Matrix cell
Organisational functioning; Safeguarding the community
Seminal and key studies on organisational influences on alcohol treatment in criminal justice and allied contexts where the main aim or a major outcome is to reduce crime or otherwise safeguard the community.
S Seminal studies
K Key studies
R Reviews
G Guidance
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Inter-service networking associated with evidence-based treatment practices (2008). Rather than large, well resourced corporations, among treatment agencies working with US criminal justice services, smaller organisations which networked with other organisations were more closely associated with the adoption of evidence-based substance use treatment practices. Discussion in bite’s Issues section.
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Organisational stress and non-interventionist philosophy undermine drinkers’ hostel (1999). Criticised by other services, a London project housing rough sleepers unwilling to stop drinking retreated into a ‘siege mentality’, while a non-interventionist stance on drinking spilled over into a dangerously laissez-faire attitude. Discussion in cell C5’s bite.
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What sort of agencies can best run ‘wet‘ day centres? (2003). Based on detailed analysis of British centres, suggestions for the kinds of organisations, premises and locations which can best handle the daunting task of offering street drinkers a place where they can start to reverse years of deterioration. Discussion in cell C5’s bite.
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Motivational interviewing style clashes with criminal justice context (2001). Actual performance of US probation staff after motivational interviewing training contradicted promising written responses, and the officers were rated as less ‘genuine’ than before – a probable example of organisational context limiting how far they could genuinely stay true to motivational principles. Same study described in this Findings essay. Discussion in bite’s Issues section.
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Integrating substance use treatment and criminal justice supervision (2003). Analyses research to find the common organisational features of effective programmes. Drug-focused but with crossovers to alcohol.
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Do criminal justice settings undermine motivational interviewing? (2006). 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. Discussion in bite’s Issues section.
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Transforming offender supervision into an agent for offender change (2002). Question addressed (p. 22) is how does the criminal justice supervision agency overcome the “social worker vs. law enforcement” conflict to transform itself into an agent not just for monitoring offenders, but bringing about positive changes in their behaviour. See also associated supervision manual. Discussion in bite’s Issues section.
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Manual for research-based offender supervision (2005). What research-based ‘tools of the trade’ (in the word of the title) does a criminal justice supervision agency need to transform it into a force for positive/therapeutic change in substance using and other offenders. See also associated review above from the same author.
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Characteristics of 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. Based on UK research, the linked page describes the qualities of services found to deliver effective interventions.
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This search retrieves all relevant analyses.
For subtopics go to the subject search page and hot topic on why some treatment services are more effective than others.
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Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text
What is this cell about?
As well as concrete things like staff, management committees, resources, and an institutional structure, organisations have histories, values, priorities, an ethos, and links with other organisations, determining whether they offer an environment in which staff and patients/clients can maximise their potential. For these and other reasons, agencies also differ in how keenly and effectively they seek and incorporate evidence-based practices. This cell is specifically about the role organisational contexts play in treatment organised and/or funded by criminal justice and other authorities which offer or impose treatment, not because it has been sought by the patient, but because it could cut crime or otherwise benefit the community.
Compared to research on interventions, organisational-level research is scarce and rarely of the gold-standard, randomised controlled trial format. Instead, researchers usually look for patterns in what naturally happens rather than manipulating it to test the consequences. Those patterns may be due the presumed cause and effect mechanisms, but may instead be due to unmeasured influences which the analysts cannot take into account. By ensuring any such influences are equalised across the focal intervention and the comparator against which it is being benchmarked, randomisation is intended to prevent them obscuring the effect of the intervention. In the absence of randomisation or an equivalent procedure, these influences remain in play, making it difficult to draw conclusions from the findings of a study.
From the relatively few documents listed in this cell, you will see that organisational research is particularly lacking on alcohol treatment intended to safeguard the community. In the expectation that organisational influences in these settings may not differ too much from those elsewhere, we can also refer you back to cells dealing with these influences in respect of brief interventions, generically across treatment, medical treatments, and psychosocial therapies.
Is small beautiful?
In 2014 a well-informed commentator on treatment systems in England described the transformation of a patchwork of local alcohol and drug treatment services into national conglomerates, as retendering exercises driven by austerity-era cost-cutting forced smaller agencies to merge with/into larger ones or face extinction. From the point of view of a leader of one such conglomerate well represented in the criminal justice sector, in 2013 the picture had looked similar:
This drive to grow is a driving force in the decisions Third Sector leaders make
“This drive to grow, to get bigger and to demonstrate significant increases in year-on-year turnover is a very evident driving force in the decisions that Third Sector leaders make … success in the substance abuse treatment marketplace has usually been defined principally in terms of growth.” Ironically, his service was later to be swallowed up by and further expand a yet larger conglomerate: click to unfold the story.
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The writer was the chief executive of the Lifeline Project, which itself had been rapidly expanding from its Manchester base to run services “spread across Yorkshire, the North East, the North West, London and the Midlands, working within diverse towns, cities and villages”, with a workforce of 1473 staff and over 1000 volunteers. Large and well established as they were, in 2017 Lifeline itself was forced to close and its services further expanded the portfolio of what was already the largest ‘Third Sector’ drug and alcohol treatment provider in the UK, Change, Grow, Live, at the time reported as having an annual income of £158 million and employing 2800 people. Whatever the other reasons for Lifeline’s collapse, the financial squeeze which has driven other mergers was apparent to the administrators appointed to manage the closure: “with further cuts to public expenditure budgets and some poorly funded projects, Lifeline had seen turnover drop and made a significant loss from its trading activities”.
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For the first commentator, the agglomeration process “reduces innovation, increases costs and limits choice for commissioners and service users.” That it might also detract from the adoption of evidence-based practices was the message of a US study of services working at the junction of substance use treatment and the criminal justice system. Researchers expected large, well-resourced organisations to be among those leading the field. Instead, indicators of resourcing and size were negatively related to evidence-based practices and other indicators of high quality treatment provision. By far the factor most closely related to such provision was the degree to which services networked and carried out joint activities with other services, especially other treatment programmes. Also related were training opportunities and the degree to which management prioritised quality.
The results suggest that the most fertile ground for quality-improving innovation at the substance use/criminal justice interface is an active network of not very large treatment providers and criminal justice agencies. How did this surprising implication come about?
First, we should acknowledge that this study shares the limitations noted above; the links it found may not have arisen from any causal connection between evidence-based practice and smaller size and greater networking, but from other processes. Taking the implications for the moment at face value prompts reflections perhaps worth pursuing regardless. Conceivably, large, service-provider conglomerates tend to be worlds unto themselves, with their own central workforce development and information hubs, their own data-collection and evaluation procedures, and their own ways of working replicated across constituent sub-services – the cost-saving structure which enables them to grow by out-competing smaller providers. These smaller organisations may in contrast be more mission-driven – perhaps newly emerging from the problems they are addressing – and need to look outside themselves for support and ideas. If they find or forge an active network, they rub up against other independent services with different ways of doing things; opportunities for learning and anti-stagnation experiences are maximised.
Here we have taken a considerable leap from the small and shaky platform provided by the study to describe a scenario compatible with, but by no means proven by, its findings. Does this scenario make sense to you, and even if it does, might any plusses of smaller organisations be counteracted by the resources larger organisations can dedicate to management, research, training and supervision?
Does the criminal justice context limit treatment?
The great advantage of treatment ordered (even if with the offender’s consent) and supervised by the criminal justice system seems to be that it has the tools and the authority to ‘hold’ patients in treatment and get them to comply with the programme sufficiently to gain benefits; it can help overcome the problems of early drop-out and patchy attendance which undermine work with ‘voluntary’ clients. But what does that coercion do to the quality of the contacts it enforces, and does the criminal justice context cramp treatment’s scope for therapeutic actions?
In respect of practitioner skills and relationship style, in cell B5’s bite we appreciated the extra challenges of maintaining a therapeutic, client-centred stance in a criminal justice context, yet also the importance of doing so. As a US expert put it, “agencies have tried to achieve two purposes – enforcer and social worker – and have found the polar nature of the two tasks often conflicting.” This same conflict was highlighted by the title (“Motivational arm twisting: contradiction in terms?”) of a Findings review listed above of motivational interviewing for clients coerced into treatment: “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”. In a criminal justice context, elements are often missing from this constellation, especially the ability for treatment staff genuinely to adopt a client-centred stance and to offer confidentiality to the client. Inevitably, the business of treatment and relationship-forging is different 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 control as well as a therapeutic role.
The consequence of a clash between organisational context and therapeutic principles seemed apparent in a study of the performance of US probation staff trained in motivational interviewing. Its implications were explored in a Findings essay on the benefits of not always adhering to the approach’s principles. They emerged from an evaluation of a two-day motivational interviewing workshop for probation staff in Oregon, who gave glowing accounts of improvements in their understanding of and proficiency in motivational interviewing, views they sustained over the subsequent four months, and which were corroborated at the end of the workshop by a pen-and-paper assessment.
After motivational interviewing training probation officers seemed less ‘genuine’ than before
The disappointment came when these assessments were checked against ratings of audiotapes of how the therapists actually behaved at three stages: before the workshop with an offender client; at the end with someone acting as a client; and with a real offender client four months later. When the raters were assessing overall adherence to motivational principles rather than specific techniques, though there were improvements, these were modest and left trainees far short of expert practice, largely because they were unable to suppress their previous interactional styles. On one dimension which attempted to reflect how “genuine” the probation officers were, things had even got worse.
By four months later, even the post-workshop boost in use of specific techniques had eroded. Clinching this negative picture was the fact that, compared to pre-workshop tapes, their clients too did not evidence greater commitment to change versus resistance.
How can we interpret these findings? It seems likely that the natural way a probation officer relates to offenders is far removed from motivational interviewing, and reversion to type was the dominant trend. In the end, training officers to go against this grain made little progress and meant they seemed less genuine in their interactions with clients after than before the workshops. Told about this finding, the trainees explained “they had simply felt less comfortable and natural in trying out this new clinical style”. It does not take much imagination to realise that within the explicitly unequal and coercive context of the criminal justice system, adopting motivational interviewing’s ‘It’s up to you’ stance might feel false to the probation officer, and also look less than genuine to observers and to the offenders being counselled. To the extent that this happens, one of the ‘common factors’ seen as underpinning successful therapy will be missing from the encounter.
Such difficulties were assessed in a review in which leading US researchers pooled their knowledge and experience to explain why real-world criminal justice programmes sometimes fail to live up to expectations derived from more ‘ideal-world’ trials. Though focused on prison and on users of illegal drugs rather than alcohol, much is relevant also to community sentences and to the treatment of drinkers. Give yourself the ten minutes or so it will take to read the Effectiveness Bank’s account of the review, and as you do, consider whether these barriers and proposed solutions apply to the British context, whether the barriers truly are the main ones facing treatment in criminal justice settings, and whether the proposed solutions are workable and optimal.
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