Transcript Motivation from Without (Prof. Keith Humphreys)

Presented at 2012 NDASG, Llandrindod Wells, Wales
Keith Humphreys
Professor of Psychiatry, Stanford University
Visiting Professor of Psychiatry, King’s College London
Research Career Scientist, VA Health Care System
[email protected]
Public Safety Threats Stemming
from Alcohol/Drug Use
 Street Violence
 Driving while Impaired
 Spousal Battering and Child Abuse
 Home Invasion, Property Theft
 Mass Transit Accidents
 Substandard or Reckless Medical Practice
Criminologist James Q. Wilson’s analogy for how
we respond to criminal offenders
Traditional Paradigm
New Paradigm
Make rules complex and covert
Make rules simple and transparent
Assume long-term orientation in offender
Assume short-term orientation in offender
Punish unpredictably
Punish with certainty
Punish harshly
Punish proportionately
Punish slowly
Punish swiftly
Use Imprisonment indiscriminantly
Employ behavioral triage to reserve prison for
appropriate offenders
Mandate treatment, hope for abstinence
Mandate abstinence, offer treatment
New paradigm
Exemplars of the New Paradigm
Physician Health Plans
HOPE Probation
24/7 Sobriety
Physician Health Plans
 Rate of physician addiction equal to general population
 Historically, doctors could get away with it until an
undeniable catastrophe occurred
 PHPs designed to change this through intensive
monitoring
Content of PHP
 Can temporarily or permanently remove license
 Not treatment, though they arrange treatment
 All conditions specified in a contract
 Comprehensive, random drug and alcohol testing
 Immediate, graduated reaction to positive test
Outcome Data on 802
Physicians over five years
 80.7% (n=647) completed all five years of monitoring
 Only 19.5% of completers had even a single positive
test
 Only 5.1% had more than one positive test
 Over 60,000 tests done total, 99.5% negative
Source: McLellan et al. (2008) BMJ, 337, a2038.
The World of Probation
 Low social capital offenders
 More serious co-occurring problems
 Overwhelmed staff
 Unclear rules, inconsistent rewards and punishments
HOPE Probation for Druginvolved offenders in Hawaii
 All probationers given full orientation to rules and
onus of responsibility placed on them
 Dirty or missed random urinalysis results in prompt
arrest and certain, modest punishment (brief jail stay)
 Treatment offered by not required
 Inexpensive because it reduces return to prison
Randomized evaluation of
HOPE
 Included all probation officers, average caseload 87
clients, average years of experience 4.3 years
 493 Felony Probationers, average 17 prior arrests
 Primary drug: Crystal meth
Major 1-year trial findings of HOPE
versus usual probation
Source: Hawken, A., & Kleiman, M. A. R. (2009). Managing Drug Involved Probationers with Swift and Certain Sanctions: Evaluating Hawaii's HOPE. Report to National Institute of Justice, Washington, D.C.
Drink drivers in the U.S.
Northern Plains
 Over 10,000 Americans a year die in alcohol-involved
car accidents
 The peak states are in the Northern Plains (e.g.,
Montana, North Dakota, South Dakota)
 Typical penalties, e.g., license removal, widely ignored
 A county prosecutor (Larry Long) decided to innovate
24/7 Sobriety for repeat drink
drivers in South Dakota
 All offenders get careful orientation to program rules
 Twice-daily breath testing or alcohol-sensing bracelet
 Alcohol use or no show results in prompt arrest and
certain, modest punishment (1 night in jail)
 Nearly self-sustaining financially because offenders
pay for own testing
Alcohol-Impaired Motor Vehicle Fatalities/Vehicle Miles Traveled
Source: U.S. National Highway Safety and Transportation Agency
Other key data points on 24/7
 Over 99% of tests collected are negative
 66% of offenders have perfect compliance
 Recidivism rates less than half of non-24/7 offenders
In summary, all three programs
 Give offenders simple, transparent rules, which
encourages responsibility and a sense of fairness
 Use swift, certain and modest consequences
 Mandate abstinence for all, treatment or prison only as
appropriate
 Have evidence of effectiveness and of cost-
effectiveness
Political Process
 Came to attention of Scottish VRU and London
Deputy Mayor
 Attracted Cross-Party interest in Parliament
 Passed as Amendment in House of Lords in March
 Law of the England and Wales as of May 1
What does the success of these programmes tell us
about drink problems?
 The Role of Treatment in Problem Resolution
 The Role of Self-Control in Drinking
 Can’t versus Won’t versus It’s Hard
Thank you for your attention!