Drug Treatment Matrix cell B5: Practitioners; Safeguarding the community

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Practitioners; Safeguarding the community

Key studies on the contribution of the practitioner to reducing crime and safeguarding the community. Risks formulating a general rule: The trickier the situation, the more the worker matters – suggesting that therapeutic skills are even more important in formally coerced than other forms of treatment. Also asks whether those skills can most effectively be deployed when therapy is divorced from criminal justice supervision.

S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

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K Judicial support motivates offenders (2001). Completion of a US court-ordered programme, urine tests for drugs, and comments from offenders, all indicate the positive influence of supportive judicial comments. See also freely available report on same study focused on relationship between comments made about the offender in court and urine test results. For discussion click and scroll down to highlighted heading.

K Praise from judges motivates UK offenders ([UK] Ministry of Justice Research, 2011). Documents the encouraging effect on offenders of the unusual experience of being praised by judges in pilot drug courts in England and Wales. For discussion click and scroll down to highlighted heading.

K Good relationship with counsellor deepens engagement in prison treatment (2008; free source at time of writing). Degree to which residents in a prison-based therapeutic community for problem drug users actively ‘worked the programme’ most closely associated with their perceptions of their counsellor’s competence, their relationships with them, and support from other prisoners in the community.

K Relationship with therapist more important for offenders than other clients (2008). At a Canadian drug rehabilitation centre, seeing their therapist as understanding and involved was related to whether patients under criminal justice supervision/pressure completed treatment, and the relationships were stronger than for other clients. For discussion click and scroll down to highlighted heading.

K Client-centred supervision motivates UK offenders ([UK] Ministry of Justice, 2014). Survey of offenders who started community sentences in 2009 to 2010 in England and Wales found they generally had good relationships with their probation officers and felt discussions on substance use particularly helped them avoid re-offending. Three-quarters who had an identified need for help relating to their drug use had discussed this with their offender manager; of these, 43% found that very useful, second only to discussions on alcohol. Officers who holistically addressed offenders’ multiple needs seemed to motivate them to make positive changes in their lives. For related discussion click and scroll down to highlighted heading.

K Mothers in Wales say staff support critical to family preservation and child welfare (Welsh Assembly Government, 2008). Evaluation of a Welsh service which worked intensively over a few weeks with substance-using parents on the drink of proceedings which could lead to their children being removed from the home. See also later evaluation (2012) of the same service. In both reports, mothers powerfully testified to the impact of individual staff. For related discussion click and scroll down to highlighted heading.

K ‘Not my job’ perception and lack of confidence impede assessment of domestic violence (2016). Interviews with stakeholders suggest that staff in substance use treatment services in England often lack the skills or confidence to ask patients about their intimate relationships and violence between partners, and may not consider these making these enquiries as part of their job. Guidelines arising from same project below. For related discussion click and scroll down to highlighted heading.

R Supervising offenders is about the quality of the relationship (2002). Downloaded PDF is the whole issue of the journal containing the article which starts on page 16, numbered 14. It reviews evidence on how to plan and implement crime-reduction programmes for substance using and other offenders, including desired skills and attributes for staff supervising offenders, highlighting the quality of the contacts that occur in the supervision setting. Associated supervision manual below. For discussions click here and here and scroll down to highlighted headings.

R Best practice in working with substance users in the criminal justice system (Australian Government, 2005). Covers desired/required working styles, attitudes and understandings of treatment and criminal justice staff.

R Can motivational interviewing work in criminal justice settings? (2005). Asks whether the contradictions of at the same time helping and punishing, controlling and being client-centred (‘motivational arm-twisting’), undermine motivational interviewing’s ethos and effectiveness. For discussions click here and here and scroll down to highlighted headings.

G Manual for research-based offender supervision (2005). Led by the author of our starting point review, a manual on how probation and other supervision staff can motivate behaviour change and manage offenders’ behaviour instead of merely monitoring it. For discussions click here and here and scroll down to highlighted headings.

G Working with men who physically abuse their partners (2015). Based partly on research in England, key capabilities (knowledge, attitude and values, ethical practice, skills and reflection and professional development) for staff treating the substance use problems of men who commit intimate partner violence. Associated study from same project above.

more Retrieve all relevant Effectiveness Bank analyses or search more specifically at the subject search page. See also hot topic on the influence of treatment staff

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What is this cell about? Whether medical or psychosocial, chosen positively or under pressure, we learnt from cell A4 that among the ‘common factors’ affecting treatment’s success is the patient’s relationships with treatment practitioners. This cell explores research on the client-worker relationship, and on workers’ attributes which affect their clients’ progress, narrowing in on situations when treatment has been offered or imposed not because it has been sought by the client, but because it is thought that treating their substance use problems could reduce offending, protect their children, or otherwise benefit the community – arguably (see section below) the trickiest in which establish a productive rapport.

Across psychotherapy the interpersonal style and other features of staff are now seen as at least as important as the intervention, but remain far less commonly researched. From the relatively few documents in this cell, you will see this lack is particularly apparent in criminal justice and allied settings. In the expectation that the influence of practitioners in these settings may not differ too much from elsewhere, for more studies we can refer you to the other cells dealing with practitioner influences: cell B1 for harm reduction; cell B2 for treatment studies in general; cell B3 for medical treatments; and cell B4 for psychosocial therapies.

Where should I start? With an excellent and freely available review listed above from a respected US researcher on the supervision and treatment of substance using offenders. From her we get a clue to why research is lacking on the quality of the relationship between practitioner and offender. Despite being able to cite 25 studies of offender supervision, she notes that “Very few … discussed the … qualitative nature of the contacts that occur in the supervision setting … The relationship … between the offender and the agent is presumed to be the basis for the offender to change due to the controls that the agent places on the offender and the attention to supervision objectives” (emphasis added).

In this vision, whether the probation or parole officer forms a good relationship with the offender is irrelevant; what matters is how consistently they adhere to supervision objectives and pull legal levers underpinned by sanctions. Research has followed these lines, focusing on the number and frequency of contacts and caseload size as proxies for the ability to exert control – yet these ‘hard’ statistics have generally been found unrelated to re-offending.

Faye Taxman, the review’s author, advances a different perspective: “Like in the therapeutic setting, the degree of rapport between the offender and agent is an important component for the supervision process to achieve better outcomes … contacts must have a function that exceeds the mere exchange of information. The contact is more of an engagement process that is designed to achieve desired outcomes.” Those outcomes are not merely suppressing offending during supervision, but more lastingly “improving compliance with general societal norms including the conditions of release”. For more on this alternative vision, see the supervision manual (listed above) drafted by a team led by Professor Taxman.

Issues to consider and discuss

Are the practitioner’s therapeutic skills really unimportant? Research may be sparse, but what we do have supports Professor Taxman’s contention (section above) that the influence of the practitioner is not unimportant in criminal justice settings, just relatively neglected. According to a study listed above at a Canadian substance use rehabilitation centre, feeling understood and that the therapist is actively involved in helping you are actually more important when the patient is under criminal justice supervision or pressure than when they are not. A possibly related finding was that compared to other patients, criminal justice patients were “less committed, more resistant and displayed more negative attitudes in treatment” – not surprising, since most entered treatment under criminal justice supervision or while awaiting charges, trial or sentencing, pressures which might have made them enter treatment against their wishes. Reading slightly between the lines, unless this distancing from treatment (‘I’m only here because I have to be’) was countered by a feeling that the therapist is, after all, ‘on my side’, drop-out was particularly likely among the criminal justice clients.

The glue of the supervision process is the manner of being between offender and agent

Therapists in the Canadian study described above were treatment staff rather than criminal justice officials supervising the offender. But for these officials too, Professor Taxman was convinced (review listed above) that “The glue of the [supervision] process is deportment or the manner of being between the offender and the agent. The contact is the key because it is the means to focus the purpose of supervision and it allows the offender and agent to develop a rapport … an important component for the supervision process to achieve better outcomes.”

The “deportment” she recommended is that systematised by motivational interviewing – empathy, avoiding arguments, rolling with resistance, highlighting where their undesired behaviour contradicts the offender’s ambitions and self-image, and bolstering confidence that they can change for the better. In criminal justice contexts, therapist skills might be even more important than usual; genuinely adopting and communicating such qualities is an uphill task when the ‘client’ is not there because they want to be, when for them you may represent an oppressive authority, and when in reality you and/or your employers do have a responsibility to at least collaborate in exerting control over the offender. As our starting point review pointed out, “agencies have tried to achieve two purposes – enforcer and social worker – and have found the polar nature of the two tasks often conflicting”. The same conflict was highlighted by the title (Motivational arm twisting: contradiction in terms?) of an Effectiveness Bank review listed above of motivational interviewing with clients coerced into treatment. The implications of these potentially conflicting roles are explored further in the final two sections below.

Another reason why in coerced treatment practitioners’ skills might be particularly important is that by the time a ‘voluntary’ patient has been driven to the point of seeking treatment, already much of the work has been done; when instead contact has been foisted on them, treatment has to do more of the engaging and motivating – and treatment’s frontline is the encounter between patient and practitioner.

‘The judge was proud of me!’ The welcome shock of coming across someone who centres on you, wants to understand and help, and sees your potential, is a recurring theme when problem substance users are asked what it was about treatment that helped. Accustomed to and/or anticipating negative judgements and rejection, these encounters sometimes take on a revelatory quality. Precisely because it is so unexpected, the impact of a judge behaving this way to an offender seems to have a similar impact. Transformation of the judicial stance to therapeutic and supportive characterises drug courts, which specialise in drug using offenders. In these the judge or magistrate negotiates a treatment process for the offender to follow instead of a more conventional punishment, and plays an active part in that process through regular face-to-face reviews of how the offender is doing, during which discussion, negotiation, praise and encouragement replace adversarial proceedings.

Observers of the process have repeatedly documented the positive reactions of offenders. An example listed above comes from a study of the first drug courts in England and Wales. The nature of the judiciary-offender interaction was seen as playing an important role in encouraging offenders to engage with the court, potentially helping reduce subsequent offending and drug use. Staff and offenders felt magistrates and judges who showed interest in and listened to offenders, and engaged with them genuinely and non-judgementally, thereby encouraged offenders to want to do well by changing their offending and drug use: “Some offenders were not used to being congratulated and valued the praise which the judiciary gave, as well as the way they made suggestions rather than telling them what to do.”

The data overwhelmingly point towards the positive impact of supportive court-monitoring comments

Pinning down what if any effect such a stance has on offending and drug use is harder. A US study did find strong links between supportive comments by judges to offenders and their chances of avoiding illegal drug use and successfully completing their sentence. However, rather than those comments helping to generate positive progress, perhaps offenders who are doing well anyway elicit supportive comments. That there was more to it was suggested by the reactions of the offenders: “The extensive interview data collected from informal conversations with offenders overwhelmingly point in the direction of the positive impact of supportive court-monitoring comments. In sum, for this study, of the many reasons why an offender may successfully complete the program, one for consideration must be the supportive comments variable.” What a drug court which thoroughly took on this message and adopted a therapeutic stance might look like has been comprehensively detailed; see page 48 of the linked file, numbered page 35.

As in other areas, what may be nevertheless be a critical influence has proved resistant to research. In this case, the problem is the impossibility of deliberately and at random allocating offenders to judges who take a supportive stance versus those who adopt the traditional judicial role (the latter will simply not become drug court judges), and even if one could, the impossibility then of ensuring everything else remains the same. For the difference in judicial stance to be ‘real’ it would have to have consequences, such as offenders being more/less often sent to prison or otherwise punished, or having their treatment changed rather than terminated. Even if the study found judicial stance related to outcomes, it could be that those events were critical, rather than the stance which led to them.

Best to split therapy and supervision? The discussion above of whether the practitioner’s therapeutic skills are really unimportant raises another issue – whether it is easier for treatment staff to sustain a therapeutic attitude if they are divorced from criminal justice supervision. Listed above, our own review of motivational interviewing with clients coerced into treatment saw it this way: “the approach can work – given that substance use is an appropriate focus, that the patients have the resources to make positive changes, the therapist can remain true to motivational principles, and the patients feel safe to open up to their therapist”. With legally coerced treatment populations, elements are often missing from this constellation, especially the ability genuinely to adopt a motivational stance and to offer confidentiality to the client. Working in these ways seems to require insulating therapists from criminal justice supervision and freeing them (with obvious exceptions if the offender or others are at serious risk) from the obligation to report back to legal authorities, and making sure patients know this is the case.

Partly because they acknowledge the difficulty of combining a therapist with a supervisor role, several probation services in the UK have introduced peer mentors as a large component of their drug and alcohol work, offering support outside the context of a controlling relationship. Peer mentors typically meet-and-greet offenders in a treatment setting, talk about their own experiences, and co-run groups. An example can be seen in the English midlands, where a peer mentor has explained that taking on this role helps offenders to open up, and has helped her cope without drinking.

A young man being supervised by the London Probation Trust explained why such arrangements may not be seen the same way by an offender:

“You’re aware that your probation officer can recall you … you need to conduct yourself in a certain way. If you think the mentoring programme is linked to probation you’ll behave the same around the mentor … you’ll put up barriers rather than just open up, because you’ll think whatever you say to him or her they’ll go back and report to probation. When [mentor] first saw me, he said he’s not probation, he’s not the police, he don’t get involved with them, he’s nothing to do with them. But he also [explained] to me if he had information or I told him I’m going to harm myself, I’m going to hurt someone else or do this or that or break my licence conditions, he has to go and tell them.”

How far is it realistic to insulate support and therapy from criminal justice supervision. Won’t someone working for criminal justice authorities always be seen by offenders as suspect, despite lacking formal powers? Even were such separation possible, is it desirable?

The trickier the situation, the more the worker matters Issues discussed above tempt us the formulation of a general rule: The greater the formal power a clinician/therapist/counsellor has over a patient’s life, the weaker their informal influence through collaborative therapy. A corollary is that engineering collaborative therapy in a formal control context requires exceptional abilities. Combine the two propositions and express the product in everyday language, and we have the title of this section: “The trickier the situation, the more the worker matters.”

The situations discussed in a section above relate to the counselling of offenders under criminal justice supervision. Also seen as ‘tricky’ is raising certain forms of criminality in substance use treatment services outside the criminal justice context – not so much the revenue-raising crime commonly associated with illegal drug use, but more intimate and stigmatised criminality, the very raising of which might be seen as jeopardising the therapeutic relationship. The more formal power over a patient’s life, the less informal power through collaborative therapy An example is the possibility that the patient has been abusive or violent towards their partner, seen as difficult (document listed above) to broach and beyond their remit and competency by staff in English substance misuse services and also in mental health services, where “enquiry and disclosure were facilitated by a supportive and trusting relationship between the individual and professional”.

Perhaps trickiest of all is therapy of parents whose substance use and other behaviours might seriously threaten their children’s welfare. The Scottish Government among others has emphasised that no matter what the context, “The welfare of the child is always paramount.” In a substance use treatment context, take this to heart and it means you cannot as a clinician focus exclusively on being there for the client. The children-first perspective requires you to ask uncomfortable questions not to do with the patient’s welfare, but that of any children, and to stand ready at all times act against the patient’s wishes if that’s what it takes to prevent serious harm to a child.

Like juggling balls with a magnetic tendency to interfere with each other’s flight

No wonder substance use treatment workers commonly sideline the whole issue of children in order “to avoid any perceived potential conflicts of interest or a need to make child protection notifications, which could jeopardise their working relationship with clients”. The situation becomes trickier in the extreme when you know a child is at risk, the client knows you know, and you are acting at the behest of services which could take the child away from the parent – a bit like not just juggling several balls at once, but balls with a magnetic tendency to interfere with each other’s flight. Only an expert juggler with exceptional reflexes and coordination could manage.

Reverting to therapy language, this was one of the key findings in the evaluations (1, listed above; 2, listed above) of the Option 2 service in Wales which worked with problem substance using parents at imminent risk of losing custody of their children. The evaluations of Option 2 were discussed in cell A5. Guidance based on the evaluation reports stressed that delivering such services “which rely on highly skilled direct work with families – is very challenging. It is easy to set-up a service that looks like Option 2. It is much more difficult to ensure that the service actually received by families is of … high quality … Doing so requires recruiting exceptional staff, providing very high levels of clinical supervision and training and ensuring that staff have the time to devote to delivering high quality work for families.”

Options 2 clients appreciated directness

One of the evaluation reports highlights the following quote from an interview with a client, illustrating that the worker whilst friendly could also be firm and communicate difficult issues when required.

“[Option 2 worker] told them that if they messed up now, the boys might get taken into care. The interviewee said that that was a good thing about [Option 2 worker]: [Option 2 worker] was really friendly but [Option 2 worker] ‘got to the point if [Option 2 worker] needed to’. [Option 2 worker] was ‘straight’, ‘blatant and honest’ and she found that really helpful.”

From Final report on the evaluation of “Option 2”, Welsh Assembly Government, 2008.

The two evaluation reports (available via our analyses: 1 2) reveal in their own words the difference mothers felt the quality of the worker and of their work made. Common themes were good listening skills, showing that they cared – including going the ‘extra mile’ and sticking with people through difficult changes – and being honest about concerns and problems. That last theme alludes to the tricky business of ‘laying down the law’ in such a way that it strengthens the relationship with the parent rather than damaging it. The panel right taken from one of the evaluation reports listed above illustrates this point. The essence of what in this context makes a good worker was also distilled by the researchers into the box on page 55 of the original report.

How difficult it is to meld support with control became apparent when an attempt was made (free source at the time of writing) to disseminate Option 2’s methods to generic child protection services. The aim was to train child and family social workers in London to use Option 2’s motivational interviewing counselling style when working on child protection cases involving problem-drinking parents. Trainees made progress, but it was patchy. Part of what stood in the way was the tension between the client-centred stance of motivational interviewing and the need in serious child protection cases to be clear about what is required of the parents, and if necessary to confront certain behaviours. More skilled workers felt able to combine these, but they were in the minority.

Now let’s subject our proposed ‘rule’ to an imaginary ‘stress-test’, bearing in mind the caution in cell A4 that in psychosocial therapy, universally applicable rules are not just hard to find, but if followed insensitively, potentially damaging. Is it really the case that when a counsellor or therapist has formal power over the client, making therapeutic progress becomes trickier and requires exceptional abilities? Could they not use this formal power to persuade the client to undertake recovery-promoting activities they would otherwise refuse, like insulating themselves against temptation by taking a drug which makes opioid use into a non-experience rather than a ‘high’? Is formal power only a complicating factor when the therapeutic relationship between clinician and client is the main treatment mechanism rather than a powerful medication like methadone? Well maybe, but take a look at cell B3’s findings on the influence of practitioners in methadone programmes. Contrary to the supposed rule, could it be that having formal power mean there is less need to be an expert therapist? If despite these questions, we really have hit on a general rule, are there exceptions?

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