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A cognitive therapy treatment program for repeat DUI offenders
Journal of Criminal Justice 36 (2008) 539–545
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Journal of Criminal Justice
A cognitive therapy treatment program for repeat DUI offenders Kathleen A. Moore ⁎, Melissa Harrison, M. Scott Young, Ezra Ochshorn Department of Mental Health Law and Policy, Florida Mental Health Institute, University of South Florida, 13301 Bruce B. Downs Boulevard, Tampa, FL 33612, United States
a r t i c l e
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a b s t r a c t Driving under the influence is a devastating problem in the United States, killing almost 17,000 people in 2005. The present article describes a cognitive treatment program aimed at repeat drinking and driving offenders. Sixty-three participants were court mandated to the four-month outpatient treatment program. Before entering and after completing treatment, participants were administered self-report instruments measuring alcohol problems, readiness to change, self-esteem/efficacy, and criminal thinking patterns. Additionally, arrest histories were examined. Findings suggested that participants were characterized not only by repeated arrests, but elevated blood alcohol content and high levels of self-reported alcohol dependency and problem-drinking behaviors. The majority of clients expressed a readiness to change their drinking and driving behaviors with 87 percent graduating from the program. A DUI recidivism rate of 13 percent was found for graduates of the program at a twenty-one month follow-up. The results demonstrate that the treatment program is a valuable tool in the battle to reduce criminal recidivism. © 2008 Elsevier Ltd. All rights reserved.
Introduction Individuals driving under the influence (DUI) of alcohol or drugs represent one of the most significant public health hazards in the United States. The Federal Bureau of Investigation (2004) estimated there were over 1.4 million arrests for DUI in the United States in 2003. In 2004, 16,694 individuals died in alcohol-related traffic accidents, an average of one every thirty minutes; this makes drunk driving the most frequently committed violent crime in the United States (National Highway Traffic Safety Administration (NHTSA), 2005). Additionally, NHTSA estimates alcohol is involved in 39 percent of fatal crashes and in 7 percent of all crashes. In 2004, 86 percent of people who died in alcohol-related accidents were killed in crashes where at least one driver had a blood alcohol content (BAC) of .08 or higher. Recognizing the link between BAC and driving accident fatalities, the federal government urged states with a legal limit above .08 to revise their statutes. All states have now adopted the legal limit of .08 BAC for adult drivers (Fell & Voas, 2006). Society as well as individuals are directly and dramatically impacted by drunk driving tragedies (e.g., damage to families, increased insurance costs, and loss of productivity). Each year, alcohol-related accidents cost the United States economy about $51 billion (Blincoe et al., 2002). The severity of this problem is reflected in the array of public interventions, including programs attempting to: (1) get drinkers home without having to drive (designated drivers and arrangements with cab companies), (2) deny driving privileges or inflict jail time on DUI offenders, (3) change the drinking and driving culture through ⁎ Corresponding author. Tel.: +1 813 974 2295; fax: +1 813 974 9327. E-mail address: [email protected] (K.A. Moore). 0047-2352/$ – see front matter © 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jcrimjus.2008.09.004
education and awareness, and (4) treat the alcohol and/or drug abuse problems (Pratt, Holsinger, & Latessa, 2000). Studies evaluating these initiatives demonstrate their efficacy in lowering recidivism rates, particularly those that incorporate substance abuse treatment and education (Wells-Parker, Kenne, Spratke, & Williams, 2000). DUI treatment efforts A common rehabilitation approach with DUI offenders is education on the effects and consequences of alcohol on physical functioning and driving ability. Educational programs alone have produced knowledge and attitude changes among first time and repeat offenders, but not meaningful behavioral changes. A review of 215 studies found that, compared to legal sanctions alone, interventions combining education, licensing sanctions, psychotherapy/counseling, and follow-up supervision, such as regular contact with a probation officer or aftercare, reduced recidivism and alcohol-related accidents by another 7 to 9 percent (Wells-Parker, Bangert-Drowns, McMillen, & Williams, 1995). This is especially pertinent for multiple offenders, who are likely to have severe alcohol problems and require multifaceted interventions to see positive change. DUI repeat offenders Approximately 12 percent of alcohol-related traffic fatalities involve individuals with DUI convictions during the past three years and about 30 percent of all drivers arrested for DUI are repeat offenders (Hedlund & McCartt, 2002). Treatment of the repeat DUI offender can be particularly challenging. In one study, within the first two years after treatment, approximately 8 percent of the repeat DUI
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offenders with two prior offenses had recidivated (Jones & Lacey, 1999). Of those with a more serious history of six prior offenses, approximately 13 percent recidivated within two years. A literature review of the characteristics of repeat DUI offenders concluded that the majority are single, White males with a high school education and are more likely than first-time DUI offenders to be alcohol dependent (Jones & Lacey, 2000). Additionally, when compared to first-time DUI offenders, repeat offenders were more likely to have engaged in other criminal activities (Gould & Gould, 1992). Current study Given the effectiveness of a multifaceted approach, an impaired driving initiative was introduced in Hillsborough County, Florida. In 2003, Hillsborough recorded 1,986 alcohol-related crashes, 1,442 injuries, and 73 fatalities, all among the highest of any county in Florida (NHTSA, 2005). In response, Hillsborough County was awarded a Justice Assistance Grant as part of a collaboration with the Hillsborough County Sheriff's Office (HCSO), the State Attorney's (SA) office, and a treatment agency, Tampa Crossroads, Inc. The goal of this initiative was to work separately and together to reduce the high rate of alcohol-related crashes, injuries, and fatalities. The Louis de la Parte Florida Mental Health Institute (FMHI) at the University of South Florida was funded as part of this initiative to describe the implementation of the TRIAD treatment program for repeat DUI offenders. To do this, the study examined the following: (1) treatment factors such as length of treatment, treatment compliance, and urinalysis results; (2) criminal justice factors such as arrest history and recidivism rates; (3) risk factors associated with repeat DUI offenses, including alcohol use and criminal thinking; and (4) protective factors associated with repeat DUI prevention, including motivation to change, self-esteem, and self-efficacy. Method
Table 1 Baseline demographics Participants (N = 63) Average age (SD)
39.2 (9.8)
Gender Male Female
78% 22%
Race Caucasian Hispanic/Latino African American Native American Other
59% 21% 13% 5% 2%
Marital status Single Married Divorced Other
54% 15% 25% 6%
Educational level Less than high school High school diploma/GED Vocational/technical Some college, no degree Bachelor's degree Post-graduate degree
11% 44% 7% 28% 5% 5%
Present health Poor Fair Good Excellent
3% 8% 59% 30%
Native American, and 2 percent as other. The majority of the sample was either single (54 percent) or divorced (25 percent); 15 percent were married, and 6 percent reported another relationship status. Only 11 percent of the sample had not completed high school or a GED. Among the others, 44 percent had completed high school or obtained a GED, and many had obtained education beyond high school: vocational or technical certification (7 percent), some college without a degree (28 percent), a bachelor's degree (5 percent), or a postgraduate degree (5 percent). Finally, the vast majority of participants (89 percent) rated their overall health as good or excellent.
Tampa Crossroads Inc. developed a treatment program entitled TRIAD aimed at decreasing DUI recidivism. While drug and alcohol use were monitored by the program, the primary focus was on identifying and correcting cognitive distortions most repeat DUI offenders exhibit to support continuation of their criminal behavior. Individuals referred to TRIAD undergo an initial assessment by Tampa Crossroads staff to determine eligibility for participating in the treatment program. Clients were required to attend TRIAD two times weekly, consisting of a sixty-minute psychoeducational group and a sixty-minute individual counseling session. Clients also completed weekly homework assignments in a program handbook (Truthought Corrective Thinking Process, 1999). They submitted to weekly drug urinalysis screenings and breathalyzer tests, and performed court-ordered community service to promote societal integration and investment. Depending on individual treatment needs, progress, and test results, clients typically completed the program in three to five months.
A demographic information sheet was administered to obtain age, gender, race, marital status, educational status, and health status. Participants filled out university IRB approved consent forms indicating agreement to participate in the program study. Participants then completed a series of self-report assessment measures at baseline (i.e., upon entry to the TRIAD program) and at post-test (i.e., immediately upon completing the program).
Participants
Self-report measures
Participants qualified for the study if they: (1) resided in Hillsborough County, Florida; (2) had been convicted of DUI two or more times in their lifetime (without causing death or serious injury); (3) were recommended by the State Attorney for participation in the program; and (4) were sentenced by the court to treatment as a result of a DUI. Sixty-three participants ranging in age from twenty to sixtyone completed the TRIAD baseline measure. As seen in Table 1, most participants (78 percent) were male. The sample represented a variety of ethnicities, with 59 percent classifying themselves as Caucasian, 21 percent as Hispanic, 13 percent as African American, 5 percent as
CAGE (Mayfield, McLeod, & Hall, 1974). CAGE is a popular brief assessment instrument of problem drinking. The four-item questionnaire was named for each item assessed: (1) the attempt to Cut down on drinking, (2) having been Annoyed by others' criticisms of one's drinking, (3) the feeling of Guilt associated with drinking, and (4) drinking in the morning as an Eye opener (Myerholtz & Rosenberg, 1997). Previous work using CAGE with a DUI population has produced an internal consistency reliability coefficient of .71 (Mischke & Venneri, 1987), and the internal consistency was .65 at pre-test in the current sample.
Procedure
K.A. Moore et al. / Journal of Criminal Justice 36 (2008) 539–545
Michigan Alcoholism Screening Test (MAST) (Selzer, 1971). This twenty-four-item measure assesses lifetime consequences of drinking. In use with DUI populations, internal consistency coefficients of .83-.88 have been reported (Mischke & Venneri, 1987; Myerholtz & Rosenberg, 1997). A cut-off score of five was originally set by Selzer (1971) to indicate alcoholism. Due to high rates of false positives, researchers have suggested scores from four to ten be categorized as “probable alcoholic,” with those above ten categorized as “positive alcoholic” (Jacobson, Niles, & Moberg, 1979). Cavaiola, Strohmetz, Wolf, and Lavender (2003) reported a mean of 5.5 when assessing repeat DUI offenders. The scale produced moderate internal consistency for the present sample, with a Cronbach's alpha based on standardized items of .67. Readiness to change questionnaire (Rollnick, Heather, Gold, & Hall, 1992). This twelve-item questionnaire was developed specifically for use with problem drinkers, with four items assessing each of the three stages of change: pre-contemplation, contemplation, and action. Wells-Parker, Williams, Dill, and Kenne (1998) tested the psychometric properties of the scale in a sample of DUI offenders. The internal consistency coefficients were reported as .49 for precontemplation, .74 for contemplation, and .83 for action (Wells-Parker et al., 1998). For the present sample, the internal consistency coefficients of the subscales were .70 for pre-contemplation, .84 for contemplation, and .75 for action. Test-retest correlations for the present sample were .46 for pre-contemplation, .55 for contemplation, and .60 for action. General self-efficacy scale (Bosscher & Smit, 1998). This twelve-item scale assesses general self-efficacy and has three subscales: initiative, effort, and persistence. Agreement with each statement is rated on a four-point scale ranging from (1) not at all true to (4) exactly true, with higher summed totals indicating higher self-efficacy. For the present sample, the subscales were internally consistent with Cronbach's alphas of .75 for initiative, .84 for effort, and .81 for persistence.
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book) on a five-point scale ranging from: (1) very satisfied to (5) very dissatisfied. Additionally, perceived program effectiveness was measured by participant agreement with a series of statements such as “I am more effective in dealing with my drinking behavior since taking this program.” Responses ranged on a five-point scale from (1) strongly agree to (5) strongly disagree. The measure's qualitative portion was intended to elicit perceived strengths and weaknesses of the program not addressed in the quantitative survey. Specifically, participants were asked to report what they liked best and least about the program. Administrative data Treatment information. This included number of days in treatment, successful graduation, and urinalysis results. Criminal history. The Hillsborough County Sheriff's Office Web site hosts a searchable data base of arrests in the county, limited to the past five years. This data base was used to determine how often each client was arrested before, during, and after treatment; charges for each arrest; and BAC level (if applicable). The records represent a rough estimate of each client's criminal history, as only local arrests during the past five years were available. Results Analyses describing treatment features and arrest history represented sixty-two of the sixty-three clients as data were not available for one client. The remaining analyses describing problem drinking behavior, readiness to change, self-efficacy, self-esteem, and criminal thinking represented a sample of sixty-three clients at baseline and forty-two clients at post-test. The satisfaction measures were administered only at the conclusion of treatment and therefore were conducted on the sample of forty-two clients who completed both a baseline and post-test measure.
Rosenberg self-esteem scale (Rosenberg, 1989). This ten-item scale assesses overall self-esteem. Agreement with each statement is rated on a five-point scale ranging from (0) strongly disagree to (4) strongly agree. Items are summed with higher totals indicating higher selfesteem. The internal consistency reliability estimates range from .82 to .89 and the measure has good psychometric properties (Baker & Gallant, 1984; Blascovich & Tomaka, 1991). The scale was internally consistent for the present sample (Cronbach's α = .84).
Treatment features
How I Think (HIT) questionnaire (Barriga, Gibbs, Potter, & Liau, 2001). This fifty-four-item measure assesses self-serving thought patterns. The questionnaire is comprised of eight scales with two domains. The first domain, cognitive distortions, consists of four scales measuring self-centeredness, blaming others, minimizing/mislabeling, and assuming the worst. The second domain, behavioral referents, consists of opposition-defiance, physical aggression, lying, and stealing. Agreement with each statement is rated on a six-point scale ranging from (1) agree strongly to (6) disagree strongly. The HIT questionnaire displays test-retest reliability estimated at .91 and internal consistency reliability estimated from .93 to .96 (Liau, Barriga, & Gibbs, 1998). The measure was originally developed to assess youth (Barriga et al., 2001), although others have reported good results with incarcerated adult populations (Barriga et al., 2001). For the present sample, the internal consistency coefficients for each of the eight major scales ranged from .72 to .83.
Successful graduation. Eighty-seven percent of participants (N = 54) successfully graduated from the TRIAD treatment program. The reasons for not graduating included never engaging in treatment (N = 6), having a positive urinalysis (N = 3), refusing treatment after arrest (N = 2), and death (N = 1).
Satisfaction measure. Composed of both quantitative and qualitative items, this measure was developed by the research team to assess satisfaction with TRIAD. The quantitative portion assessed participant satisfaction of various program components (e.g., counseling, hand-
Length of treatment. Length of treatment was measured as the duration (in days) of time from the date the participant was enrolled in treatment until he/she completed treatment or was terminated. The mean length of treatment was 110 days (SD = 38.4) with a range of 32 to 278 days. As seen in Table 2, participants were most commonly in treatment between 91 and 120 days.
Urinalysis results. Eighty-six percent of participants (N= 53) had no positive urinalysis throughout the TRIAD program. Among those that did test positive for alcohol and/or drug use (N= 9), a variety of drugs were used (e.g., cocaine, marijuana, alcohol, methamphetamine) and in a number of cases, more than one type of drug. Three of these Table 2 Number of days in treatment Length of treatment
N
%
32 to 60 days 61 to 90 days 91 to 120 days 121 to 150 days 151 to 180 days 181 or more days
5 9 29 12 6 1
8% 15% 47% 19% 10% 1%
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Table 3 Type of arrest charges Arrest charge
Table 4 Breathalyzer results for first DUI arrest 1st arrest N
DUI-related DUI misdemeanor DUI felony DUI w/property damage Subtotal
%
2nd arrest
3rd arrest
N
N
%
%
4th arrest N
%
5th+ arrest N
%
40 5 4 49
60% 7% 5% 73%
21 8 4 33
47% 18% 9% 74%
13 6 2 21
38% 18% 6% 62%
7 3 1 11
29% 13% 4% 46%
3 3 1 7
19% 19% 6% 44%
Non DUI-related Drug possession Violence Theft Fraud Criminal mischief Violation of probation Reckless driving Driving w/license revoked Subtotal
5 7 1 1 1 1 0 2
7% 10% 2% 2% 2% 2% 0% 3%
2 2 0 0 0 5 1 2
4% 4% 0% 0% 0% 11% 3% 4%
3 2 1 0 0 4 0 3
9% 6% 2% 0% 0% 12% 0% 9%
2 0 0 0 0 9 1 1
8% 0% 0% 0% 0% 38% 4% 4%
3 2 1 0 0 1 0 2
19% 12% 6% 0% 0% 7% 0% 12%
18
27%
12
26%
13
38%
13
54%
9
56%
Total
67
100%
45
100%
34
100%
24
100%
16
100%
participants did not graduate from the TRIAD program. The other six, after testing positive one or two times, agreed to comply with the rules and remained enrolled and drug-free for the remainder of the program. Arrest data Arrest history. The average number of pre-treatment arrests was 2.3 (SD = 1.44), with a maximum of seven. As seen in Table 3, the majority of the first arrest charges were DUI-related (N = 49). Among these, the vast majority were misdemeanor charges. The non-DUI-related charges (N = 18) included violence, drug possession, theft, fraud, criminal mischief, probation violation, and driving with a revoked and/or suspended license. DUI-related charges were most common among second and third arrests as well, though they represented an increasingly smaller proportion of charges among participants' third, fourth, and fifth arrests. Rearrest information. Given many participants had been arrested multiple times, it was thus important to document how many arrests
BAC level
N
%
Missing Refused .08 to .12 .121 to .16 .161 to .20 .201 to .24 .241 to .28 .281 to .32
4 20 7 10 11 7 2 2
6% 32% 11% 16% 18% 11% 3% 3%
occurred during or after completion of the treatment program. Only eight participants were arrested during treatment, the majority (67 percent) for a violation of probation. Post-treatment arrests were assessed for twenty-one months following discharge from the program. Twenty-two (35.5 percent) clients had been rearrested during the post-treatment period representing 27.8 percent of completers and 87.5 percent of non-completers. A great proportion of non-completers (75 percent) versus completers (12.9 percent) had been rearrested for a DUI offense. Other charges for arrest against completers included driving with a revoked license, reckless driving, possession of a controlled substance, possession of a firearm, battery, and trespassing. Arrest differences. The mean numbers of arrests before, during, and after treatment were calculated for those that did and did not graduate. As seen in Fig. 1, those that did not graduate had a higher mean number of arrests before, during, and after the program. Breathalyzer results. All DUI-related arrestees were requested to complete a breathalyzer test at the time of arrest. As seen in Table 4, 62 percent agreed to complete the breathalyzer test, 32 percent refused, and 6 percent had missing information. Of those completing the test, the average BAC was .17 (SD = .06), with a range from .08 to .31. Satisfaction results Participant satisfaction data were obtained to assess their experience with the TRIAD program. This was collected at the conclusion of treatment immediately following the final session. As can be seen in Table 5,
Fig. 1. Mean number of arrests for graduates and nongraduates.
K.A. Moore et al. / Journal of Criminal Justice 36 (2008) 539–545 Table 5 Satisfaction results Mean (SD) (N = 42) How satisfied were you witha: The quality of the program The quality of the counseling The quality of the handbook Overall satisfaction with TRIAD
1.4 (.82) 1.2 (.71) 2.0 (1.0) 1.5 (.80)
Counselor wasb: Knowledgeable about subject matter Well prepared Receptive to participant questions
1.3 (.50) 1.2 (.43) 1.2 (.38)
The TRIAD programb: Was well organized Was relevant to my current situation with drinking I expect to use the information from the program I would recommend it to others Material presented will be useful in dealing with my drinking I am more effective in dealing with my drinking since this program
1.5 1.7 1.4 1.6 1.5 1.5
(.55) (.82) (.55) (.67) (.63) (.63)
a Response scale: 1 = very satisfied, 2 = satisfied, 3 = neutral, 4 = dissatisfied, 5 = very dissatisfied. b Response scale: 1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, 5 = strongly disagree.
participant responses were overwhelmingly favorable. The satisfaction measure was divided into several sections described briefly below. Quality of program and counselor. The majority of participants were satisfied with the overall quality of the program, the counseling, and the handbook. The majority of participants strongly agreed that the counselors were knowledgeable, well prepared, and receptive to questions. Open-ended questions. The majority of participants (88 percent) who completed a satisfaction questionnaire responded to the two open-ended questions about the strengths and weaknesses of the program. The questions read, “What did you like best about the program?” and “What did you like least about the program?” Approximately 60 percent of participants identified the individual therapy sessions and/or the quality of the counseling as their most positive experience with the TRIAD program. Some of the favorable comments included: “Talking with other people who have dealt with the same problem that I have.” “This program and counselors helped me identify some past issues I needed to let go of.”
Areas identified as program weaknesses focused on convenience issues rather than treatment. The most commonly noted weakness was transportation, with the related issue of scheduling also causing difficulties. One participant noted that “catching the bus was very inconvenient.” Expense and length of treatment also were common complaints among participants. Problem drinking behavior All participants in the study were repeat DUI offenders ordered by the court into treatment. Using a cut-off score of two on the CAGE, 55 percent were classified as problem drinkers at baseline. A smaller proportion (26 percent) met or exceeded the more stringent cut-off score of three on the CAGE at baseline. Similarly, scores on the Michigan Alcoholism Screening Test indicated alcohol problems were considerable for this sample. The mean score on the MAST was 12.8 (SD = 9.2) at baseline. Using Selzer's cut-off of five, 76 percent of participants would be classified as alcoholics. Even using Jacobson's cut-off of ten, 57 percent would be classified as alcoholics. Table 6 presents mean MAST scores obtained in this study and in other samples reported in the literature. Independent samples t-tests indicated that MAST scores from the current study's repeat DUI offender sample were significantly higher (p b .05) than those reported among nonoffenders and repeat DUI offenders (Cavaiola et al., 2003), and DUI offenders (Mischke & Venneri, 1987), though they were significantly lower (p b .05) than the repeat DUI sample studied by Conley (2001). Readiness to change At baseline, 78 percent of the sample was classified as being in the action stage, 6 percent in the contemplation stage, and 16 percent in pre-contemplation. At post-test, 81 percent were in the action stage, 7 percent in the contemplation stage, and 12 percent in pre-contemplation. Although the majority was in the action stage at both timepoints, a significant difference was found comparing baseline to posttest, χ2 (4, N = 42) = 22.05, p b .01, indicating movement towards greater readiness to change. Self-efficacy and self esteem A repeated t-test revealed no significant differences between the baseline and post-test scores on the general self-efficacy scale. This also was true for the Rosenberg self-esteem scale. Criminal thinking Fig. 2 shows participants' baseline and post-test scores on the “how I think” measure of criminal thinking patterns. There were no
“Having very knowledgeable counselors required that I be very honest with myself.” Group interaction and support also were commonly identified as strengths of the program, with 33 percent of participants claiming this as their favorite aspect. Gaining a new perspective was noted by 14 percent of participants as the best aspect of treatment. Other strengths mentioned included program staff, program philosophy, and the handbook.
Table 6 Mean MAST scores of comparison groups Sample
Mean (SD)
N
Non-offenders (Cavaiola et al., 2003) DUI Offenders (Mischke & Venneri, 1987) Repeat DUI Offenders (Cavaiola et al., 2003) Repeat DUI Offenders (current sample at pre-test) Repeat DUI Offenders (Conley, 2001)
3.4 (3.9) 7.6 (8.4) 5.5 (5.4) 12.8 (9.2) 26.7(12.1)
61 90 77 63 117
543
Fig. 2. Mean scores on how I think (HIT) subscales at pre- and post-test.
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Table 7 Mean comparisons of treatment completers versus non-completers in criminal thinking patterns
females (78 percent to 22 percent), and Caucasians comprised 59 percent of the study population. These demographics comport with other research of DUI repeat offenders (Jones & Lacey, 2000).
Criminal thinking scale
Program completion
M
SD
t
Self-centered⁎
Non-completers Completers Non-completers Completers Non-completers Completers Non-completers Completers Non-completers Completers Non-completers Completers
1.99 1.56 2.28 1.64 2.33 1.80 2.37 1.75 1.87 1.43 2.10 1.61
.48 .52 .63 .50 .65 .61 .66 .59 .54 .50 .45 .51
t (60) = 2.049
Treatment outcomes
t (60) = 3.096
All TRIAD participants were court-ordered to undergo treatment as repeat offenders. The program completion rate was 87 percent. A positive urinalysis was the most common reason for not completing the program. The TRIAD program consisted of two weekly components: a one-hour psychoeducational group and a one-hour individual counseling session. Participants were taught to identify and correct common cognitive distortions used to rationalize drinking and driving via cognitive behavioral therapy (CBT) and motivational enhancement treatment (MET). The overwhelming majority of participants (86 percent) did not have a positive urinalysis during the treatment program. Of those testing positive, marijuana or alcohol was most often the drug used. If a participant agreed to follow program rules and remain clean, they could continue with treatment.
Blaming others⁎⁎ Opposition/defiance⁎ Lying⁎ Stealing⁎ Overall⁎
t (60) = 2.166 t (60) = 2.633 t (60) = 2.194 t (60) = 2.440
⁎ p b .05. ⁎⁎ p b .01.
significant differences between pre- and post-test scores, with a low level of criminal thinking seen at baseline. Post hoc analyses
Criminal justice outcomes Post hoc analyses using independent samples t-tests for continuous variables and chi square tests for categorical variables were conducted to compare baseline differences between those who completed treatment to those who did not. Although the group of non-completers was quite small, the analyses were conducted as an exploratory attempt to determine whether there were any baseline characteristics of non-completers that appeared to differ from completers. These characteristics could be investigated in greater depth in later research. None of the demographic characteristics significantly differed between completers and non-completers with regard to age, gender, race, marital status and education. The non-completers, however, did appear to have greater baseline levels of alcohol problems than completers. Non-completers scored significantly higher (M = 2.86, SD = 1.46) than completers (M = 1.82, SD= 1.22) on the CAGE, t (60) = 2.079, p b .05 indicating more severe alcohol problems at treatment initiation. Similarly, non-completers scored higher (M = 24.29, SD= 16.15) than completers (M= 13.09, SD= 9.55) on the Michigan Alcoholism Screening Test, although this was not a statistically significant difference. Non-completers also were more likely to hold criminal thinking patterns when compared to completers. As shown in Table 7, at baseline, non-completers responded to items on the HIT indicating significantly greater levels of self-centeredness, blaming others, oppositional defiance, lying, stealing, and overall criminal thinking.
It is important to note that data were gathered by outside interviewers; it is therefore unlikely these court-ordered participants believed their responses would affect their probation. The majority were very satisfied with the quality of the program (79 percent) and the counseling (91 percent). Additionally, most participants strongly agreed that the counselors were knowledgeable about the topic (76 percent), well prepared (76 percent), and receptive to questions (83 percent).
Discussion
Risk factors
Drunk driving is a devastating problem in the United States, killing almost 17,000 people in 2005. Research indicates about one-third of those arrested for drunk driving are repeat offenders. Given the inability of past efforts to dramatically improve the problem, new treatment strategies must be explored to supplement current intervention options. In response to this need, a three-pronged impaired driving initiative was funded in Hillsborough County involving the following agencies: Hillsborough County Sheriff's Office (HCSO), State Attorney's (SA) Office, and Tampa Crossroads, Inc., a local substance abuse treatment facility. This article described the implementation of the TRIAD treatment program for repeat DUI offenders used at Tampa Crossroads. The following factors were examined: (1) participant and treatment outcomes, (2) criminal justice outcomes, and (3) risk and protective outcomes.
Risk factors associated with repeat DUI offenses include alcohol abuse and criminal thinking. Problem drinking behavior was assessed using two measures of alcohol use. These findings are consistent with past research linking problem drinking and repeat DUI offenses. In fact, the mean score on the MAST for the present sample was about two times the mean reported by Cavaiola et al. (2003), also examining repeat DUI offenders. The mean in the present study more closely approximates that reported by Mischke and Venneri (1987) of DUI offenders, not necessarily repeat offenders, classified as “significant problem drinkers.” Considering the TRIAD participants had been convicted of at least two drinking and driving offenses, these findings are not surprising. A criminal thinking measure also was utilized because all of these participants had prior DUI convictions. This measure examines cognitive distortions including self-centeredness, blaming others, minimizing/mislabeling, assuming the worst, oppositional defiance, physical aggression, lying, and stealing. Not surprising given the participants' criminal backgrounds, the highest scores were recorded on questions involving oppositional defiance. Although the sample of
Participant outcomes The TRIAD program included sixty-three adult participants with a mean age of thirty-nine years. Males significantly outnumbered
All participants had at least two DUI arrests prior to admission. According to the HCSO Web site covering the previous five years, the average number of pre-treatment arrests was 2.3, with a maximum of seven. The majority of these arrests were DUI-related. For these, the average BAC was .17, with a range of .08 to .31. Significantly higher than the legal limit, these BAC numbers correspond to other reports of repeat offenders (NHTSA, 2005). Although the majority of participants had committed serious crimes prior to admission, only 15 percent were rearrested during treatment and 35 percent rearrested after treatment. Only two DUIrelated arrests occurred during the course of treatment. These data reflect the treatment effectiveness of the TRIAD program. Satisfaction with treatment program
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individuals who failed to complete treatment was quite small to draw many conclusions at this point, there is some indication that criminal thinking patterns may hinder one's ability to successfully complete treatment.
participants who agreed to participate in the research component of this project.
Protective factors
Baker, P. M., & Gallant, M. J. (1984). Self-esteem: Measurement strategies and problems. Humbolt Journal of Social Relations, 12, 36−48. Barriga, A. Q., Gibbs, J. C., Potter, G. B., & Liau, A. K. (2001). How I think questionnaire manual. Champaign, IL: Research Press. Blascovich, J., & Tomaka, J. (1991). The self-esteem scale. In J. P. Robinson, P. R. Shaver, & L. S. Wrightsman (Eds.), Measures of personality and social psychological attitudes (pp. 115−160). New York: Academic Press. Blincoe, L., Seay, A., Zaloshnja, E., Miller, T., Romano, E., Luchter, S., et al. (2002). The economic impact of motor vehicle crashes, 2000. Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration. Bosscher, R. J., & Smit, J. H. (1998). Confirmatory factor analysis of the general selfefficacy scale. Behaviour Research and Therapy, 36, 339−343. Cavaiola, A. A., Strohmetz, D. B., Wolf, J. M., & Lavender, N. J. (2003). Comparison of DWI offenders with non-DWI individuals on the MMPI-2 and the Michigan Alcoholism Screening Test. Addictive Behaviors, 28, 971−977. Conley, T. B. (2001). Construct validity of the MAST and AUDIT with multiple offender drunk drivers. Journal of Substance Abuse Treatment, 20, 287−295. Federal Bureau of Investigation. (2004). Uniform crime reports for the United States, 2003. Washington, DC: U.S. Department of Justice, Federal Bureau of Investigation. Fell, J. C., & Voas, R. B. (2006). The effectiveness of reducing illegal blood alcohol concentration (BAC) limits for driving: Evidence for lowering the limit to .05 BAC. Journal of Safety Research, 37, 233−243. Gould, L. A., & Gould, K. H. (1992). First time and multiple DWI offenders: A comparison of criminal history records and BAC level. Journal of Criminal Justice, 20, 527−539. Hedlund, J. H., & McCartt, A. T. (2002). Drunk driving: Seeking additional solutions. Trumbull, CT: Preusser Research Group. Jacobson, G. R., Niles, D. H., & Moberg, D. P. (1979). Identifying alcoholic and problemdrinking drivers: Wisconsin's field test of a modified NCA criteria for the diagnosis of alcoholism. In M. Galanter (Ed.), Currents in alcoholism: Treatment, rehabilitation, and epidemiology (Vol. 6, pp. 273−293). New York: Grune and Stratton. Jones, R. K., & Lacey, J. H. (1999). Evaluation of a day reporting center for repeat DWI offenders. Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration. Jones, R. K., & Lacey, J. H. (2000). State of knowledge of alcohol-impaired driving: Research on repeat DWI offenders. Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration. Liau, A. K., Barriga, A. Q., & Gibbs, J. C. (1998). Relations between self-serving cognitive distortions and overt vs. covert antisocial behavior in adolescents. Aggressive Behavior, 24, 335−346. Mayfield, D., McLeod, G., & Hall, P. (1974). The CAGE questionnaire: Validation of a new alcoholism instrument. American Journal of Psychiatry, 131, 1121−1123. Mischke, H. D., & Venneri, R. L. (1987). Reliability and validity of the MAST, MortimerFilkins Questionnaire and CAGE in DWI assessment. Journal of Studies on Alcohol, 48, 492−501. Myerholtz, L. E., & Rosenberg, H. (1997). Screening DUI offenders for alcohol problems: Psychometric assessment of the substance abuse subtle screening inventory. Psychology of Addictive Behaviors, 11, 155−165. National Highway Traffic Safety Administration. (2005). Traffic safety facts 2004: Alcohol. Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration. Pratt, T. C., Holsinger, A. M., & Latessa, E. J. (2000). Treating the chronic DUI offender “turning point” ten years later. Journal of Criminal Justice, 28, 271−281. Rollnick, S., Heather, N., Gold, R., & Hall, W. (1992). Development of a short ‘readiness to change’ questionnaire for use in brief, opportunistic interventions among excessive drinkers. British Journal of Addiction, 87, 743−754. Rosenberg, M. (1989). Society and the adolescent self-image (Rev. ed.). Middletown, CT: Wesleyan University Press. Selzer, M. L. (1971). The Michigan Alcoholism Screening Test (MAST): The quest for a new diagnostic instrument. American Journal of Psychiatry, 127, 1653−1658. Truthought Corrective Thinking Process. (1999). Just thinking: Workbook for responsible decision making. Roscoe, IL: Author. Wells-Parker, E., Bangert-Drowns, R., McMillen, R., & Williams, M. (1995). Final results from a meta-analysis of remedial interventions with drink/drive offenders. Addiction, 90, 907−926. Wells-Parker, E., Kenne, D. R., Spratke, K. L., & Williams, M. T. (2000). Self-efficacy and motivation for controlling drinking and drinking/driving: An investigation of changes across a driving under the influence (DUI) intervention program and of recidivism prediction. Addictive Behaviors, 25, 229−238. Wells-Parker, E., Williams, M., Dill, P., & Kenne, D. (1998). Stages of change and selfefficacy for controlling drinking and driving: A psychometric analysis. Addictive Behaviors, 23, 351−363.
Protective factors associated with repeat DUI offenses include motivation to change, self-esteem, and self-efficacy. More participants viewed themselves in the action stage at post-test (81 percent) than baseline (78 percent). Although a small change, it was statistically significant. There were no significant changes, however, from baseline to post-test for either self-efficacy or self-esteem. Limitations While the results support the use of the TRIAD program, there were several limitations to the current study. First, the study of the TRIAD program was conducted at the same time that the community implemented an initiative involving law enforcement and the prosecutor's office in the targeting of repeat DUI offenders. Thus, reductions in recidivism may be due to the effectiveness of the treatment program, the increased law enforcement, or the combined effect of these factors. Based on past research indicating treatment is more effective when sanctions are also administered, it would be expected that multiple factors affect the likelihood for recidivism. The intent of the study was to describe the implementation of the treatment program alongside these environmental strategies, rather than teasing apart their independent effects. Future studies should be cognizant of the environmental context in which treatment strategies are implemented. Second, the present study did not include a comparison group. Therefore, the study was unable to determine whether the treatment leads to an outcome in recidivism that is different from another method of deterrence or rehabilitation (i.e., jail, psychoeducation) or even no intervention. Program and policy recommendations Effective treatment for problem drinkers saves lives on the highways and societal costs related to the criminal justice system, rising insurance rates, loss of life, diminished productivity, and the destruction of affected families. The results of this study clearly demonstrated that the TRIAD treatment program for multiple DUI offenders was a valuable tool in the battle to reduce criminal recidivism and alcohol and/or drug use. Other jurisdictions should consider applying similar strategies in response to this ongoing problem of alcohol-related public safety issues. Acknowledgements Funding for this project was supported by the Justice Assistance Grant. The authors would like to acknowledge the collaboration of Tampa Crossroads, for their support of this program endeavor. Special thanks are due to Sara Romeo, Executive Director, and Bob Brown, MA, CAP, Director of Clinical Services, for their assistance during this project. We would also like to specifically acknowledge the support of Summer Schmuck, LCSW, Project Manager at Tampa Crossroads, who helped managed the data collection and data analysis process throughout this past year. Her dedicated contribution to the preparation and improvement of this report has greatly enhanced both its organization and clarity. Finally, we would like to thank all the TRIAD
References
Contents lists available at ScienceDirect
Journal of Criminal Justice
A cognitive therapy treatment program for repeat DUI offenders Kathleen A. Moore ⁎, Melissa Harrison, M. Scott Young, Ezra Ochshorn Department of Mental Health Law and Policy, Florida Mental Health Institute, University of South Florida, 13301 Bruce B. Downs Boulevard, Tampa, FL 33612, United States
a r t i c l e
i n f o
a b s t r a c t Driving under the influence is a devastating problem in the United States, killing almost 17,000 people in 2005. The present article describes a cognitive treatment program aimed at repeat drinking and driving offenders. Sixty-three participants were court mandated to the four-month outpatient treatment program. Before entering and after completing treatment, participants were administered self-report instruments measuring alcohol problems, readiness to change, self-esteem/efficacy, and criminal thinking patterns. Additionally, arrest histories were examined. Findings suggested that participants were characterized not only by repeated arrests, but elevated blood alcohol content and high levels of self-reported alcohol dependency and problem-drinking behaviors. The majority of clients expressed a readiness to change their drinking and driving behaviors with 87 percent graduating from the program. A DUI recidivism rate of 13 percent was found for graduates of the program at a twenty-one month follow-up. The results demonstrate that the treatment program is a valuable tool in the battle to reduce criminal recidivism. © 2008 Elsevier Ltd. All rights reserved.
Introduction Individuals driving under the influence (DUI) of alcohol or drugs represent one of the most significant public health hazards in the United States. The Federal Bureau of Investigation (2004) estimated there were over 1.4 million arrests for DUI in the United States in 2003. In 2004, 16,694 individuals died in alcohol-related traffic accidents, an average of one every thirty minutes; this makes drunk driving the most frequently committed violent crime in the United States (National Highway Traffic Safety Administration (NHTSA), 2005). Additionally, NHTSA estimates alcohol is involved in 39 percent of fatal crashes and in 7 percent of all crashes. In 2004, 86 percent of people who died in alcohol-related accidents were killed in crashes where at least one driver had a blood alcohol content (BAC) of .08 or higher. Recognizing the link between BAC and driving accident fatalities, the federal government urged states with a legal limit above .08 to revise their statutes. All states have now adopted the legal limit of .08 BAC for adult drivers (Fell & Voas, 2006). Society as well as individuals are directly and dramatically impacted by drunk driving tragedies (e.g., damage to families, increased insurance costs, and loss of productivity). Each year, alcohol-related accidents cost the United States economy about $51 billion (Blincoe et al., 2002). The severity of this problem is reflected in the array of public interventions, including programs attempting to: (1) get drinkers home without having to drive (designated drivers and arrangements with cab companies), (2) deny driving privileges or inflict jail time on DUI offenders, (3) change the drinking and driving culture through ⁎ Corresponding author. Tel.: +1 813 974 2295; fax: +1 813 974 9327. E-mail address: [email protected] (K.A. Moore). 0047-2352/$ – see front matter © 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jcrimjus.2008.09.004
education and awareness, and (4) treat the alcohol and/or drug abuse problems (Pratt, Holsinger, & Latessa, 2000). Studies evaluating these initiatives demonstrate their efficacy in lowering recidivism rates, particularly those that incorporate substance abuse treatment and education (Wells-Parker, Kenne, Spratke, & Williams, 2000). DUI treatment efforts A common rehabilitation approach with DUI offenders is education on the effects and consequences of alcohol on physical functioning and driving ability. Educational programs alone have produced knowledge and attitude changes among first time and repeat offenders, but not meaningful behavioral changes. A review of 215 studies found that, compared to legal sanctions alone, interventions combining education, licensing sanctions, psychotherapy/counseling, and follow-up supervision, such as regular contact with a probation officer or aftercare, reduced recidivism and alcohol-related accidents by another 7 to 9 percent (Wells-Parker, Bangert-Drowns, McMillen, & Williams, 1995). This is especially pertinent for multiple offenders, who are likely to have severe alcohol problems and require multifaceted interventions to see positive change. DUI repeat offenders Approximately 12 percent of alcohol-related traffic fatalities involve individuals with DUI convictions during the past three years and about 30 percent of all drivers arrested for DUI are repeat offenders (Hedlund & McCartt, 2002). Treatment of the repeat DUI offender can be particularly challenging. In one study, within the first two years after treatment, approximately 8 percent of the repeat DUI
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offenders with two prior offenses had recidivated (Jones & Lacey, 1999). Of those with a more serious history of six prior offenses, approximately 13 percent recidivated within two years. A literature review of the characteristics of repeat DUI offenders concluded that the majority are single, White males with a high school education and are more likely than first-time DUI offenders to be alcohol dependent (Jones & Lacey, 2000). Additionally, when compared to first-time DUI offenders, repeat offenders were more likely to have engaged in other criminal activities (Gould & Gould, 1992). Current study Given the effectiveness of a multifaceted approach, an impaired driving initiative was introduced in Hillsborough County, Florida. In 2003, Hillsborough recorded 1,986 alcohol-related crashes, 1,442 injuries, and 73 fatalities, all among the highest of any county in Florida (NHTSA, 2005). In response, Hillsborough County was awarded a Justice Assistance Grant as part of a collaboration with the Hillsborough County Sheriff's Office (HCSO), the State Attorney's (SA) office, and a treatment agency, Tampa Crossroads, Inc. The goal of this initiative was to work separately and together to reduce the high rate of alcohol-related crashes, injuries, and fatalities. The Louis de la Parte Florida Mental Health Institute (FMHI) at the University of South Florida was funded as part of this initiative to describe the implementation of the TRIAD treatment program for repeat DUI offenders. To do this, the study examined the following: (1) treatment factors such as length of treatment, treatment compliance, and urinalysis results; (2) criminal justice factors such as arrest history and recidivism rates; (3) risk factors associated with repeat DUI offenses, including alcohol use and criminal thinking; and (4) protective factors associated with repeat DUI prevention, including motivation to change, self-esteem, and self-efficacy. Method
Table 1 Baseline demographics Participants (N = 63) Average age (SD)
39.2 (9.8)
Gender Male Female
78% 22%
Race Caucasian Hispanic/Latino African American Native American Other
59% 21% 13% 5% 2%
Marital status Single Married Divorced Other
54% 15% 25% 6%
Educational level Less than high school High school diploma/GED Vocational/technical Some college, no degree Bachelor's degree Post-graduate degree
11% 44% 7% 28% 5% 5%
Present health Poor Fair Good Excellent
3% 8% 59% 30%
Native American, and 2 percent as other. The majority of the sample was either single (54 percent) or divorced (25 percent); 15 percent were married, and 6 percent reported another relationship status. Only 11 percent of the sample had not completed high school or a GED. Among the others, 44 percent had completed high school or obtained a GED, and many had obtained education beyond high school: vocational or technical certification (7 percent), some college without a degree (28 percent), a bachelor's degree (5 percent), or a postgraduate degree (5 percent). Finally, the vast majority of participants (89 percent) rated their overall health as good or excellent.
Tampa Crossroads Inc. developed a treatment program entitled TRIAD aimed at decreasing DUI recidivism. While drug and alcohol use were monitored by the program, the primary focus was on identifying and correcting cognitive distortions most repeat DUI offenders exhibit to support continuation of their criminal behavior. Individuals referred to TRIAD undergo an initial assessment by Tampa Crossroads staff to determine eligibility for participating in the treatment program. Clients were required to attend TRIAD two times weekly, consisting of a sixty-minute psychoeducational group and a sixty-minute individual counseling session. Clients also completed weekly homework assignments in a program handbook (Truthought Corrective Thinking Process, 1999). They submitted to weekly drug urinalysis screenings and breathalyzer tests, and performed court-ordered community service to promote societal integration and investment. Depending on individual treatment needs, progress, and test results, clients typically completed the program in three to five months.
A demographic information sheet was administered to obtain age, gender, race, marital status, educational status, and health status. Participants filled out university IRB approved consent forms indicating agreement to participate in the program study. Participants then completed a series of self-report assessment measures at baseline (i.e., upon entry to the TRIAD program) and at post-test (i.e., immediately upon completing the program).
Participants
Self-report measures
Participants qualified for the study if they: (1) resided in Hillsborough County, Florida; (2) had been convicted of DUI two or more times in their lifetime (without causing death or serious injury); (3) were recommended by the State Attorney for participation in the program; and (4) were sentenced by the court to treatment as a result of a DUI. Sixty-three participants ranging in age from twenty to sixtyone completed the TRIAD baseline measure. As seen in Table 1, most participants (78 percent) were male. The sample represented a variety of ethnicities, with 59 percent classifying themselves as Caucasian, 21 percent as Hispanic, 13 percent as African American, 5 percent as
CAGE (Mayfield, McLeod, & Hall, 1974). CAGE is a popular brief assessment instrument of problem drinking. The four-item questionnaire was named for each item assessed: (1) the attempt to Cut down on drinking, (2) having been Annoyed by others' criticisms of one's drinking, (3) the feeling of Guilt associated with drinking, and (4) drinking in the morning as an Eye opener (Myerholtz & Rosenberg, 1997). Previous work using CAGE with a DUI population has produced an internal consistency reliability coefficient of .71 (Mischke & Venneri, 1987), and the internal consistency was .65 at pre-test in the current sample.
Procedure
K.A. Moore et al. / Journal of Criminal Justice 36 (2008) 539–545
Michigan Alcoholism Screening Test (MAST) (Selzer, 1971). This twenty-four-item measure assesses lifetime consequences of drinking. In use with DUI populations, internal consistency coefficients of .83-.88 have been reported (Mischke & Venneri, 1987; Myerholtz & Rosenberg, 1997). A cut-off score of five was originally set by Selzer (1971) to indicate alcoholism. Due to high rates of false positives, researchers have suggested scores from four to ten be categorized as “probable alcoholic,” with those above ten categorized as “positive alcoholic” (Jacobson, Niles, & Moberg, 1979). Cavaiola, Strohmetz, Wolf, and Lavender (2003) reported a mean of 5.5 when assessing repeat DUI offenders. The scale produced moderate internal consistency for the present sample, with a Cronbach's alpha based on standardized items of .67. Readiness to change questionnaire (Rollnick, Heather, Gold, & Hall, 1992). This twelve-item questionnaire was developed specifically for use with problem drinkers, with four items assessing each of the three stages of change: pre-contemplation, contemplation, and action. Wells-Parker, Williams, Dill, and Kenne (1998) tested the psychometric properties of the scale in a sample of DUI offenders. The internal consistency coefficients were reported as .49 for precontemplation, .74 for contemplation, and .83 for action (Wells-Parker et al., 1998). For the present sample, the internal consistency coefficients of the subscales were .70 for pre-contemplation, .84 for contemplation, and .75 for action. Test-retest correlations for the present sample were .46 for pre-contemplation, .55 for contemplation, and .60 for action. General self-efficacy scale (Bosscher & Smit, 1998). This twelve-item scale assesses general self-efficacy and has three subscales: initiative, effort, and persistence. Agreement with each statement is rated on a four-point scale ranging from (1) not at all true to (4) exactly true, with higher summed totals indicating higher self-efficacy. For the present sample, the subscales were internally consistent with Cronbach's alphas of .75 for initiative, .84 for effort, and .81 for persistence.
541
book) on a five-point scale ranging from: (1) very satisfied to (5) very dissatisfied. Additionally, perceived program effectiveness was measured by participant agreement with a series of statements such as “I am more effective in dealing with my drinking behavior since taking this program.” Responses ranged on a five-point scale from (1) strongly agree to (5) strongly disagree. The measure's qualitative portion was intended to elicit perceived strengths and weaknesses of the program not addressed in the quantitative survey. Specifically, participants were asked to report what they liked best and least about the program. Administrative data Treatment information. This included number of days in treatment, successful graduation, and urinalysis results. Criminal history. The Hillsborough County Sheriff's Office Web site hosts a searchable data base of arrests in the county, limited to the past five years. This data base was used to determine how often each client was arrested before, during, and after treatment; charges for each arrest; and BAC level (if applicable). The records represent a rough estimate of each client's criminal history, as only local arrests during the past five years were available. Results Analyses describing treatment features and arrest history represented sixty-two of the sixty-three clients as data were not available for one client. The remaining analyses describing problem drinking behavior, readiness to change, self-efficacy, self-esteem, and criminal thinking represented a sample of sixty-three clients at baseline and forty-two clients at post-test. The satisfaction measures were administered only at the conclusion of treatment and therefore were conducted on the sample of forty-two clients who completed both a baseline and post-test measure.
Rosenberg self-esteem scale (Rosenberg, 1989). This ten-item scale assesses overall self-esteem. Agreement with each statement is rated on a five-point scale ranging from (0) strongly disagree to (4) strongly agree. Items are summed with higher totals indicating higher selfesteem. The internal consistency reliability estimates range from .82 to .89 and the measure has good psychometric properties (Baker & Gallant, 1984; Blascovich & Tomaka, 1991). The scale was internally consistent for the present sample (Cronbach's α = .84).
Treatment features
How I Think (HIT) questionnaire (Barriga, Gibbs, Potter, & Liau, 2001). This fifty-four-item measure assesses self-serving thought patterns. The questionnaire is comprised of eight scales with two domains. The first domain, cognitive distortions, consists of four scales measuring self-centeredness, blaming others, minimizing/mislabeling, and assuming the worst. The second domain, behavioral referents, consists of opposition-defiance, physical aggression, lying, and stealing. Agreement with each statement is rated on a six-point scale ranging from (1) agree strongly to (6) disagree strongly. The HIT questionnaire displays test-retest reliability estimated at .91 and internal consistency reliability estimated from .93 to .96 (Liau, Barriga, & Gibbs, 1998). The measure was originally developed to assess youth (Barriga et al., 2001), although others have reported good results with incarcerated adult populations (Barriga et al., 2001). For the present sample, the internal consistency coefficients for each of the eight major scales ranged from .72 to .83.
Successful graduation. Eighty-seven percent of participants (N = 54) successfully graduated from the TRIAD treatment program. The reasons for not graduating included never engaging in treatment (N = 6), having a positive urinalysis (N = 3), refusing treatment after arrest (N = 2), and death (N = 1).
Satisfaction measure. Composed of both quantitative and qualitative items, this measure was developed by the research team to assess satisfaction with TRIAD. The quantitative portion assessed participant satisfaction of various program components (e.g., counseling, hand-
Length of treatment. Length of treatment was measured as the duration (in days) of time from the date the participant was enrolled in treatment until he/she completed treatment or was terminated. The mean length of treatment was 110 days (SD = 38.4) with a range of 32 to 278 days. As seen in Table 2, participants were most commonly in treatment between 91 and 120 days.
Urinalysis results. Eighty-six percent of participants (N= 53) had no positive urinalysis throughout the TRIAD program. Among those that did test positive for alcohol and/or drug use (N= 9), a variety of drugs were used (e.g., cocaine, marijuana, alcohol, methamphetamine) and in a number of cases, more than one type of drug. Three of these Table 2 Number of days in treatment Length of treatment
N
%
32 to 60 days 61 to 90 days 91 to 120 days 121 to 150 days 151 to 180 days 181 or more days
5 9 29 12 6 1
8% 15% 47% 19% 10% 1%
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Table 3 Type of arrest charges Arrest charge
Table 4 Breathalyzer results for first DUI arrest 1st arrest N
DUI-related DUI misdemeanor DUI felony DUI w/property damage Subtotal
%
2nd arrest
3rd arrest
N
N
%
%
4th arrest N
%
5th+ arrest N
%
40 5 4 49
60% 7% 5% 73%
21 8 4 33
47% 18% 9% 74%
13 6 2 21
38% 18% 6% 62%
7 3 1 11
29% 13% 4% 46%
3 3 1 7
19% 19% 6% 44%
Non DUI-related Drug possession Violence Theft Fraud Criminal mischief Violation of probation Reckless driving Driving w/license revoked Subtotal
5 7 1 1 1 1 0 2
7% 10% 2% 2% 2% 2% 0% 3%
2 2 0 0 0 5 1 2
4% 4% 0% 0% 0% 11% 3% 4%
3 2 1 0 0 4 0 3
9% 6% 2% 0% 0% 12% 0% 9%
2 0 0 0 0 9 1 1
8% 0% 0% 0% 0% 38% 4% 4%
3 2 1 0 0 1 0 2
19% 12% 6% 0% 0% 7% 0% 12%
18
27%
12
26%
13
38%
13
54%
9
56%
Total
67
100%
45
100%
34
100%
24
100%
16
100%
participants did not graduate from the TRIAD program. The other six, after testing positive one or two times, agreed to comply with the rules and remained enrolled and drug-free for the remainder of the program. Arrest data Arrest history. The average number of pre-treatment arrests was 2.3 (SD = 1.44), with a maximum of seven. As seen in Table 3, the majority of the first arrest charges were DUI-related (N = 49). Among these, the vast majority were misdemeanor charges. The non-DUI-related charges (N = 18) included violence, drug possession, theft, fraud, criminal mischief, probation violation, and driving with a revoked and/or suspended license. DUI-related charges were most common among second and third arrests as well, though they represented an increasingly smaller proportion of charges among participants' third, fourth, and fifth arrests. Rearrest information. Given many participants had been arrested multiple times, it was thus important to document how many arrests
BAC level
N
%
Missing Refused .08 to .12 .121 to .16 .161 to .20 .201 to .24 .241 to .28 .281 to .32
4 20 7 10 11 7 2 2
6% 32% 11% 16% 18% 11% 3% 3%
occurred during or after completion of the treatment program. Only eight participants were arrested during treatment, the majority (67 percent) for a violation of probation. Post-treatment arrests were assessed for twenty-one months following discharge from the program. Twenty-two (35.5 percent) clients had been rearrested during the post-treatment period representing 27.8 percent of completers and 87.5 percent of non-completers. A great proportion of non-completers (75 percent) versus completers (12.9 percent) had been rearrested for a DUI offense. Other charges for arrest against completers included driving with a revoked license, reckless driving, possession of a controlled substance, possession of a firearm, battery, and trespassing. Arrest differences. The mean numbers of arrests before, during, and after treatment were calculated for those that did and did not graduate. As seen in Fig. 1, those that did not graduate had a higher mean number of arrests before, during, and after the program. Breathalyzer results. All DUI-related arrestees were requested to complete a breathalyzer test at the time of arrest. As seen in Table 4, 62 percent agreed to complete the breathalyzer test, 32 percent refused, and 6 percent had missing information. Of those completing the test, the average BAC was .17 (SD = .06), with a range from .08 to .31. Satisfaction results Participant satisfaction data were obtained to assess their experience with the TRIAD program. This was collected at the conclusion of treatment immediately following the final session. As can be seen in Table 5,
Fig. 1. Mean number of arrests for graduates and nongraduates.
K.A. Moore et al. / Journal of Criminal Justice 36 (2008) 539–545 Table 5 Satisfaction results Mean (SD) (N = 42) How satisfied were you witha: The quality of the program The quality of the counseling The quality of the handbook Overall satisfaction with TRIAD
1.4 (.82) 1.2 (.71) 2.0 (1.0) 1.5 (.80)
Counselor wasb: Knowledgeable about subject matter Well prepared Receptive to participant questions
1.3 (.50) 1.2 (.43) 1.2 (.38)
The TRIAD programb: Was well organized Was relevant to my current situation with drinking I expect to use the information from the program I would recommend it to others Material presented will be useful in dealing with my drinking I am more effective in dealing with my drinking since this program
1.5 1.7 1.4 1.6 1.5 1.5
(.55) (.82) (.55) (.67) (.63) (.63)
a Response scale: 1 = very satisfied, 2 = satisfied, 3 = neutral, 4 = dissatisfied, 5 = very dissatisfied. b Response scale: 1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, 5 = strongly disagree.
participant responses were overwhelmingly favorable. The satisfaction measure was divided into several sections described briefly below. Quality of program and counselor. The majority of participants were satisfied with the overall quality of the program, the counseling, and the handbook. The majority of participants strongly agreed that the counselors were knowledgeable, well prepared, and receptive to questions. Open-ended questions. The majority of participants (88 percent) who completed a satisfaction questionnaire responded to the two open-ended questions about the strengths and weaknesses of the program. The questions read, “What did you like best about the program?” and “What did you like least about the program?” Approximately 60 percent of participants identified the individual therapy sessions and/or the quality of the counseling as their most positive experience with the TRIAD program. Some of the favorable comments included: “Talking with other people who have dealt with the same problem that I have.” “This program and counselors helped me identify some past issues I needed to let go of.”
Areas identified as program weaknesses focused on convenience issues rather than treatment. The most commonly noted weakness was transportation, with the related issue of scheduling also causing difficulties. One participant noted that “catching the bus was very inconvenient.” Expense and length of treatment also were common complaints among participants. Problem drinking behavior All participants in the study were repeat DUI offenders ordered by the court into treatment. Using a cut-off score of two on the CAGE, 55 percent were classified as problem drinkers at baseline. A smaller proportion (26 percent) met or exceeded the more stringent cut-off score of three on the CAGE at baseline. Similarly, scores on the Michigan Alcoholism Screening Test indicated alcohol problems were considerable for this sample. The mean score on the MAST was 12.8 (SD = 9.2) at baseline. Using Selzer's cut-off of five, 76 percent of participants would be classified as alcoholics. Even using Jacobson's cut-off of ten, 57 percent would be classified as alcoholics. Table 6 presents mean MAST scores obtained in this study and in other samples reported in the literature. Independent samples t-tests indicated that MAST scores from the current study's repeat DUI offender sample were significantly higher (p b .05) than those reported among nonoffenders and repeat DUI offenders (Cavaiola et al., 2003), and DUI offenders (Mischke & Venneri, 1987), though they were significantly lower (p b .05) than the repeat DUI sample studied by Conley (2001). Readiness to change At baseline, 78 percent of the sample was classified as being in the action stage, 6 percent in the contemplation stage, and 16 percent in pre-contemplation. At post-test, 81 percent were in the action stage, 7 percent in the contemplation stage, and 12 percent in pre-contemplation. Although the majority was in the action stage at both timepoints, a significant difference was found comparing baseline to posttest, χ2 (4, N = 42) = 22.05, p b .01, indicating movement towards greater readiness to change. Self-efficacy and self esteem A repeated t-test revealed no significant differences between the baseline and post-test scores on the general self-efficacy scale. This also was true for the Rosenberg self-esteem scale. Criminal thinking Fig. 2 shows participants' baseline and post-test scores on the “how I think” measure of criminal thinking patterns. There were no
“Having very knowledgeable counselors required that I be very honest with myself.” Group interaction and support also were commonly identified as strengths of the program, with 33 percent of participants claiming this as their favorite aspect. Gaining a new perspective was noted by 14 percent of participants as the best aspect of treatment. Other strengths mentioned included program staff, program philosophy, and the handbook.
Table 6 Mean MAST scores of comparison groups Sample
Mean (SD)
N
Non-offenders (Cavaiola et al., 2003) DUI Offenders (Mischke & Venneri, 1987) Repeat DUI Offenders (Cavaiola et al., 2003) Repeat DUI Offenders (current sample at pre-test) Repeat DUI Offenders (Conley, 2001)
3.4 (3.9) 7.6 (8.4) 5.5 (5.4) 12.8 (9.2) 26.7(12.1)
61 90 77 63 117
543
Fig. 2. Mean scores on how I think (HIT) subscales at pre- and post-test.
544
K.A. Moore et al. / Journal of Criminal Justice 36 (2008) 539–545
Table 7 Mean comparisons of treatment completers versus non-completers in criminal thinking patterns
females (78 percent to 22 percent), and Caucasians comprised 59 percent of the study population. These demographics comport with other research of DUI repeat offenders (Jones & Lacey, 2000).
Criminal thinking scale
Program completion
M
SD
t
Self-centered⁎
Non-completers Completers Non-completers Completers Non-completers Completers Non-completers Completers Non-completers Completers Non-completers Completers
1.99 1.56 2.28 1.64 2.33 1.80 2.37 1.75 1.87 1.43 2.10 1.61
.48 .52 .63 .50 .65 .61 .66 .59 .54 .50 .45 .51
t (60) = 2.049
Treatment outcomes
t (60) = 3.096
All TRIAD participants were court-ordered to undergo treatment as repeat offenders. The program completion rate was 87 percent. A positive urinalysis was the most common reason for not completing the program. The TRIAD program consisted of two weekly components: a one-hour psychoeducational group and a one-hour individual counseling session. Participants were taught to identify and correct common cognitive distortions used to rationalize drinking and driving via cognitive behavioral therapy (CBT) and motivational enhancement treatment (MET). The overwhelming majority of participants (86 percent) did not have a positive urinalysis during the treatment program. Of those testing positive, marijuana or alcohol was most often the drug used. If a participant agreed to follow program rules and remain clean, they could continue with treatment.
Blaming others⁎⁎ Opposition/defiance⁎ Lying⁎ Stealing⁎ Overall⁎
t (60) = 2.166 t (60) = 2.633 t (60) = 2.194 t (60) = 2.440
⁎ p b .05. ⁎⁎ p b .01.
significant differences between pre- and post-test scores, with a low level of criminal thinking seen at baseline. Post hoc analyses
Criminal justice outcomes Post hoc analyses using independent samples t-tests for continuous variables and chi square tests for categorical variables were conducted to compare baseline differences between those who completed treatment to those who did not. Although the group of non-completers was quite small, the analyses were conducted as an exploratory attempt to determine whether there were any baseline characteristics of non-completers that appeared to differ from completers. These characteristics could be investigated in greater depth in later research. None of the demographic characteristics significantly differed between completers and non-completers with regard to age, gender, race, marital status and education. The non-completers, however, did appear to have greater baseline levels of alcohol problems than completers. Non-completers scored significantly higher (M = 2.86, SD = 1.46) than completers (M = 1.82, SD= 1.22) on the CAGE, t (60) = 2.079, p b .05 indicating more severe alcohol problems at treatment initiation. Similarly, non-completers scored higher (M = 24.29, SD= 16.15) than completers (M= 13.09, SD= 9.55) on the Michigan Alcoholism Screening Test, although this was not a statistically significant difference. Non-completers also were more likely to hold criminal thinking patterns when compared to completers. As shown in Table 7, at baseline, non-completers responded to items on the HIT indicating significantly greater levels of self-centeredness, blaming others, oppositional defiance, lying, stealing, and overall criminal thinking.
It is important to note that data were gathered by outside interviewers; it is therefore unlikely these court-ordered participants believed their responses would affect their probation. The majority were very satisfied with the quality of the program (79 percent) and the counseling (91 percent). Additionally, most participants strongly agreed that the counselors were knowledgeable about the topic (76 percent), well prepared (76 percent), and receptive to questions (83 percent).
Discussion
Risk factors
Drunk driving is a devastating problem in the United States, killing almost 17,000 people in 2005. Research indicates about one-third of those arrested for drunk driving are repeat offenders. Given the inability of past efforts to dramatically improve the problem, new treatment strategies must be explored to supplement current intervention options. In response to this need, a three-pronged impaired driving initiative was funded in Hillsborough County involving the following agencies: Hillsborough County Sheriff's Office (HCSO), State Attorney's (SA) Office, and Tampa Crossroads, Inc., a local substance abuse treatment facility. This article described the implementation of the TRIAD treatment program for repeat DUI offenders used at Tampa Crossroads. The following factors were examined: (1) participant and treatment outcomes, (2) criminal justice outcomes, and (3) risk and protective outcomes.
Risk factors associated with repeat DUI offenses include alcohol abuse and criminal thinking. Problem drinking behavior was assessed using two measures of alcohol use. These findings are consistent with past research linking problem drinking and repeat DUI offenses. In fact, the mean score on the MAST for the present sample was about two times the mean reported by Cavaiola et al. (2003), also examining repeat DUI offenders. The mean in the present study more closely approximates that reported by Mischke and Venneri (1987) of DUI offenders, not necessarily repeat offenders, classified as “significant problem drinkers.” Considering the TRIAD participants had been convicted of at least two drinking and driving offenses, these findings are not surprising. A criminal thinking measure also was utilized because all of these participants had prior DUI convictions. This measure examines cognitive distortions including self-centeredness, blaming others, minimizing/mislabeling, assuming the worst, oppositional defiance, physical aggression, lying, and stealing. Not surprising given the participants' criminal backgrounds, the highest scores were recorded on questions involving oppositional defiance. Although the sample of
Participant outcomes The TRIAD program included sixty-three adult participants with a mean age of thirty-nine years. Males significantly outnumbered
All participants had at least two DUI arrests prior to admission. According to the HCSO Web site covering the previous five years, the average number of pre-treatment arrests was 2.3, with a maximum of seven. The majority of these arrests were DUI-related. For these, the average BAC was .17, with a range of .08 to .31. Significantly higher than the legal limit, these BAC numbers correspond to other reports of repeat offenders (NHTSA, 2005). Although the majority of participants had committed serious crimes prior to admission, only 15 percent were rearrested during treatment and 35 percent rearrested after treatment. Only two DUIrelated arrests occurred during the course of treatment. These data reflect the treatment effectiveness of the TRIAD program. Satisfaction with treatment program
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individuals who failed to complete treatment was quite small to draw many conclusions at this point, there is some indication that criminal thinking patterns may hinder one's ability to successfully complete treatment.
participants who agreed to participate in the research component of this project.
Protective factors
Baker, P. M., & Gallant, M. J. (1984). Self-esteem: Measurement strategies and problems. Humbolt Journal of Social Relations, 12, 36−48. Barriga, A. Q., Gibbs, J. C., Potter, G. B., & Liau, A. K. (2001). How I think questionnaire manual. Champaign, IL: Research Press. Blascovich, J., & Tomaka, J. (1991). The self-esteem scale. In J. P. Robinson, P. R. Shaver, & L. S. Wrightsman (Eds.), Measures of personality and social psychological attitudes (pp. 115−160). New York: Academic Press. Blincoe, L., Seay, A., Zaloshnja, E., Miller, T., Romano, E., Luchter, S., et al. (2002). The economic impact of motor vehicle crashes, 2000. Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration. Bosscher, R. J., & Smit, J. H. (1998). Confirmatory factor analysis of the general selfefficacy scale. Behaviour Research and Therapy, 36, 339−343. Cavaiola, A. A., Strohmetz, D. B., Wolf, J. M., & Lavender, N. J. (2003). Comparison of DWI offenders with non-DWI individuals on the MMPI-2 and the Michigan Alcoholism Screening Test. Addictive Behaviors, 28, 971−977. Conley, T. B. (2001). Construct validity of the MAST and AUDIT with multiple offender drunk drivers. Journal of Substance Abuse Treatment, 20, 287−295. Federal Bureau of Investigation. (2004). Uniform crime reports for the United States, 2003. Washington, DC: U.S. Department of Justice, Federal Bureau of Investigation. Fell, J. C., & Voas, R. B. (2006). The effectiveness of reducing illegal blood alcohol concentration (BAC) limits for driving: Evidence for lowering the limit to .05 BAC. Journal of Safety Research, 37, 233−243. Gould, L. A., & Gould, K. H. (1992). First time and multiple DWI offenders: A comparison of criminal history records and BAC level. Journal of Criminal Justice, 20, 527−539. Hedlund, J. H., & McCartt, A. T. (2002). Drunk driving: Seeking additional solutions. Trumbull, CT: Preusser Research Group. Jacobson, G. R., Niles, D. H., & Moberg, D. P. (1979). Identifying alcoholic and problemdrinking drivers: Wisconsin's field test of a modified NCA criteria for the diagnosis of alcoholism. In M. Galanter (Ed.), Currents in alcoholism: Treatment, rehabilitation, and epidemiology (Vol. 6, pp. 273−293). New York: Grune and Stratton. Jones, R. K., & Lacey, J. H. (1999). Evaluation of a day reporting center for repeat DWI offenders. Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration. Jones, R. K., & Lacey, J. H. (2000). State of knowledge of alcohol-impaired driving: Research on repeat DWI offenders. Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration. Liau, A. K., Barriga, A. Q., & Gibbs, J. C. (1998). Relations between self-serving cognitive distortions and overt vs. covert antisocial behavior in adolescents. Aggressive Behavior, 24, 335−346. Mayfield, D., McLeod, G., & Hall, P. (1974). The CAGE questionnaire: Validation of a new alcoholism instrument. American Journal of Psychiatry, 131, 1121−1123. Mischke, H. D., & Venneri, R. L. (1987). Reliability and validity of the MAST, MortimerFilkins Questionnaire and CAGE in DWI assessment. Journal of Studies on Alcohol, 48, 492−501. Myerholtz, L. E., & Rosenberg, H. (1997). Screening DUI offenders for alcohol problems: Psychometric assessment of the substance abuse subtle screening inventory. Psychology of Addictive Behaviors, 11, 155−165. National Highway Traffic Safety Administration. (2005). Traffic safety facts 2004: Alcohol. Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration. Pratt, T. C., Holsinger, A. M., & Latessa, E. J. (2000). Treating the chronic DUI offender “turning point” ten years later. Journal of Criminal Justice, 28, 271−281. Rollnick, S., Heather, N., Gold, R., & Hall, W. (1992). Development of a short ‘readiness to change’ questionnaire for use in brief, opportunistic interventions among excessive drinkers. British Journal of Addiction, 87, 743−754. Rosenberg, M. (1989). Society and the adolescent self-image (Rev. ed.). Middletown, CT: Wesleyan University Press. Selzer, M. L. (1971). The Michigan Alcoholism Screening Test (MAST): The quest for a new diagnostic instrument. American Journal of Psychiatry, 127, 1653−1658. Truthought Corrective Thinking Process. (1999). Just thinking: Workbook for responsible decision making. Roscoe, IL: Author. Wells-Parker, E., Bangert-Drowns, R., McMillen, R., & Williams, M. (1995). Final results from a meta-analysis of remedial interventions with drink/drive offenders. Addiction, 90, 907−926. Wells-Parker, E., Kenne, D. R., Spratke, K. L., & Williams, M. T. (2000). Self-efficacy and motivation for controlling drinking and drinking/driving: An investigation of changes across a driving under the influence (DUI) intervention program and of recidivism prediction. Addictive Behaviors, 25, 229−238. Wells-Parker, E., Williams, M., Dill, P., & Kenne, D. (1998). Stages of change and selfefficacy for controlling drinking and driving: A psychometric analysis. Addictive Behaviors, 23, 351−363.
Protective factors associated with repeat DUI offenses include motivation to change, self-esteem, and self-efficacy. More participants viewed themselves in the action stage at post-test (81 percent) than baseline (78 percent). Although a small change, it was statistically significant. There were no significant changes, however, from baseline to post-test for either self-efficacy or self-esteem. Limitations While the results support the use of the TRIAD program, there were several limitations to the current study. First, the study of the TRIAD program was conducted at the same time that the community implemented an initiative involving law enforcement and the prosecutor's office in the targeting of repeat DUI offenders. Thus, reductions in recidivism may be due to the effectiveness of the treatment program, the increased law enforcement, or the combined effect of these factors. Based on past research indicating treatment is more effective when sanctions are also administered, it would be expected that multiple factors affect the likelihood for recidivism. The intent of the study was to describe the implementation of the treatment program alongside these environmental strategies, rather than teasing apart their independent effects. Future studies should be cognizant of the environmental context in which treatment strategies are implemented. Second, the present study did not include a comparison group. Therefore, the study was unable to determine whether the treatment leads to an outcome in recidivism that is different from another method of deterrence or rehabilitation (i.e., jail, psychoeducation) or even no intervention. Program and policy recommendations Effective treatment for problem drinkers saves lives on the highways and societal costs related to the criminal justice system, rising insurance rates, loss of life, diminished productivity, and the destruction of affected families. The results of this study clearly demonstrated that the TRIAD treatment program for multiple DUI offenders was a valuable tool in the battle to reduce criminal recidivism and alcohol and/or drug use. Other jurisdictions should consider applying similar strategies in response to this ongoing problem of alcohol-related public safety issues. Acknowledgements Funding for this project was supported by the Justice Assistance Grant. The authors would like to acknowledge the collaboration of Tampa Crossroads, for their support of this program endeavor. Special thanks are due to Sara Romeo, Executive Director, and Bob Brown, MA, CAP, Director of Clinical Services, for their assistance during this project. We would also like to specifically acknowledge the support of Summer Schmuck, LCSW, Project Manager at Tampa Crossroads, who helped managed the data collection and data analysis process throughout this past year. Her dedicated contribution to the preparation and improvement of this report has greatly enhanced both its organization and clarity. Finally, we would like to thank all the TRIAD
References