1 WORKING WITH CRIMINAL JUSTICE CLIENTS IN DRUG AND ALCOHOL TREATMENT Interviewer: Alison Churchill (AC), CEO, Community Restorative Centre Interviewee: Astrid Birgden (AB), Director, Compulsory Drug Treatment Program, Corrective Services NSW (formerly dept of corrective services). Length: (12.15min) AC: Astrid can you tell us about your position in the department of correct services AB: I m a forensic psychologist and I ve worked for 20yrs with resistant clients or as I call it reluctant customers. So currently I m the Director of compulsory drug treatment program in corrections NSW working with drug related offenders AC: Many people working within the drug and a rehab sector believe that people involved in the criminal justice system are less likely to succeed in treatment. They hold the belief that people that are coerced into treatment tend to be less motivated. Could you tell us your views on that issue? COERCED TREATMENT AND MOTIVATION AB: There s really three types of coercion; Legal coercion which is what you re talking about; Formal where employers might coerce their staff into doing regular drug tests, so footballers are an example; and, the third is from family and friends. What I want to cover is how there s not a lot of difference between those three. So it s not that legal coerced are over here, and then there s people who are voluntarily there without getting pressure from the friends and families. There s compulsory treatment where the law might order someone into drug treatment and rehab and their given no choice. The other aspect is quasi compulsory and that is where the person might be given a forced choice so their general drug treatment program would say to the person you either come to us for treatment or you go down the ordinary system and it s your choice. So that s what is called a forced choice. It s a little bit of a different style. And it might be more what the residential treatment program are experiencing. If someone wants to get parole they get parole on the agreement they go to a rehab centre. Legal coercion has been used in Australia and New Zealand for about 30 years now, so it s not majorly new and the question most people ask is, is legal coercion effective? And the problem is with the research is that the evidence is not clear cut. People define coercion differently. What the research concludes is that some people who are voluntary are more likely to have effective outcomes in treatment, other times it may be that the involuntary client is more likely to finish
2 treatment. What we do know is that if people drop out of treatment earlier, they do worse than if they never started in the first place. At the end of the day, whether the person is voluntarily going in does not have an impact on the treatment outcomes. One thing we know, is that it may be better to have a motivated coerced person then an unmotivated volunteer. At the end of the day, if drug related offenders are diverted from the criminal justice system they re less likely to reoffend, less likely to use drugs and less likely to die. The research is showing that it is really around the lack of motivation or what I call treatment readiness to change which is important, so rather than asking if coercion is effective, like does it matter if family or friends referred the client, or if the law told the person they have to do treatment, a better question is what helps the client to change. It s worth considering how the client preserves the coercion. So I reckon that is a better question. How does the person perceive it? And in the area of mental health there are people who have been looking at the area of perceived coercion and they have created scales that measure it. So an example is psychiatric patients who have been coerced into psychiatric medical treatment. And what those studies have shown is that a person who has a medical problem who is coerced into treatment is more likely to stick to the treatment they can trade it for things like disability benefits getting housing prevention from going into hospital or jail. It doesn t necessarily reduce the treatment readiness though when they use stages of change scales which I hope they re being used in the residential centres they ve seen that the impact of coerced treatment does not affect readiness. That people do become more ready to change. THE ROLE OF RESPECT IN TREATMENT I think what is particularly important is that perceived coercion is lower if the person feels the staff have acted out of genuine concern, treating them respectfully, and their letting the person give their side of the story. So there is a lot of research at the moment around problem solving courts like the drug court, where it s been shown that the judge is from their position of authority, if their listening to the persons story and treating them respectfully even though the client may not agree with the outcome if they re happy with the process and think it s fair, they re more likely to accept the outcome. If we forget who referred the client it s not a useful question to be asking, we then look at how does the person perceive the coercion so that third aspect is how do you then engage the person to change. ENGAGING THE CLIENT A lot of the focus in research and service delivery has been on who refers the client but i think it s better to move beyond this and work out how we can help the client. But it s looking at things like what is the person s drug of choice looking at any offending behaviour or likelihood, because at the end of the day, you might have a drug user who is on a slippery slide in to the criminal justice system. So it s not those who have offended and those who have not offended, people who use drugs might start committing crimes to support an increasing habit or they might commit crime while they are out of it, so they re sort of sitting on the edge of the criminal justice system. So if you re looking at drug use, you re looking at the context or the behaviour in terms of the interaction with the criminal justice system, I ve always separated offences because people often get tagged with an offence. I actually look at it as the behaviour. So an example may be an altercation with the police. They get charged with harassing the police, but you want to know what exactly was the
3 behaviour. How physically aggressive where they. Those kinds of things. What trigged it. So it s actually doing an analysis around the behaviour. If the client feels coerced, well what do you do about it. I think it s about to the service providers to engage the person. So the onus is on the service, it s not on the client to change. You have to find a way that you engage that person to change. And often when someone hits the criminal justice system their in crisis so i call it the teachable moment or the window of opportunity. So depending on how the system manages you either tip the person towards thinking about change because you have the golden opportunity to work with them, or something about how you handle it will tip them towards resistance to change. The sector would be very familiar with the whole motivational interviewing technique about how you engage people, move them into change and an important aspect of that is the therapeutic environment. THERAPEUTIC ENVIRONMENT I run a drug treatment and rehabilitation centre within corrections which makes it a little bit more difficult because I have some constraints because at the end of the day we are a prison, although I like to think of it as a community health centre with a fence around it. So I think the residential settings are in a much better position to be truly therapeutic. And within that it s about the relationship between the staff and the clients and what I call a therapeutic alliance or an ethic of care. So it s about putting out a helping hand to assist people to change. And so in terms of motivationally interviewing we re aware that people will slide up and down on readiness, I don t think it works to say well let s get somewhere else in the system to get the person into the action phase beyond pre contemplation, contemplation, and then we ll deal with them, because people will slide up and down. So it s about moving with the person backwards and forwards. RISK OF RE-OFFENDING When offenders get referred to other agencies there s talk about the risk of re-offending, because they re the tools corrections use. There s a difference between the risk of reoffending and the seriousness of offence. And they re two totally separate concepts. So you can have someone who is low risk of reoffending but a serious offender. So that may be someone who s got a amphetamine induced psychosis, they committed quite a violent crime, but if the psychiatric condition is handled they are less likely to reoffend. So that person is low risk of reoffending. On the other hand a more extreme case would be a pick pocket. So somebody who s constantly going round nicking things off people. They could be high risk of reoffending but they are not a serious offender. It s when staff are looking at risk of reoffending that they separate those two concepts and there s a whole bunch of tools that corrections use that are scientific tools that the low medium high categories are purely policy decisions. There s no science that says where you put those lines. It s just that corrections might say we ve only got x dollars to treat high risk people therefore this part of the group will be considered high risk. COMPULSORY DRUG TREATMENT CENTRE What we do is that we re compulsory and the only service that we know of in Australia, the only legislation that orders people in to jail for drug treatment and rehabilitation. So what we ve done to counteract it is that we are very engaging. So we know that it is our responsibility to engage them to
4 change. So we are really like a human face when they first arrive. We ve got a reputation for being a safe place, and a place where people want to come. We re using very much an evidences based approach, so we have a theoretical framework which underpins what we are doing, and it s not a once size fits all solution for each client. So we work out exactly what is the link between the drug use and the offending for this particular person and what programs can we put in place for them. If the program is not working, we come back and rejig what we are doing. It s not about expecting the client to change. We treat our offenders very respectfully. They re partners, they re developing the treatment plan together with us, we negotiate, they don t always agree, but at least they feel like they have a voice. So that same concept they might not agree with the outcome but at least they feel like they were heard in the process. And what we do is that we balance two things, we manage the risk factors for reoffending and drug use, but we re also meeting their physical, social and psychological human needs. So it s very much a human service delivery model. And one of the first questions is not how many drugs did you take, when was the last time, how long have you been using for the first question we ask is what kind of life do you want to lead. What do you visualise for your future. So we want to know what their version of a good life is. And their version might not match our version. But we ve got at least about 12months to try and get the two together, but at the end of the day you might see someone walking out the door, whose lifestyle is not what we would like. We work with very clear guidelines around acceptable and unacceptable behaviour. So we say we expect community standards behaviour, and if you act in a pro social way, this is how you ll be rewarded and if you don t, these are the consequences. And they are very logical consequences. So, I m not in to punishing people by locking them up in their cells, taking TV s off them, we don t do any of that sort of stuff. RELEVANCE OF CHOICE One of the key things around engaging people to change is the helping hand, the ethic of care, but also providing choice as much as possible. So as our guys start moving in to the community, we expose them to both the NA model and the smart recovery model. So at the third phase when they are living in the community, they can choose and at least their choice is informed. Because I think what often happens is when people upfront reject treatment, they haven t actually been given the opportunity, or have taken the time, to work out the pros and cons. If you do treatment, this is the likelihood of what will happen for your future. And if you don t do treatment, this is the likelihood. So if someone refuses treatment, at least it s an informed choice. HUMAN RIGHTS So I guess at the end of the day, what we do is we keep trying. And if it doesn t work, we re constantly trying another way. If someone goes out into the community and uses drugs, what we re trying to find out is what was the context of the drug use, what where they trying to achieve, how come they had to do it this why, why couldn t they use more pro social skills, that kind of thing. I don t think drug users who are in the criminal justice system are any different from other users. And for me there is a very simple rule that human beings have human rights. Offenders are human beings. And therefore offenders have human rights. They should be able to access services like any other person. Offenders are only in corrections for a little blip in their lives generally and then there are the rest of all their other identities that they have. So if we re to ask what helps clients to change I think it s the helping relationship offered to the client, and it s offered by people who want to assist
5 them, and are helping them to imagine a different kind of life. With behaviour change at least 40% of the change is influence by the relationship between the staff person assisting the client so it doesn t matter if you re lying on the couch doing Freud, or whether you re doing hard core cognitive behavioural therapy, that s maybe 10 or 20% of the change, so it doesn t matter the type of program, it s really about how it s delivered.