A Report into the Effectiveness of Civil Commitment in the Treatment of Alcoholism, and its Suitability for Implementation the Northern Territory

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1 A Report into the Effectiveness of Civil Commitment in the Treatment of Alcoholism, and its Suitability for Implementation the Northern Territory Win Yee Tan and Melanie Johnson Aurora Project Summer 2013

2 INTRODUCTION Alcohol and Australian Communities Alcohol plays a significant role in the way of life for many Australians, with people drinking for enjoyment, to socialise and celebrate. Unfortunately, as a nation with a high per capita consumption of alcohol, it is perhaps also unsurprising that alcoholism has created major problems in Australia. Alcoholism is a multi-faceted issue. Not only does alcohol abuse have devastating effects on its consumer, it also poses serious threats to the individual's community. Alcoholism is a significant contributor towards a number of long and short term health problems, as well as socio-economic issues in society. With the second highest per capita consumption rates in the world, alcoholism is especially detrimental in the Northern Territory. Shockingly enough, with an average of 14.6 litres per NT resident aged 15 years and above, the PCAC (Per Capita per Alcohol Consumption) rate of the Northern Territory is almost five litres higher than the national figure 1. As a result, minimising alcohol related harm and anti-social behaviour is a high priority for the NT government. Despite the achievements of many programs that have produced short term improvements, it is undeniable that alcoholism remains a large problem in the Northern Territory. The Proposal Recently, the Country Liberal Party has proposed a model of civil commitment for problem drinkers. 2 Under the planned scheme, if a person is arrested for being drunk three times within a six month period, they will become subject to an order that will require compliance with a voluntary rehabilitation program. If the individual fails to complete the program (thus breaching the order) they will be guilty of the offence of having breached the order. If found guilty of the breach, they will face a mandatory sentence of 3 months in a rehabilitation centre. 3 The centres, famously promoted as a 'world first', and 'one of the best tools for combatting alcohol abuse in the Territory', have been met with considerable opposition 4. Many have labelled the policy as 'dangerous', with the potential to kill dependant users through for example, the effects of further traumatisation on mental health, rather than rehabilitation 5. Current Australian civil commitment laws, upon which the proposal will likely be based, have been strongly criticised on a number of ethical, moral and legal grounds. 6 1 Department of Health, Northern Territory. Alcohol Use in the Northern Territory, Tollner, D. (2013), Media Release 4 February 2013, Health-Based Rehab Preferred Approach, ABC release 3 Parry, D. (2012): NT Government Details Mandatory Rehabilitation Plan, Stateline Northern Territory, Darwin: Australian Broadcasting Association, 14/9/12 4 Aikman, A. (2012): Country Liberal Party Pushes Forced Rehab for Alcoholics, The Australian, 22/08/ Smith, S. (2012): CLP Wants Alcoholic Offender Prisoner Farms, ABC News, 22/08/ Pritchard, Mugavin, and Swan (2007): Key Factors Associated with Compulsory AOD Treatment, in Compulsory Treatment in Australia: A Discussion Paper on the Compulsory Treatment of Individuals Dependent on Alcohol and/or Other Drugs, 9-29

3 Many have argued that mandatory rehabilitation is not an ethical process, and should not be implemented unless it has been proven to be highly beneficial for subjects of the treatment. Civil commitment legislation from Victoria and New South Wales have faced condemnation as they potentially breach numerous human rights, including those of liberty, freedom from arbitrary detention, least restrictive treatment and access to an acceptable appeals and review process. 7 As a consequence, there is also the risk that the legislation may breach the Universal Declaration of Human Rights and the International Covenant on Civil and Political Rights. 8 This paper wishes to explore existing evidence from studies on both civil and forensic mandatory rehabilitation in order to evaluate if this is indeed an efficacious form of treatment for alcohol dependant persons, and if it would be appropriate to implement such a regime in the Northern Territory. Given the lack of evidence for the effectiveness of civil commitment, the potentially significant impact that is will have upon the freedoms individuals, families and the community. it appears that it could be difficult to justify the proposal. 7 Alcoholics and Drug-Dependent Persons Act 1968 (Vic) and the Inebriates Act 1912 (NSW) 8 Pritchard, Mugavin, and Swan (2007)

4 MANDATORY REHABILITATION Mandatory rehabilitation, in its broadest and simplest sense, is the involuntary retainment of Individuals with the goal of restoring them to a previous (proper) condition or status. With regards to alcohol users, mandatory rehabilitation seeks to combat alcohol dependency issues, and encourage sober lifestyles amongst participants. There are a few ways in which mandatory rehabilitation may be implemented. The two major categories, civil and forensic commitment, will be further discussed later in the paper. Besides this, participants of mandatory rehabilitation may either attend treatment as an inpatient at residency programs, or as an outpatient, who lives in a court approved residence, but is not admitted to the treatment centre. These will also be investigated throughout the paper. Historical Basis Civil commitment developed throughout Europe in the 20 th Century as a measure to combat the growing severity and prevalence of drunkenness. 9 Following World War II, civil commitment legislation was expanded in numerous countries in order to deal with the increased alcohol consumption that followed the violence, and has similarly occurred following the Vietnam War, conflicts in Russia, Afghanistan and Croatia. 10 In Australia, legal coercion to enter forensic alcohol programs has become a well-utilised practice for the past 20 years, however civil commitment legislation has been implemented with caution, and with little empirical review. 11 Legal Justification It is important to discuss theory of parens patriae. 12 This is a legal authorisation that the State should serve as the ultimate guardian for disabled and dependent individuals. As mandatory rehabilitation is commonly applied for mentally-ill patients, it is understandable that this may be justified by the parens patriae doctrine. However, many argue that mandatory rehabilitation for alcohol addicts is not justified, as they are not disabled, nor are they dependent in a manner that requires the care of a guardian. Alcoholics, in their drunkenness, could be regarded as temporarily having lost self-autonomy; however, it is not correct to assume that they have completely lost ability to make decisions for themselves. 13 Although the consumption of alcohol to excess might not be deemed to be a positive life choice by many, alcoholism could be seen as a rational choice by an individual facing of difficult circumstances. 9 Gerdner and, Israelsson (2010). 10 Gerdner and Israelsson (2010). 11 Hall, W., (1997), The Tole of Legal Coercion in the Treatment of Offenders with Alcohol and Heroin Problems, Australian and New Zealand Journal of Criminology, (30), , Carney, T. (1987). Drug Users and the Law in Australia: From Crime Control to Welfare. The Law Book Company, Sydney. 12 Pritchard, E., Mugavin, J., Swan, A. (2007) 13 Caplan, A., (2008): Denying Autonomy in Order to Create it: the Paradox of Forcing Treatment on Addicts, Addiction, 103(12):

5 It is also necessary to investigate mandatory rehabilitation with regards to therapeutic jurisprudence. The notion of therapeutic jurisprudence assumes that legal procedures, such as policies that concern wellbeing, may operate in such ways that are therapeutic to individuals who are subject to the policy. In the case of mandatory rehabilitation, therapeutic jurisprudence assumes that patients in such treatment programs will benefit from compulsory treatment. Therapeutic jurisprudence incorporates social science knowledge in order to maximise therapeutic outcomes for the individual. As a legal theory that seeks to serve citizens in the most beneficial way possible, therapeutic jurisprudence is argued to be an important aspect of mandatory rehabilitation. However, skeptics remain suspicious of whether or not compulsory treatment is the best method of healing for an alcohol dependent person. The deprivation of liberty through civil incarceration has historically (and rightfully) been met by staunch opposition, as freedom of choice is a fundamental right, and expectation of all individuals. As famously expressed by J. S. Mill, it is not for others to dictate how one should live their life: 14 The only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others. His own good, either physical or moral, is not sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so, because it will make him happier, because, in the opinion of others, to do so would be wise, or even right. 15 Gaps in Evidence Evidential justification for the efficacy of civil commitment for alcohol rehabilitation is scarce, incomplete and largely anecdotal. 16 There is little empirical evidence in support of such programs producing long-lasting positive behavioural changes, or ongoing rehabilitation. 17 A review of the Alcoholics and Drug-Dependent Persons Act 1968 (Vic), found that there is no available evidence to support or reject compulsory treatment for non-offenders, however there have been few successful cases reported. 18 There is some evidence that any type of alcohol treatment for non-indigenous persons can be beneficial. 19 However, many reports highlight the insufficient research into the effectiveness of such programs for Indigenous populations, thus it must be with care that efficacy in Indigenous peoples is assumed. 20 There is limited evidence available addressing mandatory 14 Mill, J.S. (1859), On Liberty 15 Mill (1859) 16 See eg: Pritchard, Mugavin and Swan (2007); Rustad,J.,Junquera,P.,Chaves,L.,Eth,S.(2012) Civil Commitment Among Patients With Alcohol and Drug Abuse: Practical, Conceptual, and Ethical Issues, Addictive Disorders and Their Treatments; 11: ; Proude, E., Lopatko, O., Lintzeris, N., Haber, P. (2009) The Treatment of Alcohol Problems: A Review of the Evidence, University of NSW. 17 Pritchard, Mugavin and Swan (2007); Rustad et al. (2012) 18 Pritchard, Mugavin, and Swan (2007). 19 Gray, D., Saggers, S., Wilkes E., Allsop, S., Ober C. (2010) Managing Alcohol Related Problems Amongst Indigenous Australians: What the Literature Tells Us Australian and New Zealand Journal of Public Health; 34; Gray et al (2010), Proude et al (2009)

6 rehabilitation for alcoholics in any populations, and there is a definite lack of information relating specifically to mandatory civil incarceration. Does mandatory rehabilitation provide more benefits than disadvantage to alcoholics? Although excessive alcohol usage has been shown to be damaging, the circumstances for civil incarceration should be carefully analysed to ensure there is sufficient justification for mandatory rehabilitation. At present, there is inadequate evidence of effectiveness to support deferral of autonomy in such a scenario. At present, on ethical, moral and potentially legal standpoints, involuntary treatment is likely to be controversial, ineffective and deleterious. 21 Given the sensitive nature of mandatory rehabilitation, a few questions have been designed in order to maintain critical engagement throughout the paper. These questions aim to encourage the reader to think about the advantages, as well as disadvantages of mandatory rehabilitation. Questions 1. Does mandatory rehabilitation help the individual and the community? 2. Does mandatory rehabilitation re-integrate the individual into society? 3. Does mandatory rehabilitation improve the individual's health and social functions? 4. How does compulsion affect the individual's motivation? 5. Do police and judges have sufficient knowledge to refer individuals to appropriate treatment interventions? CIVIL COMMITMENT Throughout the different studies, it has been observed that the term 'civil commitment' has been used with a great deal of ambiguity. As such, it is important to provide a solid definition of civil commitment in order to further comprehend the true nature of the term. Throughout the literature, civil commitment has been used to describe the treatment mandated for criminals. It is necessary to emphasise that this is not the case. Civil commitment to alcohol treatment is defined as the legally sanctioned, involuntary commitment of a non-offender into treatment for drug or alcohol dependence. 22 Those detained in this manner have not committed any offence, and they have no say as to their involvement or incarceration. Many issues have been raised with the ethical, moral, legal and logistical development of a broader civil 21 Wild, C., Roberts, A., Cooper, E. (2002) Compulsory Substance Abuse Treatment: An Overview of Recent Findings and Issues, European Addiction Research, 8:84 93; Bourquin-Tieche, D., Besson J., Lambert, H (2001), Involuntary Treatment of Alcohol-Dependent Patients: A Study of 17 Consecutive Cases of Civil Commitment, European Addiction Research, 7: Pritchard, Mugavin and Swan (2007); Report on the Inebriates Act 1912, (2004)

7 incarceration model being implemented in Australia, however there is current legislation in four Australian jurisdictions that provide for such commitment. 23 The following case studies are examples of past and current cases of civil commitment for alcohol dependent persons. They will be evaluated with regards to their goals, general outcomes, and how these programs are implemented. Civil Commitment: Treatment Profile 1 Country of origin: Sweden Title: The Swedish Care of Alcoholics, Drug Abusers and Abusers of Volatile Solvents (Special Provisions) Act (henceforth referred to as LVM) Dates: present Aims 24 : 1. To immediately stop a destructive way of life (immediate) 2. To motivate patients to seek further treatment, if such a process is required (short term) 3. To overcome addiction and hence achieve a better lifestyle (long term) Legal procedure: Under the LVM, social workers are obliged to force a person into treatment (civil commitment), if they match a set of criteria set by the Swedish government. The criteria are as follows: 1. If the individual is risking his/her psychological health on purpose or by helplessness 2. Destroys the prospect of his/her future due to substance misuse 3. Risks the security of him/herself or intimate associates 4. Necessary intervention is not possible on a voluntary basis Treatment: The Swedish treatment approach is unlike conventional rehabilitation programs in the way that its main aim is not to put a stop to substance misuse; but to reintegrate individuals into society, with the supplementary goal of motivating patients to seek treatment voluntarily. Motivation: How does Swedish mandatory rehabilitation affect the motivation of its clients? Although there is a dearth of (English) resources regarding this topic, this is an important question to consider. Given Sweden's 90+ year history with mandatory rehabilitation, it would be interesting to study the short 23 Pritchard, Mugavin and Swan (2007). 24 Storbjork, J.(2006): Swedish Alcohol and Drug Treatment, in: The Social Ecology of Alcohol and Drug Treatment: Client Experiences in Contact, Stockholm University, Stockholm, 37-43

8 and long term effects amongst clients of such a treatment system. Does compulsory treatment motivate patients to achieve sobriety? Or does it deter them from such a goal? Considering that many patients do not take part in aftercare programs, one may be inclined to assume that mandatory rehabilitation does not enhance a client's motivation in treatment. Discussion: Treatment staff generally believe in, and are satisfied with their work. They are optimistic about treatment results, and perceive themselves to be helpers, rather than controllers, throughout the process of rehabilitation. It is worth noting that compulsory treatment is strongly in favour in Swedish society. It is generally supported by the population that the State has extensive rights to intervene in the private lives of individuals if such an act is necessary, thus the ethical legitimacy of mandatory rehabilitation is not regarded in a negative light in Sweden. Many healthcare professionals also agree that it is sometimes 'necessary' to admit patients into compulsory treatment, regardless of the patient's own volition. Results: Most treatment programs do not achieve abstinence amongst participants, and many individuals do not follow up with after care programs. Reports have also shown that many patients often return to unsatisfactory living environments subsequent to rehabilitation. 25 Ethics: Despite Sweden's long history with compulsory treatment, it would appear that the results of these programs have generally been considered to be unsatisfactory. Given the strong supporting evidence regarding the benefits of aftercare in a rehabilitative program, 26 can Sweden's treatment system be considered effective, despite low client engagement in aftercare? Recent reports have raised doubts as to whether or not mandatory rehabilitation is an effective method of restoring the long term wellbeing of patients, leading social scientists to question if it is ethically justified for such treatment to continue in Sweden. 27 As aforementioned, the Swedish population is highly in favour of compulsory treatment. Although no existing literature discusses the reasons behind this factor, it is possible that this is due to the fact that such State intervention provides security and comfort for the Swedish society. This may possibly be regarded as a benefit of mandatory rehabilitation; however, is it ethical to trade the freedom and self- 25 Ekendahl, M.(2007): Aftercare and Compulsory Substance Abuse Treatment: A Venture with Potential?, Contemporary Drug Problems, 31(1): , information credited to Larsson, H. & Ollus, M. (1999): Ett ar efterutskrivning- vad hande sen? En uppfoljning av 31 LVM-klienter och deras situation ett ar efter uts krivning. SiS foljer upp och udvarer. SiS-rapport 5/99, Stockholm: Statens insitutionsstyrelse 26 Horng, FF., Chueh, K.H.(2004): Effectiveness of Telephone Follow-up and Counseling in Aftercare for Alcoholism, The Journal of Nursing Research, 12(1): Ekendahl (2007)

9 autonomy of alcohol misusers in return for the security of the larger society? Conclusion: Overall, compulsory treatment is a long standing system in Sweden. Despite its ethical legitimacy, one may argue that sufficiently favourable benefits must exist, as such programs are widely supported within the country. However, in terms of the patient, it is undeniable that mandatory rehabilitation does not appear to be a suitable treatment method. Treatment Profile 2 Country of Origin: New Zealand Title: Alcoholism and Drug Addiction Act Dates: present Aims 28 : To provide compulsory detention for alcoholics and drug addicts in certified institutions so that they may undergo assessment, detoxification, and treatment. Legal procedure: An alcoholic, defined as 'any person whose persistent and excessive indulgence in alcoholic liquor is causing or is likely to cause serious injury to his health or is a source of harm, suffering, or serious annoyance to others or renders him incapable of properly managing himself of his affairs' may be ordered to undergo civil commitment through the following process 29 : 1. Court-ordered detention on application of a relative, a police officer, or 'any other reputable person' 2. District Court Judge issues warrant for the arrest of the alleged alcoholic, possible compulsory medical examination 3. Judge determines whether or not treatment is appropriate in the person's own interests or the interests of his/her relatives 4. Judge secures a treatment institution that is willing to accept the person Treatment: Alcohol treatment takes place at certified institutions, such as public hospitals, or non-governmental organisations. These facilities administer abstinence-based programs, with a combination of 28 Chapter 16, Alcoholism and Drug Addiction Act 1966, Law Commission Issues Paper, Controlling and Regulating Drugs 29 Alcoholism and Drug Addiction Act, s2

10 education, work, counselling, as well as variations of the 12-step program. Clients are generally detained for two years in an approved rehabilitation centre, unless a discharge takes place under the Act beforehand. Motivation: Motivation in New Zealand's rehabilitation system is positively affected by two main factors. Firstly, clients who repeatedly refuse treatment will not be approved to be participants of civil commitment. Secondly, the District Court Judge is required to assess whether or not rehabilitation will be expedient for the alleged alcoholic and their family. These key points help ensure that clients who are not ready for treatment will not progress through to a rehabilitation program. Furthermore, this also aids in confirming that those who proceed to treatment are genuinely motivated and able to begin their healing process. Discussion: The court does not have the right to detain the alleged alcoholic in civil commitment, if he or she does not pose any risk of self-harm, or danger for others It is important for the judge to assess whether or not the individual is able to care for themselves. If self-care is achievable, the individual will be rejected from civil commitment. Patients who repeatedly refuse treatment will be permitted to leave the program before treatment completion. Results: It has been noted that more than half of detainees usually leave their rehabilitation centres within three months of the program, and most leave by the sixth month. 30 Results show that this is mainly due to the inability of the Act to cater a suitable type of treatment in accordance to client need, a lack of certified institutions, and also institutions being unable or unwilling to receive clients. These are mainly due to the small number of government approved civil commitment rehabilitation programs in New Zealand. Ethics: A significant issue with regards to New Zealand's Alcoholism and Drug Addiction Act is its ethical legitimacy within the context of morals and values in current society. Many have argued that a mentally sound adult should be permitted to make their own decisions regarding treatment and alcohol consumption, and that long term compulsory treatment should be discontinued. The Act is not as popular as it once was, and many people now argue that it is an outdated document that does not agree with modern civil liberty statutes. 31 It has previously been calculated that there was an 30 Policy Branch, (1999): Review of the Alcoholism and Drug Addiction Act 1966: A Discussion Paper for Consultation, Ministry of Health 31 Report of the Law Commission of New Zealand (Te Aka Matua O Te Ture), September 2010, Wellington, New Zealand (Report 118) on the Compulsory Treatment for Substance Dependence: A review of the Alcoholism and Drug Addiction Act 1966, Commonwealth Law Bulletin, 37:1,

11 81.25% decrease in committal orders between the 1970's, and This huge decline is mainly due to the change of societal values over the years. What was once regarded as a necessary and practical treatment method, is now considered to be potentially inhumane, and inappropriate. Conclusion: New Zealand's Alcoholism and Drug Addiction Act is theoretically sound. It considers treatment readiness in alcoholics, and does not force non-consensual treatment on unwilling participants. However, it is undeniable that the dearth of results with regards to aftercare makes it challenging to properly evaluate the effectiveness of the mandatory rehabilitation system. Furthermore, considerations must be made with regards to the out dated values of the Act. It is imperative that amendments are made, in order to fully maximise treatment and rehabilitation potential amongst clients. Overall, it is impossible to fully judge the effectiveness and benefits of the New Zealand Alcoholism and Drug Addiction Act, as there is not enough evidence to support any existing opinion. Treatment Profile 3 Country of origin: United States of America Title: Massachusetts General Law, Chapter 123, Section 35 Dates: present Aims: To 'help an individual achieve personal change and accept responsibility toward an improved quality of life' Legal procedure 32 : Under the law, an alcoholic who put themselves or others at risk is able to be detained at an inpatient substance abuse treatment centre for a period of up to 30 days. An individual may be subject to civil commitment through the referral of an adult who is either a spouse, blood relative, guardian, or a police officer, physician, or court official. The aforementioned adult is required to file a written petition for committal, which is forwarded to the court for review. The court may order commitment under the following circumstances- 1. There is a medical diagnosis of alcoholism, AND 2. A likelihood of serious harm to the subject or others as a result of the substance abuse exists 32 Section 35, Massachusetts General Law

12 (i.e. person induces fear of violence in community) If civil commitment is approved, the individual is sent to the Women's Addiction Treatment Center (WATC), or the Men's Addiction Treatment Center (MATC), or another community treatment centre in Massachusetts for a thirty day period. Those who are determined to have a high potential of causing serious harm as a result of their alcohol addiction may be ordered to have an extended treatment of 90 days, followed by department provided case management services for up to a year subsequent to rehabilitation. This will require a review at four different reviews during the commitment Treatment: Both WATC and MATC have separate programs for individuals admitted under Section 35. Within each facility, addicts have access to the detoxification unit, clinical stabilisation services, and transitional support services. 33 All three programs provide 24 hour care, and patients are expected to attend daily in-house commitment groups. Firstly, the detoxification unit focuses on safe withdrawal from substance misuse. The physician-led treatment team consists of licensed counsellors, and case managers. Treatment involves individual and group counselling, family support and education, and aftercare planning. Clinical stabilisation services is another rehabilitation program that combines both individual and group counselling, as well as other treatment approaches, such as the 12-step program, and other psycho-education groups, lectures, and overdose prevention workshops. Patients within this service learn about relapse prevention, as well as coping skills. They are expected to develop an enhanced treatment plan along with the treatment team, and any family member who wishes to participate. The transitional support services bridges the transitory stage between detoxification and/or stepdown services and residential rehabilitation. It provides short-term residency, further stabilisation subsequent to detox, next-step case management, and safe, sober placement. Referrals will be facilitated as required, and residents will attend workshops relating to self-help, men s and women's recovery issues, as well as other topics related to a successful and restoring lifestyle. Motivation: It is difficult to discuss the effectiveness of this program with regards to patient motivation, as there seems to be little information on the subject. Discussion: Most adult admissions to substance abuse treatment services were White males. The prevalence of patients from other ethnic backgrounds was extremely low when compared to 33 Brockton Meadowcreek Campus(2010): Highpoint Treatment Centre [online], [Accessed: 14th February 2013]

13 the percentage of White patients in treatment 34. This is not due to the significantly lower rates of alcohol abuse amongst minority groups 35 ; rather, these statistics serve to reconfirm previous assumptions that the structure and processes that support civil commitment generally exclude individuals from minority groups 36. Can one regard Section 35 as a highly helpful program in society, if it only caters to individuals within the dominant demographic group? Results: In their most recent Annual Report, the South Eastern Regional Network featured the positive feedback received from past substance abusers. 37 Despite previous failed rehabilitation attempts, it was shown that patients eventually managed to complete treatment successfully. However, it is interesting to note that despite the sufficiently long history of civil commitment in Massachusetts, it has been challenging to find substantial information regarding results and satisfaction. Ethics: Public opinion regarding Section 35 was scarce. One of the sole resources with any opinion concerning Section 35 was found on a public online forum regarding marijuana9. The users of this particular website are especially resentful of the Massachusetts civil commitment act, as they feel that such a procedure is more suited for those with 'a serious addiction problem', such as 'meth heads', or 'coke heads'. It is arguable that the strong disagreement against Section 35 may be due to the general demographics of users on Grass City; however, it is also arguable that these are the people who require treatment. If they evidently have no desire for rehabilitation, is it ethical for the government to enforce treatment upon them? It could also be argued that Section 35 is an inappropriate form of alcohol treatment. Restorative justice, such as civil commitment, often widens the net of social control, resulting in the unnecessary incarceration of individuals who would otherwise not be involved in the justice system. 38 Massachusetts' Section 35 causes net widening through unnecessary police involvement. Subsequent to the submission of the petition for civil commitment, the police is required to pick up the alleged alcoholic at their place of residence. This is often a challenging process, as subjects of % of patients were White, whereas only 7.9% were Black, 9.4% were of another single race, whilst 11.2% were Hispanic 35 Galvan, F.H., Caetano, R.(2003): Alcohol Use and Related problems Among Ethnic Minorities in the United States, Alcohol Research and Health, 27(1): Pritchard, E., Mugavin, J., Swan, A.(2007): Compulsroy Treatment in Australia: A Discussion Paper on the Compulsory Treatment of Individuals Dependent on Alcohol and/or Other Drugs, Canberra: Australian National Council on Drugs 37 Organisation committed to the support of individuals, families, and communities impacted by addiction, mental illness, domestic violence, or homelessness in Southeastern Massachusetts; Southeast Regional Network (2011): Annual Report 38 URGENT: Section 35 Massachusetts (2011): Grass City [online], [Accessed 11 February 2013]

14 civil commitment are often unwilling to receive treatment. The presence of police serves to augment the pressure and tension felt by the subject, as well as their family and friends, which in turn, has the potential to result in violence. A Grass City forum discusses an instance where the alleged substance misuser resorts to violence as a consequence of the possibility of civil commitment. This resulted in a warning for disorderly conduct, which could have led to a potential arrest. This situation clearly illustrates the high probability of net widening in the context of civil commitment. Net widening is an undesirable outcome that is almost inevitable in Section 35. It is an effect that causes more challenges for substance misusers, and thus is not a helpful situation for these individuals. It is, therefore, important to question whether or not civil commitment is important, despite negative consequences, such as net widening. Conclusion: One could argue that Section 35 is an inadequate alcohol treatment system for citizens. As is common in civil commitment, it excludes minority groups from joining the program, whilst also increasing the potential of net widening with police involvement and mandated court attendance. However, the treatment system appears to be a comprehensive and beneficial model. Overall, due to an insufficient amount of information regarding treatment results, it is difficult to assess whether or not this is an effective program. FORENSIC REHABILITATION Forensic incarceration is defined as legally coerced drug and alcohol treatment entered into by persons charged with or convicted of an offence to which their alcohol or drug dependence has contributed. 39 It is often used as a method of diverting offenders away from the criminal justice system, and instead into alcohol and other drug (AOD) rehabilitation programs. 40 Utilised in Australia and in numerous other countries, particularly with young offenders, the diversion process can occur before or after a charge is laid, as part of sentencing or as part of a prison release or parole program. 41 Entry into the system can be voluntary or mandated by a court order, with Australian schemes including pre-arrest diversion through the national Illicit Drug Diversion Initiative, MERIT and CREDIT programs, and drug courts. 42 Those entering into forensic incarceration or diversion programs are offenders ie have admitted responsibility, or have been found guilty of committing a crime. They are exposed to varying degrees of coercion to enter the system, but ultimately have a choice as to their participation. The structure of the following forensic profiles will be slightly different from those of civil commitment. Motivation of prisoners, results, and ethics of the program will not be discussed, as these have not 39 Wild, Roberts and Cooper (2002) 40 Wild, Roberts and Cooper (2002), Pritchard, Mugavin and Swan (2007) 41 Pritchard, Mugavin and Swan (2007) 42 Pritchard, Mugavin and Swan (2007)

15 been investigated in previous studies. This is mainly due to the fact that forensics programs are held for offenders. There are fewer 'ethical dilemmas' associated with prison-led programs, as prisoners are perceived to be deserving of the treatment with which they are provided. Furthermore, many regard alcohol/drug abuse as strongly associated with criminal activity amongst prisoners. 43 This validates the reasons behind treatment, and encourages treatment to be held. The 'discussion' and 'conclusion' components of the profile will also be incorporated into one single section. Forensic Rehabilitation: Treatment Profile 1 Country of origin: United States of America Title: Reflections Court Alternative Program (Reflections CAP) 44 Dates: present Aims: To provide recovery home services as a court/prison alternative to criminals with substance misuse issues. Legal procedure: Referrals are made to the program by the District Attorney's office, a probation officer, or an attorney for an offender (aged 18+ and non-violent), who qualifies as having a substance abuse disorder that resulted in the client's incarceration. Treatment: Reflections is a one year program that consists of a three month residential stabilisation system, followed by nine months of case management in community-based settings. The residential component of Reflections CAP is intensive and highly structured. Programs aim to encourage open discussion amongst clients. Throughout the residential program, clients will be expected to join psycho-educational and stabilisation groups for approximately 6-8 hours a day. These are interactive groups, which are based on recovery. Individual counselling and community care planning sessions are also a significant aspect of the Reflections CAP treatment agenda. Each day, there are also scheduled times of meals, chores, and wellness activities. Clients are permitted to receive approved visitors on alternate weeks, approximately one month subsequent to program initiation. 43 Grann, M., Fazel, S.(2004): Substance Misuse and Violent Crime: Swedish Population Study, British Medical Journal, 328, Reflections CAP (2010): High Point Treatment Center [online], [Accessed 18 February 2013]

16 Discussion/ Conclusion: Reflections CAP is not a locked program; however, it is a staff secure facility. Men and women are treated in separate centres, and only go into community for medical appointments and court appearances. 45 The 2011 South Eastern Regional Network Report has published articles by inmates who are grateful for the Reflections program. 46 These participants feel that the program has genuinely assisted their recovery, and re-integration into society. From this point of view, one may regard Reflections as a successful program. However, these articles are highly anecdotal, and results cannot be generalised for the rest of the treatment population. Treatment Profile 2 Country of origin: Sweden Title: Care of Alcoholics, Drug Abusers, and Abusers of Volatile Solvents, Special Provision Act Dates: present Aims:... the time of an inmate in custody, prison and under probation, must be used to motivate the drug abuser (alcoholics included) to treatment... Inmates as well as staff in prisons and custody have the right to a drug-free environment... In order to achieve a drug-free environment, a combination of powerful motivation and treatment interventions, as well as well-balanced control measures, are required 47 Legal procedure: Criminals with substance abuse disorders are presented with three treatment options within the Swedish penal system. Firstly, inmates may choose to be placed outside prison, if he or she can receive interventions that assist with reintegration into society. The inmate's necessity for drug and alcohol treatment will be strongly considered, and treatment is generally intended for prisoners with long-term sentences (at least two years). 45 Residential Services (2010): High Point Treatment Center [online], [Accessed 18 February 2013] 46 Southeast Regional Network (2011): Annual Report 47 Found in Storbjork, J.(2006): Swedish Alcohol and Drug Treatment, in: The Social Ecology of Alcohol and Drug Treatment: Client Experiences in Contact, Stockholm University, Stockholm, 37-43, information credited to Prop. 2001/02:91. Regeringens proposition. Nationell narkotikahandlingsplan (Go- vernmental bill. National drug action plan), January 17, 2002.

17 The second option is contract treatment. This provides the inmate with substance problems with an alternative to a prison sentence. The individual will receive treatment for alcohol or drug problems at an institution or in a private home, with a probation officer who assesses and administers this treatment. If the individual breaches the 'contract' by not attending treatment, or by consuming drugs/alcohol, the court can decide to send him or her to prison. The third option is becoming more widely used, and involves more clients. This involves motivational efforts and treatment in prison, where 'every drug (and alcohol) abuser shall be motivated to treatment'. The Swedish government argues that the criminal justice system is one of the 'most important arenas for fighting drugs', and as such, endeavours to encourage treatment during incarceration. Treatment: Treatment focuses on the inmates' adaptation to life in society. As such, the Swedish government wishes to counteract the 'harmful effects of imprisonment', and instead, chooses to view the criminal justice system as an innovative treatment facility. Details of actual treatment are not discussed; however, similar to civil commitment, substance misuse workers are expected to motivate, rather than force treatment amongst prisoners. Discussion/Conclusion: It is worth noting that substance misuse treatment within the Swedish criminal justice system could be viewed as a utilitarian approach. Firstly, treatment effectively separates the substance misusers from non-users in prison, thus preventing violence from the former group of inmates. Secondly, this also protects non-users (inmates and staff alike) from the influence of drugs and alcohol. This helps to further promote a drug-free environment both within, and outside of prison. However, whether or not this approach is an effective one is debatable. Due to the lack of English literature regarding rehabilitation within the criminal justice system in Sweden, it is hard to gauge whether or not this is a beneficial treatment system. Treatment Profile 3 Country of origin: New Zealand Title: Alcohol and Drug Addiction Act 1966 (Section 21) Dates: present Aims: To provide voluntary and involuntary treatment for prisoners with substance misuse

18 problems within the New Zealand criminal justice system. 48 Legal procedure: The transfer of prisoners from prison to rehabilitation treatment centres is initiated at the ministerial level. The Act does not contain any criteria to guide the minister with regards to transferal, and it has been proposed that involuntary and voluntary transfers should meet criteria under respective sections of civil commitment under sections 8 and 9. Treatment: Treatment is identical to clients within civil commitment programs. As aforementioned, this includes a combination of education, work, counselling, as well as variations of the 12-step program. Clients are generally detained for two years in an approved rehabilitation centre, unless a discharge takes place under the Act beforehand. Discussion/ Conclusion: The treatment facilities are secure. However, it is an offence for persons committed under New Zealand's Alcohol and Drug Addiction Act to escape from, or wilfully refuse to return to treatment facilities. The police, or any employee of the institution is permitted to arrest without warrant any patient who is unlawfully absent from institution, and return him/her to the treatment facility. It is also interesting to note that the Act is now rarely used for prisoners, due to the recent establishment of drug and alcohol treatment units within prisons in New Zealand. Many have recommended the Act to be repealed, as it no longer relevant to prisoners. 49 As the Act is now rarely employed, there are few reportss regarding effectiveness of treatment. Australian Examples Treatment Profile 1 Title: Western Australian Drug Court 50 Dates: present Aims: 48 Chapter 16, Alcoholism and Drug Addiction Act 1966, Law Commission Issues Paper, Controlling and Regulating Drugs 49 Report of the Law Commission of New Zealand (Te Aka Matua O Te Ture), September 2010, Wellington, New Zealand (Report 118) on the Compulsory Treatment for Substance Dependence: A review of the Alcoholism and Drug Addiction Act 1966, Commonwealth Law Bulletin, 37:1, Sentencing Act 1995 (WA)

19 Reduce recidivism Reduce re-arrest Reduce drug-related crime-free Provide cost savings to the community and the government Legal procedure: Offenders may be referred to the Drug Court, if they are 18 years of age or over, and are drug dependent. They must also be willing to undertake treatment, and live within the Perth area. Offenders are required to plead guilty to each complaint referred. Treatment: Treatment is implemented at three different scales, and participants are referred to the treatment model that best suits their level of dependency. 1. Brief Intervention Regime: This is for minor-offenders. It includes the Pre-sentence Opportunity Program, the Young Person's Opportunity Program, and the Indigenous Diversion Program. 2. Supervised Treatment Intervention Regime: This is aimed at offenders who have committed mid-range offences. Offenders are required to attend rehabilitation treatment. 3. Drug Court Regime: This is the most intensive intervention program. The program targets those whose substance use and offences are most severe. Participants must undergo judicially case-managed treatment and monitoring, which involves weekly court appearances. Despite having ceased due to funding issues, it is interesting to discuss the Geraldton Alternative Sentencing Regime (GASR). This program aimed to promote the rehabilitation of offenders with substance abuse, domestic violence, and other such offending-related problems. Offenders were required to participate in a Court Supervision Regime for 4-6 months, where they attended court, and also received treatment for their substance misuse issues. Treatment included AOD counselling, medical treatment, vocational guidance, accommodation support, and stress reduction programs (such as transcendental meditation). Discussion/ Conclusion:- There is a marked decrease in drug use amongst participants of the Western Australian Drug Court Program. Participants also reported decreased stress levels, anxiety, and substance abuse. It is worth noting that participants who took part in transcendental meditation through the GASR reported that they had improved relationships with family. Community corrections officers also reported that clients who practised meditation were a lot calmer, less anxious, had clearer thinking and decision making abilities. These clients were more open and readily engaged in other rehabilitation programs suggested by their community corrections officer. It is interesting to note the benefits of meditation within rehabilitation programs. Perhaps this is a treatment method that should be considered in the

20 Northern Territory model for mandatory rehabilitation. Treatment Profile 2 Title: Queensland Drug Court 51 Dates: present Aims: Reduce level of drug dependency in community Reduce level of criminal activity Reduce health risks to community associated with drug dependency Reduce pressure on resources in the court and prison systems. Legal Procedure: The Queensland Drug Court targets serious offenders who are likely to be imprisoned. Offenders are eligible to participate in the program if they plead guilty to their offence, are over 18 years of age, and are likely to be sentenced to imprisonment. Offenders should also be drug-dependent, with their dependency contributing towards their committed offence. They must also live within the prescribed areas in Queensland. Treatment: Participants are placed on an Intensive Drug Treatment Order (IDRO). This program consists of three phases, and takes approximately months for completion. During their time in the program, participants are kept under intensive supervision and monitoring by the drug court. Offenders are required to take part in an ordered course of drug treatment, which may include methadone maintenance, detoxification, and rehabilitation. They must also report to a case manager, and undergo drug tests twice a week. The program includes sanctions, such as community service, and imprisonment. Rewards, such as reduced community service hours, are also provided to encourage compliance. Participants may request to leave the program at any time; however, this would imply that the original sentence is replaced with a new and final sentence. 51 Drug Rehabilitation (Court Diversion) Act 2000 (QLD)

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