or imposed not because it has been sought by the patient, but because it is thought that treating their drinking problems could cut crime, safeguard the drinker’s family, and prevent harm to others through drink-driving or other alcohol-affected behaviour. Studies which document the community and family impacts of treatment in general may also be found in this cell.
Where should I start? It is rare to find reviews focused on workforce development in such a narrow sector as substance use treatment in criminal justice contexts, but the Australian state of Victoria commissioned just such a review to inform its training programme. Published jointly with the Australian government, it benefits from an unusually well resourced national focus on workforce development in substance use treatment. Among other things, it thoughtfully explores the role of management, training and supervision in the melding of disparate objectives and philosophies. On the basis of a review of research findings, the same document also offers management guidance.
Among its messages on training are: that it must focus on offending as well as substance use; that along with educational programmes, it can underpin collaboration between criminal justice and treatment systems despite their “very different operating principles, values and procedures”; and that managers and supervisors play a key role in making sure skills learnt in training are sustained on return to work.
The justice system usually communicates to the offender that treatment is punishment
Also stressed is that staff competence is critical to implementing rehabilitation in criminal justice settings where “the justice system usually communicates to the offender that treatment is punishment”, and that management is critical to developing and sustaining competence through training and ongoing support. In cell B5 the argument was made that in criminal justice, child protection and other contexts where treatment is coerced or mandated, staff competence is perhaps more important than when treatment is given a head start by the client wanting it and wanting to change of their own volition. In turn this would make management support for staff training and development more important too. When a host of possible influences were thrown into the mix, several most strongly related to evidence-based practice in the treatment of offenders in US services were management training, knowledge, and orientation to quality and rehabilitation as opposed to punishment. An example of how management can reduce recidivism by organising staff training and ongoing support can be found below in the Highlighted study section.
The so-called ‘risk-need-responsivity’ model has been very influential in guiding treatment interventions with criminal offenders. Its three core principles are:
Risk Providing intensive services to clients at higher risk of reoffending and minimal services to lower risk clients.
Need Target criminogenic needs or the dynamic risk factors which underlie or drive criminal behaviour such as pro-criminal attitudes and substance use.
Responsivity Match the style and mode of intervention to the abilities, motivation, and learning style of the offender.
Highlighted study Despite the prominence of the ‘risk-need-responsivity’ model ( panel) in criminal justice treatment interventions, training offender supervisors to implement this model has rarely been evaluated. Canada hosted the first trial. It evaluated the training of probation officers to match intensity of services to risk of reoffending, to target the factors which underlie criminal behaviour, and to match intervention style and content to the offender. The offender sample was not exclusively problem drinkers or drug users, but overall their substance use was considered a major issue in their offending. Both the model the officers were trained in and the training itself stressed targeting problematic attitudes and thoughts using cognitive-behavioural principles. This randomised trial showed such training can not only improve officers’ skills and sharpen their practice, but also reduce the recidivism of the offenders chart.
Note from our analysis that the training seems to have embodied effective interactive methods. Perhaps crucially, these included feedback on actual performance and continued post-training support ‘pushed’ to the officers rather than left for them to access (or not) on their own. However, a study of this kind can only make a stab at identifying the active ingredients stimulated by the training which led to the recidivism reductions. Analysis of supervision session tapes suggested that the sole factor which accounted for these reductions was the use of cognitive techniques to alter pro-criminal attitudes – a suggestion difficult to substantiate, as use of these techniques were bound up with the training and with how well the probation officers had responded to this training.
Why this study was so important can be appreciated by turning back to cell B5, where we learnt that adjustments to the number and frequency of supervision contacts and caseload size (considered proxies for the officer’s ability to exert control over the offender) have generally made no difference to reoffending. Instead, the quality of the work undertaken between supervisor and offender seems the active ingredient; this study promises to have found a way to improve quality in a way which reduces offending. But before you accept these implications, read carefully through our commentary, and ask yourself if you can rely on the study’s findings to guide the training of offender supervisors and how they conduct their supervision.
Is cognitive-behavioural the way to go? Published in 2005, our starting point review was upbeat about the interventions available for managers and trainers in the criminal justice system to build on: “Recent evaluations ... reflect a promising deviation from previous perceptions of ‘nothing works’ to an era of practice that is driven by rigorous program evaluation and evidence-based service delivery”. Adhering to the ‘risk-need-responsivity’ model ( panel above) and stressing cognitive-behavioural approaches, the authors might have been even more optimistic had they been able to see the results of the later trial described in the Highlighted study section.
That study was about training probation officers to apply broad principles and ways of fostering change incorporating certain supervision styles and cognitive-behavioural approaches. But when those approaches are packaged into set ‘programmes’, does optimism remain warranted by the research? Check back on cell A5’s bite where we asked, “Why is the record so poor?” – in particular, for cognitive-behavioural programmes. A case in point was the major British study which found that when required by the courts, the main cognitive-behavioural programme (ASRO) applied to problem substance users on probation could not be shown to have reduced reconviction rates relative to sentences without this requirement. The findings were not atypical; no convincing evidence from elsewhere supports such programmes for offenders relative to alternative or usual approaches.
For substance use treatment in general, research findings do not warrant a ‘nothing works’ pessimism about psychosocial approaches, but do suggest that overall ‘nothing works better’ than any other similarly coherent approach; as with other approaches, cognitive-behavioural programmes do not stand out as exceptionally effective. Arguably the key thing is that training in any coherent approach instils optimism and re-moralises a perhaps jaded workforce, and offers a credible treatment rationale via which they can communicate that optimism to the offender – some of the ‘common factors’ highlighted in cell A4’s bite. Training in these approaches also offers trainees specific activities and intermediate targets via which offender and therapist can collaborate, communicate, and develop their relationship – thought critical at least since Carl Rogers’ seminal work, focused on in cell B4’s bite.
What is the essential performance-promoting core of training? Transmission of specific understandings and skills, or are these mainly a vehicle for bolstering non-specific common factors? Can the latter be done without the former? Are cognitive-behavioural techniques active ingredients in generating positive change, and if they are, is it best to try to ensure quality by mandating an expertly crafted programme, or to risk ‘drift’ by focusing on principles and leaving wide discretion to the counsellor or offender supervisor? Might the answer be, ‘It depends’ – on how skilfully the practitioner can use that discretion?
Is this the most difficult management task in the addictions field? What we are referring to is running ‘wet’ centres where street drinkers can continue to drink. Here the management challenge seems so daunting that before undertaking it a probing appraisal should be made of whether an organisation’s management, staff and resources, and the way it plans to work with service users, are capable of making things better for clients and community – or could make things worse.
Two British studies of wet day centres and of a residential wet hostel illustrate the difficult balance between offering a welcoming, relaxed venue which attracts drinkers off the street and avoids them causing offence and concern to local residents and businesses, versus the need to exert some degree of control to ensure safety in the venue, and some degree of therapeutic challenge/pressure to move the drinkers on to better lives. Control and challenge/pressure risk generating conflict and deterring attendance, jeopardising the service’s objectives.
Control and therapeutic challenge/pressure risk jeopardising the service’s objectives
Strong, clear management of the right kind was key in both sorts of venues. At the day centres, it was “unusually important that, alongside a strong client oriented ethos, line management functions are vigilantly applied ... Persuading and enabling clients to make positive changes is far more difficult than being welcoming and reassuring”. Partly due to management failures, at first the hostel “never developed into a safe environment ... and failed to provide services which might further improve [residents’] health and help tackle their alcohol problems ... Unwillingness to turn people away ... or to enforce a disciplinary code on ‘alcoholics’ considered unable to control themselves contributed to ... tension, arguments and sometimes violence which led some residents to leave and deterred potential applicants”. But as at the day centres, difficult as they were, these challenges could be managed: “Management changes helped create a much improved atmosphere: casual ‘drop in’ stayers ... were banned, the disciplinary code enforced, and key working properly instituted”. So these projects can operate safely to the benefit of both their users and the local population, but this is by no means a given. Whether they degenerate into just another drinking venue, or make the hoped-for differences to users and the community, are substantially down to management.