234

Treatment

Rehabilitation Countermeasures for
    Drinking Drivers

     Kathryn Stewart          .\
Pacijic Institute for Research and Evaluation
      Hennq Virginia

     Vernon S. Ellingstad
Department of Psychology, Universiy of South Dakota
      Vermillion, South Dakota

The primary goal of rehabilitative programs for drunk driving offenders is to reduce
the probability of subsequent drinking and driving. Punishment, such as licensing
penalties, lines, and incarceration, is also designed to prevent subsequent drinking and
driving either by making the consequences of arrest so unpleasant and costly as to
discourage the offense or by eliminating the offenders' capacity to drive (by putting them
in jail or by invalidating their drivers' licenses).

Rehabilitation is based on one of two assumptions: That offenders drink and drive
because they lack knowledge about the effects of alcohol, the potential consequences of
drinking and driving, and strategies for avoiding drinking and driving; or that drinking
and driving results from an abusive, addictive, or otherwise uncontrolled pattern of
alcohol consumption. Therefore, offenders must receive education to help them ration-
ally choose not to drink and drive or they must receive treatment so they can eliminate
abusive drinking and thus stop drinking and driving.

The goals of rehabilitation are certainly important-almost one-third of convicted
drinking drivers have a previous offense (Sweedler and Smith 1984). Preventing some
part of this recidivism is desirable. From the perspective of individual offenders, gaining
information and skills and receiving treatment to allow them to avoid drinking and
driving can save them from additional expense, humiliation, inconvenience, and potential
tragedy. Rehabilitation can also have positive effects on other areas of the offenders'
lives if abusive drinking is reduced.

It is important to emphasize that even programs that are extremely effective in
reducing recidivism cannot be expected to have major effects on traffic safety. Reed
(1981) estimated that even if all persons arrested for drunk driving were prevented from
ever combining drinking and driving again, fatal crashes would decrease by only 3
percent. Other efforts aimed at prevention or general deterrence such as well-publicized
enforcement crackdowns have the potential to save many more lives.

Characteristics of Rehabilitation Countermeasures

There is wide variation in what are referred to as rehabilitative programs. Programs
can vary in length, format, content, and structure. Programs may be quite brief (8 to 10


TREATMENT

235

hours) or more lengthy (50 or 100 hours). They maybe presented in a concentrated form
over a few days or stretched over several weeks or months or even years. The format may
be didactic with offenders sitting through a series of lectures, or the program may include
more active participation by the offender. Some programs include group or individual
counseling. Some programs involve spouses or other people close to the offender.

The content of programs also varies greatly. Some programs' focus on information
about the effects of alcohol, the law, potential consequences of drinking and driving, and
strategies for avoiding drinking and driving (including both strategies for decreasing
drinking and strategies for avoiding driving while intoxicated, such as appointing desig-
nated drivers). Other programs focus more heavily on helping offenders to identify
abusive or addictive drinking patterns and providing (or persuading participants to seek)
alcoholism treatment. Programs also exist that emphasize development of the right
hemisphere of the brain as a way of reducing problem drinking or that teach assertiveness
skills in hopes that these skills will help participants avoid drinking and driving.

Rehabilitative programs also vary considerably in the ways they are used. For ex-
ample, in some States, offenders go through an assessment process to determine the
nature and severity of their alcohol problems and are assigned to one of a number of
rehabilitative programs based on the outcome of the assessment. In other States,
offenders are assigned to programs based on other criteria such as blood alcohol
concentration at the time of arrest or the number of previous alcohol-related offenses.
The manner in which compliance with rehabilitative orders is enforced also varies, as
well as other penalties that are applied along with rehabilitation.

States vary in the way these programs are administered. Some programs are delivered
by State agencies while others are carried out under contract with a wide variety of
private agencies (everything from alcoholism treatment facilities to driving schools). The
amount of control that the State exerts in determining program content, format, and
standards also varies. States monitor program quality and adherence to standards in
varying degrees as well.

Issues in Rehabilitation Program Evaluation

Assessment of the effectiveness and value of rehabilitation programs is at best a
complicated endeavor, and a number of important issues must be considered in evaluat-
ing such programs and in considering the results of evaluation studies. The criterion
issue, or the explicit definition of program success, is a pervasive problem for any
complex applied program, but is particularly difficult for rehabilitation programs oper-
ated within a larger traffic safety context. In this context an alcohol treatment program
would be successful if rehabilitation reduced the probability of subsequent involvement
in alcohol-related crashes, or at least, if the frequency of the behavior assumed to lead
to such crash involvement (i.e., drunk driving) was diminished.

Measures such as alcohol-related crash involvement or driving while intoxicated
(DWI) or driving under the influence (DUI) arrests and convictions are frequently
chosen as criteria of success. But these measures pose at least two important meth-
odological problems. First, and perhaps most importantly, being arrested for DUI or
even being involved in an alcohol-related crash should probably be considered as only
incidental to the drinking problems toward which many treatment programs are
directed; these measures are certainly not comprehensive indicators of the intended
effects of treatment. Second, despite the fact that alcohol-related crashes and drunk
driving arrests occur frequently enough to justify countermeasures, the probability of
these recidivist events is so low that statistical comparisons between treatment and
no-treatment groups are usually not sensitive to treatment effects (the comparisons


236

BACKGROUND PAPERS

usually have low statistical power). That is, the sample size must be very large or the
group differences in recidivism very substantial for these differences to be empirically
identified.

To address these methodological problems, some evaluations of rehabilitation
programs have used other measures of success such as self-reports of drinking behavior,
indices of personal adjustment, and other indicators tied more closely to the expectations
of the treatment programs. Such measures are not without their methodological
shortcomings, including their frequent reliance on unsubstantiated self-reports.

Another methodological problem, which has constrained assessments of treatment
effectiveness at least as much as measurement shortcomings, concerns the adequacy of
the experimental or quasi-experimental designs for contrasting treatment against no-
treatment effects. In an ideal case, treatment evaluations would be conducted under
carefully controlled experimental conditions, with individuals randomly assigned to
treatment and no-treatment conditions, and the posttreatment performance of treat-
ment and control groups compared. These conditions have not been uniformly available
in rehabilitation evaluation studies, and many of the results reported in the literature
represent less than rigorous experiments.

Evaluation Results

Keeping in mind the variability in the nature of rehabilitative programs and the
difficulties in accomplishing a full and fair assessment of their effectiveness, we may
proceed to a discussion of the results of evaluations of rehabilitation programs con-
ducted during two distinctly different periods. The Alcohol Safety Action Projects
(ASAP) of the 1970s introduced rehabilitation modalities as part of an integrated set of
alcohol/traffic safety countermeasures. The 1980s brought a number of locally tailored
programs, including a program based on skills-building tested in California, the Week-
end Intervention Program originated at Wright State University in Ohio, and programs
to provide court-mandated alcoholism treatment.

The ASAP Era

In June of 1970, the National Highway Safety Bureau (later to become the National
Highway Traffic Safety Administration- NHTSA) of the new U.S. Department of
Transportation introduced nine traffic safety countermeasure demonstration projects,
which came to be known as Alcohol Safety Action Projects or ASAPs. Twenty additional
ASAPs were funded iu 1971, and a final six projects were initiated during 1972. Each
ASAP was designed to operate as a local drinking/driving control system (Joscelyn and
Jones, 1971) which coordinated the efforts of traditional traffic safety and driver control
agencies such as traffic courts, police departments, motor vehicle departments, and
community health resources. Some of the ASAPs operated in single metropolitan areas,
others covered large city/county regions, and still others operated as statewide projects.

The NHTSA intent in funding these local projects was to provide for a demonstration
(or rather, 35 replications of a demonstration) of the feasibility of an integrated systems
approach to the alcohol traffic safety problem. The goal of each project was to reduce
alcohol-related motor vehicle crashes by reducing the number of persons who drive while
intoxicated or impaired. Rehabilitation modalities shared this project goal with law
enforcement agencies, judicial systems, and public information and education com-
ponents of the ASAPs. The conceptual model that prescribed the general role of
rehabilitation in the ASAPs is shown in figure 1.

ASAP rehabilitation countermeasures were conceived of as a bridge between the


TREATMENT

COURTS

o CONVICTION

. SENTENCING

ASAP "TRANSITION"

and/or

  COUNSELING CHEMOTHERAPY

        I            1

I r&sir-

  COMMUNITY
HEALTH RESOURCES

o DETOXIFICATION

. IN-PATIENT

o INOIV. THERAPY

Fhe
Jail     PREiENTENCE     ALCOHOL      GROUP
                 __+ SAFETY                 REFERRAL
Revocation    INVESTIGATION      SCHOOL    THERAPY,                 o ??
Suspensh .
Probation   I              4           4               - o MENTAL HEALTH
                    I         I    I        CLINICS
  I                                             0 ETC..
                        PROBATION

Figure 1. ASAP rehabilitation: A court-referral system

traffic court systems that adjudicated drunk driving offenses and various community
heahh and mental health resources that provided alcohol treatment. As demonstration
projects, the ASAPs were expected to provide rigorous assessments of all counter-
measures employed by the projects, including rehabilitation. Each project included an
evaluation function to accomplish this purpose.

ASAP Rehabilitation Countermeasures

ASAP rehabilitation systems were, in each of the 35 projects, designed to supplement
the driver control functions of the police, courts, and licensing agencies. A fundamental
assumption of ASAP rehabilitation countermeasure programs was that a significant
proportion of individuals arrested and convicted of drunk driving offenses were "prob-
lem drinkers" whose control over their drinking behavior (and thus drinking/driving
behavior) was Iimited. This assumption created a systems requirement to perform at
least a minimal diagnosis to discriminate "problem" from"nonproblem" drinkers among
the ASAP? drunk driver clientele, and presentence investigations represented a primary
liaison between the traffic courts and each project's rehabilitation countermeasures
program.

A substantial number of rehabilitation programs were conducted by the projects, or
received referrals from the ASAPs. Thirty-two of the thirty-five projects used an "alcohol
safety school" as a rehabilitation modality. Most of these schools were conducted by the
ASAPs themselves. Some projects used the alcohol safety school as a re-education/
rehabilitation modality for nonproblem drinkers, some as a treatment alternative for
problem drinkers, and still others as a rehabilitation countermeasure for both problem
and nonproblem drinkers. The schools were short-term (2-6 sessions), educationally
oriented programs designed to handle a substantial number of drunk driver referrals.
The school was frequently the sole rehabilitation assignment for nonproblem drinkers
while for problem drinkers, schools were often used in conjunction with other treatment
alternatives.

237


238

BACKGROUND PAPERS

In 10 ASAPs, special group therapy programs were developed and conducted by the
projects themselves. Generally, these programs used weekly or biweekly sessions of an
hour or two in length that extended over a period of a month to 6 weeks. The primary
source of alcohol rehabilitation services across the ASAP sites was, however, the existing
rehabilitation system of the community, and most ASAP treatments were provided by
community treatment agencies. Outpatient treatment services provided by these agen-
cies included both group therapy and individual counseling. Some projects established
cooperative arrangements with local Alcoholics Anonymous chapters and utilized AA
as a referral resource. Limited use was made, across projects, of inpatient treatment
referrals. A few projects used chemotherapy (primarily disulfiiam) as a treatment
modality, usually in combination with some kind of group or individual therapy.

Analyses of treatment effectiveness were conducted at the individual project level and
also at the overall program level (Ellingstad and Springer 1976). The general approach
taken to the evaluation of rehabilitation effectiveness at both levelsinvolved comparing
the performance of individuals who had been exposed to ASAP-sponsored or -coor-
dinated treatment with the performance of individuals who were not referred to
rehabilitation. Unfortunately, with but two exceptions (Nassau County, New York and
Phoenix, Arizona), the demonstration projects were not structured to provide robust
experimental tests of rehabilitation with random assignment of clients to treatment and
no-treatment conditions. The "no-treatment controls" at most ASAP sites were of
individuals excluded from treatment because there was no room in the treatment
programs when they entered the system, they refused to participate, or for one reason
or another they were judged to be unsuitable for entry into treatment.

Project-level analyses of treatment program effectiveness were reported to NHTSA
annually in Analysis of Akohol Rehabilitation Efforts, a mandated analytic study
prepared by the local project evaluation component. A number of summaries of these
studies have been reported (see, for example, Ellingstad, 1976; Spiegel and Struckman-
Johnson 1978). Evaluations included overall assessments of rehabilitation system effec-
tiveness (all treatment modalities combined) as well as assessments of individual
rehabilitation countermeasures. Criteria on which these analyses were based included
crash recidivism, arrest recidivism, and in some cases, other measures obtained by testing
or interviewing program participants. The most common criterion of program success
was alcohol-related arrest recidivism. While isolated reports of treatment impact on
traffic safety criteria (crash or arrest recidivism) came from some of the 35 projects, an
inverse relationship was also apparent between the methodological adequacy of the
analytic study and its likelihood of reporting significant results.

Despite the generally pessimistic results of these analyses when critically evaluated,
some indications of success were present. Process-oriented studies of alcohol safety
schools almost universally demonstrated them to be capable of altering levels of
knowledge and attitude, even though the effects of these treatment programs on
recidivism was equivocal. Most analyses of the more intensive treatment programs
showed no clear evidence of treatment effectiveness. A notable exception concerned the
Disulliram Clinic operated by the Los Angeles ASAP. This program demonstrated a
statistically significant reduction in recidivism associated with disulfiram treatment in a
well-controlled and statistically sound analysis.

Program-level analyses of ASAP rehabilitation countermeasure effectiveness were
also performed by pooling data (mostly arrest recidivism data) submitted by the in-
dividual projects (Ellingstad and Springer 1976). Comparisons of survival rates (propor-
tions of clients avoiding rearrest) over a 3-year followup period for nonproblem drinkers
(as determined in presentence investigations) showed the pooled across-project trcat-
ment group to have outperformed the pooled no-treatment group. This program-level
result was at least suggestive that treatment may have had some of its intended effect on
nonproblem drinkers. A similar comparison for problem drinkers did not show sig-


TREATMENT

239

nificant differences in survival rates between individuals who had been referred to ASAP
treatments and those who had not received treatment.

It seems fair to conclude that, on balance, the results produced by the ASAPs in
identifying effective alcohol rehabilitation countermeasures were disappointing. Sig-
nificant methodological problems constrained both project- and program-level analyses
of rehabilitation system effectiveness and prevented clear tests of treatment effect. The
absence of adequate experimental controls seemed to be the principalissue.

The Short-Term Rehabilitation Study

It became apparent after the first few years of ASAP operations that the methodologi-
cal problems alluded to previously were likely to seriously handicap assessments of
rehabilitation effectiveness within this program. Because of this concern and because of
project-level interest in a relatively new alcohol treatment program called Power Motiva-
tion Training (PMT), a series of important changes in the implementation and evaluation   i
of ASAP rehabilitation countermeasures were introduced beginning in 1973 (Ellingstad
1976b). PMT, developed by McBer and Company, alcohol treatment researchers, was
based on a distinct set of theoretical principles and consisted of a well-defined and
carefully described set of therapeutic procedures. Moreover, PMT was a short-term
modality that did not depend on highly trained professional therapists and could be
readily implemented within the ASAP rehabilitation systems (Cutter, et al. 1975). The
PMT program was formally begun in eight sites in early 1975. McBer and Company,
under contract with NHTSA, trained therapists at the participating sites (Boyatzis 1976).
In addition, an evaluation function was created to develop a system to collect, monitor,
and process data from the PMT sites and to develop instruments to provide measures
of relevant indices of treatment effectiveness. The name was changed to the Short-Term
Rehabilitation (STR) Study to reflect the fact that several treatment alternatives in
addition to PMT were to be included in the experimental designs at some of the sites,
and that an additional three ASAPs that did not use PMT but did employ random
assignment procedures and no-treatment control groups were to be added to the study.

Each site in the STR study used its presentence investigation procedures to identify
a pool of mid-range problem drinkers considered to be the most appropriate clients for
PMT and related treatment programs (both social or nonproblem drinkers and alco-
holics were excluded). From this pool, clients were randomly assigned to either treat-
ment or control conditions. A comprehensive data collection procedure involving
extensive interviews, questionnaires, and record checks was conducted at the time of
assignment, as well as at 6-, 12-, and l&month followup contacts.

A total of 3,663 clients were randomly assigned to treatment and no-treatment
conditions at the 11 sites, with 2,462 clients exposed to various short-term rehabilitation
modalities and 1,201 clients assigned to no-treatment or "minimum exposure" control
groups (some sites required a minimal treatment such as the distribution of literature
about alcohol and driving instead of a true no-treatment control condition - this affected
only four sites),

The extensive data collection employed within the STR study provided for a large
battery of outcome criteria including: traffic safety outcome measures such as crash and
arrest recidivism; direct indices of drinking behavior such as duration of abstinence,
average level of alcohol consumption, and incidence of abusive drinking; lie status
measures such as current drinking problems, physical health problems, and employ-
ment/economic stability; and measures of personality characteristics (Ellingstad and
Struckman-Johnson 1978).

Detailed analyses were conducted for each set of dependent variables within the
experimental designs of each of the 11 STR sites individually (Struckman-Johnson and
Ellingstad 197&z). No compelling evidence of treatment effectiveness was found in any


240

of these analyses and, in fact, statistically significant negative effects were observed in
two or three instances.

Program-level analyses were also performed on data pooled from the 11 sites (Struck-
man-Johnson and Ellingstad 197%). A large number of statistical comparisons revealed
some evidence of treatment effectiveness for alcohol safety schools (employed as a
treatment alternative by four of the STR sites), and some evidence suggested a negative
treatment effect for PMT as a single modality treatment assignment.

The CDUI Project

Despite the fact that the STR study had involved thousands of drunk driver clients
and had been able to achieve the methodological requirements (random assignment and
control groups) of a true experiment, the fact that the study encompassed 11 very
different jurisdictions presented organizational difficulties that may have prevented as
powerful a test of rehabilitation countermeasures in the traffic safety context as might
be desired. In late 1976, a massive, single site experimental project called the Com-
prehensive Driving Under the Influence of Alcohol Offender Treatment Demonstration
(CDUI) Project was initiated in Sacramento, California.

The CDUI Project operated from September 1977 through January 1981 in
Sacramento County, receiving its referrals from the Sacramento County Municipal
Court. The project employed two separate experimental designs, one for first-offense
drunk drivers, the other for drivers convicted of multiple DUI offenses. The lirst-
offender design provided random assignment of 4,639 individuals convicted of DUI to
one of three treatment alternatives: (1) an in-class education program consisting of four
classroom sessions of 2 l/2 hours each over a 4-week period, using a standard alcohol
education program patterned after others in use around the United States; (2) a home
study program consisting of an organized set of reading materials designed as a self-study
package, which was presented to the clients in a l-hour orientation session; and (3) a
control group who received no treatment. All clients were placed on 2-year informal
probation and received a reduced line as an incentive to participate. In addition to the
treatment assignments, one-half of each treatment group was randomly assigned to
receive quarterly monitoring letters to remind them of their probation status and to
encourage them to drive soberly. Half the clients were also randomly assigned to receive
followup interviews designed primarily to collect life activities data for treatment out-
come analyses.

Both the in-class and home study education programs were shown to produce
significant reductions in DUI recidivism relative to the no-treatment control group.
Neither program, however, had significant impact on crash involvement or on the variety
of life status measures collected at followup intervals 10 and 20 months subsequent to
treatment entry (Reis 1982).

The principal CDUI multiple offender design involved a postconviction presentence
(PCPS) procedure under which a guilty plea to DUI was accepted prior to referral, but
final disposition and sentencing was postponed 13 months to permit participation in the
assigned treatment condition. Those clients who successfully completed the assigned
treatment then had the charge reduced to reckless driving, thereby avoiding the man-
datory licensing action that would have resulted from the DUI conviction. The 1,103
clients available to the PCPS multiple offender design were randomly assigned to the
following conditions: (1) Control (341): No educational or rehabilitative treatment, no
educational counseling, no chemotherapy, and no biweekly contacts; (2) Biweekly
contacts only (326): Twenty-six 15-minute individual interviews with a probation officer
every other week for 1 year; (3) Skills workshop (110): A group educational counseling
approach developed for the CDUI project consisting of 34 2-hour group counseling
sessions with the first 16 sessions meeting weekly and the final 18 sessions every other


TREATMENT

241

week for the remainder of the year of treatment; (4) Skills workshop and chemotherapy
(109): Three supervised administrations of disulliram per week for the first 6 months of
the assignment were combined with the skills workshop group therapy program;
(5) Educational eclectic therapy (109): Counselors conducting eclectic groups had
complete freedom to organize group therapy sessions according to their preferred style.
The first four 2 l/2-hour sessions were alcohol education classes identical to the
first-offender classes. They were followed by 28 weekly 2-hour group therapy sessions;
and (6) Educational eclectic therapy and chemotherapy (108): Three supervised admin-
istrations of disulliram per week for the first 6 months of the assignment were combined
with the educational eclectic therapy program.

Followup of multiple offender clients over a 20-month period showed both counseling
programs to produce significant reductions in DUI recidivism in comparison to the
no-treatment control group. Adding chemotherapy to counseling programs did not
improve the recidivism performance of these rehabilitation programs. Chemotherapy
was shown to be effective in reducing levels of alcohol consumption for up to 14 months
beyond the termination of disultiram treatment in clients who completed a counseling  :
program. None of the multiple offender treatments affected crash involvement (Reis
1982).

In contrast to the earlier ASAP and STR experiences, the CDUI results provided
considerably more encouragement with respect to the efficacy of alcohol rehabilitation
programs operated within the context of a traffic safety system.

Post-ASAP Rehabilitation Programs

Despite the mixed and disappointing results of evaluations of the various rehabilita-
tive programs carried out in the ASAP era, the concept of rehabilitation still generated
interest. Additional program models have been tested in recent years.

Skills Building

While some ASAP programs were able to show some reduction in recidivism and
subsequent crashes, the magnitude of the reductions was disappointing. However, many
of the program models evaluated seemed rather weak and not well grounded in theoreti-
cal or empirical knowledge about alcohol abuse or behavior change (Kunkel 1983).
Moreover, little attention seemed to have been paid to the quality of implementation.
Programs as they occur in actual practice often bear little resemblance to programs as
they appear on paper (French and Kaufman 1981). It seemed possible that the dii-
appointing outcomes might be due in part to weak program models or poor
implementation.

To give rehabilitation countermeasures the best chance of showing effectiveness, the
State of California sponsored an evaluation effort that included an extensive program
model development effort and careful attention to quality of implementation (Stewart
et al. 1987). The model program that was developed resembled traditional first-offender
programs implemented in the ASAPs in many respects. It included information on the
effects of alcohol, on drinking and driving laws, on symptoms of alcohol addiction, etc.
It also had several distinctive features, including a focus on the development of skills to
enable the offenders to separate drinking from driving. This aspect of the program was
based on Bandura's Self-Efficacy model (Bandura 1977) in which participants develop
strategies for dealing with a series of risky situations of increasing difficulty.

Over the course of the program, offenders were helped to develop, rehearse, and
practice realistic strategies to avoid drinking and driving. In addition, rather than


242

BACKGROUND PAPERS

attempting to deal with serious problems such as alcoholism within the constraints of the
program, a strong emphasis was placed on assessing the offenders' problems and
referring them to other helping resources in the community. The program was structured
to include a great deal of enforced participation so that the offenders were compelled
to be actively engaged in the program. Staff at the program sites received extensive
training and ongoing technical assistance and monitoring to ensure that the quality of
implementation would be high.

The program had two segments. The first segment was a6-week (15 hour) educational
program and the second was a 7-week (11 hour) counseling program. Offenders were
randomly assigned to the education-only or the education-plus-counseling segments to
determine whether programs of differing lengths and intensities would have different
effects.

The two versions of the model program were compared to two existing California
programs and to a control group (which participated in community service projects but
received no formal program content). Participants were randomly assigned to these
program conditions. The driver records of the participants in the four groups were
followed over 5 to 11 months to determine recidivism rates. In addition, a sample of
participants was interviewed before program entry and again 6 months later to include
more sensitive indicators of program success by broadening outcome measures to
include drinking behavior, symptoms of alcohol dependency and undetected drinking
and driving. Close associates of a sample of the respondents were also interviewed to
validate self-reports of drinking and drinking/driving.

Even given this carefully designed, well-implemented program, no differences could
be detected between the self-reported drinking behavior and drinking/driving behavior
of first offenders randomly assigned to the four program conditions, including the control
condition. Though some decreases in drinking and in frequency of drinking and driving
were reported, these decreases were reported equally by respondents in all program
groups. Thus, no evidence was found of the superiority of any program type over any
other, including the control group, which received no program at all. In fact, the observed
changes could be due to the natural reaction to any intervention or could be the result
of a statistical artifact (regression to the mean). The followup time for recidivism was
quite short, but no significant differences in recidivism were detected.

Thus, the modest effects demonstrated by other evaluations of rehabilitative
programs were not improved upon by altering program content and format. Within the
range of standard programs, no program type appears to have any outcome advantage
over any other, and the potential traffic safety effects of any program are very small
indeed.

The Weekend Intervention Program

The Weekend Intervention Program (WIP) (Siegal and Moore 1985) was based on
the assumption that it is unrealistic to expect a long-term pattern of problem drinking to
be altered after a short period of treatment or education. The intervention approach
does not &y to treat the problem drinker. Instead, it is designed to identify whether a
problem exists, to assess its extent and severity, and to refer offenders in need of
treatment to appropriate facilities. The offenders follow through on the referral on their
own, sometimes with the encouragement or order of the court.

As the title implies, the program takes place over the weekend. Educational and
counseling activities takes place in a medical school, and clients are housed in a nearby
motel in the evenings under police supervision. The goals of the program are to carry
out an assessment or diagnosis, to break down denial in those participants who have a
serious problem, and to prepare offenders to accept treatment if needed.


TREATMENT

243

An evaluation of WIP indicated that the program was effective in lowering the
recidivism rate as compared to nonequivalent comparison groups who received a
suspended sentence or who were sentenced to jail. The effect was strongest for repeat
offenders. During a l- to 2-year followup of repeat offenders, 21.8 percent of WIP
participants recidivated compared to 26.8 percent of jailed offenders and 30.4 percent
of offenders with suspended sentences. For first-time offenders, the recidivism rate for
WIP participants was 9.2 percent while the rate for all other first offenders was 12.7
percent (Siegall987).

The program was acceptable to the community in Ohio. It was easily understood by
the public and was acceptable to law enforcement and judicial personnel. It was less
expensive than traditional incarceration and, apparently, had a more positive effect on
subsequent drinking and driving (Siegal and Moore 1985). Clearly, however, the effects
on recidivism were modest. The program may serve a function in the community by
providing an acceptable form of punishment that may also be advantageous to the
offender, but its effects on traffic safety were negligible.

Compulsory `keatment Models

Some more intensive program models have been tried to deal with habitual offenders
or those with severe alcohol problems. One intervention is court mandated alcoholism
treatment for offenders who are addicted. Questions have been raised about the appro-
priateness or efficacy of compulsory treatment. Some research indicates that the out-
come of treatment for patients receiving treatment as part of a suspended sentence for
drunk driving compare favorably with improvements in alcoholics treated voluntarily
(Ben-Arie et al. 1983). A 7- to g-year followup was carried out with 50 offenders who
had been diagnosed alcoholic (most of whom were multiple offenders) and who received
compulsory treatment. At the time of followup, 14 of the offenders had been convicted
of further driving offenses. Thus, the treatment cannot be considered highly successful
in terms of reducing recidivism. Forty percent of the offenders were either sober or
generally sober, indicating that the treatment may have been useful in overcoming
alcoholism (Ben-Arie, et al. 1986).

A second model that has been implemented in several locales is the combination of
incarceration and treatment. Special facilities are set up to incarcerate drunk driving
offenders, usually repeat offenders. During their incarceration, inmates participate in a
highly structured education and treatment program, usually including detoxification (if
necessary), educational sessions, and group and individual counseling. A program of this
type carried out in Massachusetts reported a recidivism rate of 6 percent compared to
a statewide rate of 25 percent and a 19-percent rate for low security institutions similar
to the program's (LeClair 1987).

In the Netherlands, an educational program for incarcerated drunk drivers used
volunteers from various areas of the drunk driving system to teach sessions on the nature
and impact of alcohol abuse and provide information on community alcoholism treat-
ment services. Positive effects were reported on knowledge, attitudes, and driving
behavior when it was evaluated (Bovens 1987).

These studies provide some preliminary support for compulsory treatment programs,
either as mandated by the courts or as a component of incarceration. Here again,
however, while some individual offenders may be helped to overcome addictive drinking
or to avoid later drinking and driving, the impact on traffic safety is quite smalL

Conclusions

Because of the nature of the alcohol-related crash problem, rehabilitative approaches
can only have a very small effect on traffic safety, even if maximally effective. A wide


244

BACKGROUND PAPERS

variety of rehabilitative programs based on a variety of theoretical models, and delivered
in a variety of settings have never been able to'achieve more than modest effects on
recidivism. Although many evaluations of these programs suffered from methodological
weaknesses, the conclusion seems inescapable that to achieve improvements in traffic
safety, other strategies must be employed.

Rehabilitative programs may serve other purposes, such as providing an additional
appropriate and acceptable form of punishment to offenders, enforcing a general
societal message that drlnkiig and driving is unacceptable behavior, and providing a
mechanism for intervention into the driig problems of individuals. It is important to
keep in mind, however, that these possible benefits must be weighed against the costs of
the programs. Rehabilitative programs are not free.In many States, a substantial industry
(often a for-profit industry) supportiig hundreds or even thousands of employees has
grown up to provide these mandatory programs. Usually, the direct cost of the programs
is borne primarily by fees paid by offenders. These fees can be viewed as just another
part of the fines and other monetary penalties offenders are required to pay. From this
perspective, the effectiveness of the programs may not be an issue. However, the extent
to which these fees are purchasing services valuable to the individual or to society may
be called into question.

While possible benefits to individuals have been discussed, these beneficial effects
have not been thoroughly evaluated. A number of evaluations report attitude changes in
offenders (Foon 1988). However, evaluations that measured drinking levels or improve-
ments in other life areas, found very few effects (Stewart et al. 1987, Reis 1982). The
possibility that some programs may actually have harmful effects cannot be ignored. In
some States, rehabilitative programs are not closely monitored, and the appropriateness
of program content and the qualifications of staff may not be carefully evaluated.
Programs must deal with content that is highly charged emotionally. There is risk of
harmful effects if these areas are not handled with skill and caution.

It is important to compare the effectiveness of rehabilitative programs to other
sanctions - specifically license penalties. A 1984 study (Sadler and Perrine) compared
the impact of alcohol treatment programs to that of license suspensions on subsequent
crash rates and drunk driving recidivism. The study found that license suspensions have
a significant positive impact on traffic safety, more so than did the treatment programs
(although treatment programs had a greater impact on alcohol-related crashes and
arrests). Hagen et al. (1980) found that license suspensions and revocations produced
significant reductions in subsequent convictions and crash rates for multiple offenders.
In a review of a number of evaluations of the effectiveness of license actions, Peck et al.
(1985) drew this conclusion: "... there is no question that license suspensions have a
significant effect in reducing the accident and drunk driving frequency of convicted DUI
offenders."

Recommendations

Given the weak traffic safety benefits of rehabilitation countermeasures, it is very
important that the continuation of rehabilitative programs not be allowed to deflect
attention or resources away from drinking/driving countermeasures that have more
powerful effects.

Strategies that primarily attempt to bring about specific deterrence will necessarily
be limited in their ability to improve traffic safety. Even within that limited realm,
licensing penalties have been shown to be more effective in reducing recidivism than
rehabilitative programs, whatever their form. In many States, participation in a
rehabilitative program is offered as a substitute for license suspension or revocation.


TREATMENT

Such substitution is clearly counterproductive from the standpoint of traffic safety. If the
positive effects of rehabilitative programs are sufficient to justify their continued exist-
ence, these programs must be used in addition lo rather than instead of license penalties.

A larger question can be raised about all drinking/driving strategies that focus on
individual behavior with little consideration of the environment that shapes that behavior
(Wallack 1984). It is easier for society to blame the problem of, drinking and driving on
a defmed group of individuals rather than on money-making produc'ts, industries, and
systems that support drinking and driving and amplify its destructive potential (Vingilis
1987). In our zeal to deal with the population of identified drinking drivers, we should
not lose sight of social forces such as the political and economic climate, cultural
patterns, and values and norms that all combine to determine how alcohol is used and
what consequences that use will have for our health and Gfety.

245

REFERENCES

Bandura, A. Self-efficacy: Toward a unifying theory of behavior change. Psychological Review
   S&191-215, 1977.

Ben-Arie, 0.; George, G.C.W.; and Hirschowitz, J. Compulsory treatment of 50alcoholic drunken
   drivers. South Afican Medical Journal 63~241-243, 1983.
Ben-Arie, 0.; Swartz; and George, G.C.W. The compulsory treatment ofalcoholic drunken drivers
   referred by the courts: A 7 to 9 years outcome study. The Journal of Law and Psychiatry
    1986.

Bovens, R. Alcohol program: An educational program for drunken drivers in prison. In: Brand-
   Koolen, M.J.M., ed. Studies on the Dutch Prison System. Berkeley, CA: Kugler Publica-
   tions, 1987. p.151-157.

Boyatzis, R.E. "Implementation of Power Motivation Training as a Rehabilitation Counter-
   measure for DWIs. Technical report No. DOT-HSSOl- 834, McBer and Company,
   Boston, February 1976.

Cutter, H.S.; McClelland, D.C.; Boyatzis, R.E.; and Blancy, D.D. "The Effectiveness of Power
   Motivation Training for Rehabilitating Alcoholics." Technical report, McBer and Com-
   pany, Boston, 1975.

Ellingstad, V.S. "1975 Interim Analyses of ASAP Rehabilitation Efforts, Interim Report." Human
   Factors Laboratory, University of South Dakota, March, 1976a.
Ellingstad, V.S. "Program Level Evaluation of ASAP Diagnosis, Referral and Rehabilitation
   Efforts. Vol. IV: Development of the Short Term Rehabilitation (STR) Study." Technical
   report DOT-HS-191-3-759- F4, Human Factors Laboratory, University of South Dakota,
   June, 1976b.

Ellingstad, V.S., and Springer, T.J. "Program Level Evaluation of Diagnosis, Referral and
    Rehabilitation Efforts. Vol. III: Evaluation of Rehabilitation Effectiveness." Technical
   report DOT-HS-191-3- 759-F3, Human Factors Laboratory, University of South Dakota,
   June, 1976.

Ellingstad, V.S., and Struckman-Johnson, D.L. "The Short Term Rehabilitation Study. Vol.11:
   Development and Description of Measurement Battery." Report HFL-78-12, Human
   Factors Laboratory, University of South Dakota, November, 1978.
French, J.F., and Kaufman, N. Handbook for Prevention Evahtation. Rockville, MD: National
   Institute on Drug Abuse, 1981.

Foon, AE. The effectiveness of drinking-driving treatment programs: A critical review. Inrerna-
   rional Journal of the Addictions 23(Z): 15 l-174, 1988.
Hagen, R.E.; McConnell, EJ.; and Williams, R.L. Abstract of Suspension and Revocation Eflects
   on rhe DUI Offender. Sacramento, CA California Department of Motor Vehicles, 1980.
Joscelyn, J.D., and Jones, R.K. A Systems Analysis of rhe Trafic Law System: Summary Volume.
  NHTSA Report No. DOT-HS-800-640, Institute for Research in Public Safety, Indiana
   State University, October, 1971.

Kunkel, E. Driver improvement courses for drinking drivers reconsidered. AccidentAnalysis and
   Prevention 1.5(6):429, 1983.

LeClair, D.P. Use of Prison Conjinemenr for the Treatment ofMuhiple Dnrnk Driver wenders: An
   Evalumion of the Longwood Treatment Center, Bcutive Summq. Massachusetts


246

BACKGROUND PAPERS

Department of Corrections, Division of Research. Washington, DC: National Institute of
Justice, U.S. Department of Justice, 1987.

Peck, R.C.; Sadler, D.D.; and Perrine, M.W. The comparative effectiveness of alcohol rehabilita-
   tion and licensing control actions for drunk driving offenders: A review of the literature.
  Akoho& Drugs and Lkiving l(4): 1539,198s

Reed, D.S. Reducing the costs of drinking and driving. In: Moore, M.H., and Get-stein, D.R., eds.
  Alcohol and Public Policy: Beyond the Shadow of Prohibition. Washington, DC: National
   Academy Press, 1981.

Reis, R. E., Jr. Ike Trafic Safety Eflectiveness of Education Programs for First mense Drunk
  Drivers. Final report, Comprehensive Driving Under the Influence of Alcohol Offender
   Treatment Demonstration Program, County of. Sacramento Health Department.
   Sacramento, CA California Department of Motor Vehicles, 1982.
Sadler, D.D., and Perrine, M.L.W., The Long-Tenn Traffic Safety Impact of a PilotAlcoholAbuse
   Treatment as an Alfemative to License Szqension. Sacramento, CA: California Depart-
   ment of Motor Vehicles, 1984.

Siegal, HA Intervention: A Successful Technique for Repeat offenders: Reyrt of an Evaluation,
  Alcohol LIrugs and Trafic Safety. Eighth International Conference on Alcohol, Drugs and
   Traffic Safety. Amsterdam: Elsevier, 1987.

Siegal, HA., and Moore, D. "Rehabilitating the Drinking or Drug Impaired Driver: Its Evolution
   From Education to Intervention." Paper presented at the 34th International Congress on
   Alcoholism and Drug Dependence, Calgary, Alberta, 1985.
Spiegel, D.K., and Struckman-Johnson, D.L. "1977 Interim Assessments of Drinker Diagnosis,
   Referral and Rehabilitation." Report HFL-78- 5, Human Factors Laboratory, University
   of South Dakota, July, 1978.

Stewart, K; Epstein, L.; Gruenewald, P.; Laurence, S.; and Roth, T. "The California First DUI
   Offender Evaluation Project." Final Report, Pacific Institute for Research and Evaluation,
   Walnut Creek, California, 1987.

Struckman-Johnson, D.L., and Ellingstad, V.S. "The Short Term Rehabilitation Study. Vol.111:
   Site Specific Analyses of Effectiveness." Report HFL-78-11, Human Factors Laboratory,
   University of South Dakota, November 197&z.

Struckman-Johnson, D.L., and Ellingstad, V.S. "The Short Term Rehabilitation Study. Vol. IV
   Program Level Analyses of Effectiveness." Report HFL-78-9, Human Factors
  Laboratory, University of South Dakota, November 19786.
Sweedler, B.M., and Smith, L. "The Repeat Offender Drunk Driver: Where Has the System
   Failed."Paper presented at the International Workshopon Punishment and/orTreatment
   for Driving Under the Influence of Alcohol and Other Drugs, Stockholm, Sweden, 1984.
Vingilis, E. The six myths of drinking-driving prevention.hlealth Education Research 2(2):145-149,
    1987.

Wallack, L. Practical issues, ethical concerns and future directions in the prevention of alcohol-
   related problems. Journal of Primary Prevention 4: 199-224, 1984.