The alcohol treatment needs of violent and non-violent prisoners

Practice The alcohol treatment needs of violent and non-violent prisoners N Bowes A Sutton S Jenkins FORENSIC PSYCHOLOGICAL SERVICES, NOMS CYMRU, HMP CARDIFF J McMurran INSTITUTE OF MENTAL HEALTH, UNIVERSITY OF NOTTINGHAM ABSTRACT In 2004, HM Prison Service launched an alcohol strategy that promotes treatment of alcohol-related problems in imprisoned offenders. In commissioning services for prisoners, the needs of any prison population must first be established. The purpose of this study was to establish the need for an alcohol intervention in a local prison and to explore whether there might be a need to address alcohol-related violence, rather than simply looking at alcohol misuse. The research identified the extent of the need for alcohol interventions in a UK prison for men, concluding that in this sample those who had also committed violent index offences might require interventions that specifically target alcohol-related violence. KEYWORDS AUDIT; alcohol-related violence; prisoners; treatment needs Introduction Alcohol is a known risk factor for violence, with evidence from epidemiological studies (Room & Rossow, 2001), longitudinal studies (Fergusson et al, 1996) and laboratory studies (Exum, 2006). The magnitude of the effect of alcohol as a violence risk factor depends on the person who is drinking, how much has been consumed and at what speed, and the context in which drinking occurs (McMurran, 2007a). Men but not women who are dispositionally aggressive are more likely to be aggressive at high doses of alcohol when they meet with a provocation (Hoaken & Pihl, 2000). Intoxication and provocation are both more likely to occur in social settings and, unsurprisingly, high rates of alcohol-related aggression are observed in and around drinking venues, especially where young men gather and drink heavily on week-end nights (Lang et al, 1995). Unsurprisingly, offender populations show high levels of alcohol consumption and a high incidence of alcohol-related problems. Using the Alcohol Use Disorders Identification Test (AUDIT; Babor et al, 2001) with prisoners in England and Wales, Singleton, Farrell and Meltzer (1999) identified 63% hazardous drinkers among male sentenced prisoners and 58% hazardous drinkers among male remand prisoners. This level of drinking is a concern not only with regard to physical and mental health problems (WHO, 2002a), but also 3

with regard to the risk of violence (WHO, 2002b). In 2004, HM Prison Service launched an alcohol strategy (HM Prison Service, 2004), with an accompanying Alcohol Treatment/Interventions Good Practice Guide (HM Prison Service & DH, 2004). These documents promote the idea of treating imprisoned offenders for alcohol-related problems, and indicate that the needs of any prison population must be established before delivering services,. The purpose of this study was to explore the level of need for alcohol interventions in a prison in Wales in which managers were interested in providing interventions for alcohol misuse. Guidance was also requested on whether the need was for programmes focusing on alcohol use only or a programme focusing on alcohol-related violence was required. The present research, therefore, aimed to investigate levels of harmful and hazardous drinking among offenders located in one Welsh prison and to determine whether there were differences in need between violent and non-violent offenders. Method Participants The participants were resident in a category B local prison, holding a maximum of 425 adult males (remand, convicted and sentenced). All men detained in the prison on 4th December 2007 were invited to participate in the study. Of the 425 questionnaires distributed, 92 (22%) were returned. Two participants were excluded due to missing data, so data from 90 participants was analysed (21%). Procedure Prison managers authorised the collection of data. Participants were informed of the purpose of the study and asked to complete the survey over the lunch time period, when a lock down occurs in the prison, allowing participants to complete the measures in private. Measures Participant information The participants were asked their age at the time of the index offence and whether or not their current offence was classified as violent (yes or no). If participants were unsure about classifying their offence, they were asked to state their offence(s) and these were then categorised by researchers. The Alcohol Use Disorders Identification Test (AUDIT; Babor et al, 2001) The AUDIT is a self-report screening test developed to identify hazardous drinking. There are 10 items, covering the quantity and frequency of drinking, control and adverse consequences. For this study, the instructions were modified to focus on drinking during the most recent period spent in the community prior to imprisonment. Each question is rated on a 5-point scale (0 4) and the total score ranges from 0 to 40, with a cut-off of 8 for harmful and hazardous drinking. Babor et al (2001) recommends that those scoring between 8 and 15 should be offered advice focusing on reducing hazardous drinking, those scoring between 16 and 19 should receive brief counselling, and those scoring over 20 require a specialist diagnostic evaluation for alcohol dependence. Analysis The data did not meet the criteria for parametric testing, and comparisons on the AUDIT between violent and non-violent groups were made using the Mann Whitney U test. Results Participants The mean age of the 90 participants at the time the index offence was committed was 30.35 years (SD = 11.65). When compared with the most recent demographic information, this was consistent with the prison s mean population age of 31.7 years (Bowes, 2007). Of the total sample, 42 participants reported their index offence as violent, 38 participants stated that their index offence was not violent and 10 participants omitted this item. The total mean AUDIT score for the sample was 16.56 (SD = 12.70), indicating that overall these prisoners are harmful or hazardous drinkers (Babor et al, 2001). Those with a violent index offence group scored higher (mean = 19.45, SD = 12.04) than those with a non-violent index offence (mean = 14.21, SD = 12.51), and this difference was almost significant (p =.056). Numbers and percentages of violent and non-violent offenders requiring no treatment (AUDIT score 0 8), advice (AUDIT score 9 15), counselling (AUDIT score 16 19) and specialist assessment (AUDIT score 20 40) are presented in Table 1, opposite. These distributions do not differ significantly (² = 5.19, df = 3, ns), suggesting that the proportio of offenders needing alcohol intervention does not differ by group; similar proportions of those who reported violent offences and those who reported nonviolent offences require help. Mean scores on individual AUDIT items are presented in Table 2, overleaf. Differences between 4

Table 1: Numbers and percentages of violent, non-violent and all offenders in each AUDIT category No treatment: Advice: Counselling: Specialist assessment: AUDIT score 0 8 AUDIT score 9 15 AUDIT score 16 19 AUDIT score -40 Non-violent 6 10 5 17 offenders (17%) (26%) (12%) (45%) (N = 38) Violent 16 9 3 14 offenders (39%) (21%) (8%) (32%) (N = 42) Total sample 22 19 8 31 (N = 80) (28%) (24%) (10%) (39%) offenders with violent and non-violent index offences are evident on items 2, 7 and 9. These findings, contrary to the total scores reported above, suggest that there were subtle differences between those who report violent offences and those who report non-violent offences. Violent offenders report drinking more on any one drinking occasion (2), which is consistent with evidence that acute intoxication is associated with violence (WHO, 2002b). Violent offenders reported more guilt and remorse after drinking (7), which is indicative of harmful alcohol use. Unsurprisingly, violent offenders also reported more injury to self or others after drinking (9). Discussion The results show that there is a need to address alcohol use among 73% of the prison population overall, and that about a quarter of the population could benefit from advice and 10% from counselling, while 39% require specialist assessment. The AUDIT may provide clinicians with a method of determining which type of intervention to offer and in what dosage, from simple information to more intensive and specialist interventions. A number of programmes are currently available in UK correctional services, including the Short Duration Substance Misuse Programme, the Alcohol Free Good Lives Programme, and the Control of Violence for Angry Impulsive Drinkers programme. Additionally, alcohol detoxification, Alcoholics Anonymous meetings and therapeutic communities for substance abusers are available in prisons. The AUDIT may help stream people into these interventions appropriately. These results suggest that there are few main differences overall between offenders whose offences are non-violent and those whose offences are violent; those who reported violent index offences drink more alcohol on any drinking occasion, but do not report drinking more than eight units on any drinking occasion. It may be that consuming eight units of alcohol is common among offenders, who are a heavy-drinking group, and so this cut-off does not discriminate violent from nonviolent offenders. Violent offenders in the sample tended to have more serious alcohol treatment needs, the total score of the AUDIT for those who reported violent offences rating higher (although not significantly: p = 0.057) than for those reporting non-violent offences. The violent offender group reported more injuries resulting from their use of alcohol than the non-violent group. Interestingly, AUDIT does not discriminate harm to others from harm to self in this item. The significant difference on this item between the groups suggests that the violent group are engaged in more risky behaviour, resulting in harm to self or others. Further exploration of this point might be beneficial, exploring whether engaging in such behaviour is related solely to alcohol consumption. The finding related to guilt about alcohol use may be important to consider when designing interventions. The experience of guilt may affect the approach an individual has to an intervention, perhaps leading to denial of a problem rather than being open to addressing it. This has implications for the strategies used to motivate violent offenders with alcohol problems into treatment. These results indicate specific issues that may need to be addressed in alcohol interventions with violent offenders, namely acute intoxication, the relationship between drinking and violence, and feelings about drinking and violent crime. 5

Table 2: Mean AUDIT item scores for violent and non-violent prisoners 1. How often did you have a drink containing alcohol? 2. On days when you drank, how many standard drinks containing alcohol did you usually have? 3. How often did you have EIGHT or more drinks on one occasion? 4. How often during that time have you found that you are not able to stop drinking once you have started? 5. How often during that time did you fail to do what was normally expected of you because of drinking? 6. How often during that time did you need a first drink in the morning to get yourself going after a heavy drinking session? 7. How often during that time did you have a feeling of guilt or remorse after drinking? 8. How often during that time were you unable to remember what happened the night before because of your drinking? 9. Have you or someone else been injured because of your drinking? 10. Has a relative or friend, or a doctor or other health worker been concerned because of your drinking or suggested that you cut down? Total Sample Violent Index Offence Non-Violent Index Offence Mann Whitney U 2.31 (1.49) 2.50 (1.38) 2.37 (1.53) 764.5 2.34 (1.52) 2.82 (1.30) 2.11 (1.56) 534.5* 2.13 (1.49) 2.39 (1.39) 1.97 (1.53) 656.0 1.64 (1.65) 1.78 (1.65) 1.54 (1.71) 690.0 1.55 (1.56) 1.76 (1.53) 1.3 (1.56) 639.0 1.17 (1.62) 1.36 (1.67) 0.89 (1.56) 679.0 1.18 (1.50) 1.50 (1.53) 0.82 (1.35) 588.0* 1.36 (1.51) 1.60 (1.55) 1.16 (1.48) 656.0 1.52 (1.66) 2.1 (1.67) 0.92 (1.46) 466.5** 1.71 (1.86) 2.05 (1.87) 1.32 (1.83) 604.5 Total score 16.56 (12.70) 19.45 (12.04) 14.21 (12.51) 601.0 standard deviations * p < 0.05 ** p< 0.01 Limitations There are several limitations of the present study that indicate caution in interpreting the results. Only self-reported index offence data was used to categorise offenders. Use of index offence is a useful method in practice, as it relates to recommendations in the sentence planning and intervention processes in the Criminal Justice System. However, future studies should include previous violence, as this might offer a more robust exploration of the link between an individual s alcohol use and violence. There are concerns related to the small sample size and the small proportion of respondents (21% of the total prison population). The data presented here may not be a representative sample of the whole prison population. Nevertheless, these data are comparable with findings of a study of 126 men in a different prison in Wales (McMurran, 2005). This sample gave a similar mean AUDIT score (17.36 cf 16.56) and 50% were identified hazardous drinkers, that is, scoring 16 or above on the AUDIT, equivalent to the sample reported here, where 49% scored 16 or more. The concordance between these studies suggests that the information presented here may be generalisable, at least to prisons in South Wales. Nevertheless, a more robust exploration those who have problems with alcohol-related violence and their specific treatment needs is required. Conclusion This research identifies the extent of need for 6

alcohol interventions in one UK prison for men. Three-quarters of the population require advice, counselling or specialist assessment. Half of them are violent offenders who may require interventions that specifically target alcohol-related violence. The Good Practice Guide (HMPS/DH, 2004) lists a range of assessments and effective treatments that form the basis of a model treatment framework. Given the level of need, it is important to work towards making the model treatment framework a reality. Implementation of interventions to address alcoholrelated violence is clearly required. Bullet list of implicaitons for practice to come.. Address for correspondence N Bowes Forensic Psychological Services NOMS Cymru HMP Cardiff Knox Road Cardiff CF240UG References Babor TF, Higgins-Biddle JC, Saunders JB & Monteiro MG (2001) AUDIT: The Alcohol Use Disorders Identification Test. Geneva: World Health Organisation. Bowes N (2006, unpublished) Demographic Evaluation Report. HMPS Wales Area Psychological Services. Elliott DS, Huizinga D & Ageton SS (1985) Explaining Delinquency and Drug Use. Newbury Park, CA, USA: Sage. Exum ML (2006) Alcohol and aggression: an integration of findings from experimental studies. Journal of Criminal Justice 34 131 45. Fergusson DM, Lynskey MT & Horwood LJ (1996) Alcohol misuse and juvenile offending in adolescence. Addiction 91 483 94. Gustafson R (1986) Alcohol and Human Physical Aggression: The mediating role of frustration. Uppsala, Sweden: University of Uppsala. HM Prison Service (2004) Addressing Alcohol Misuse: A Prison Service alcohol strategy for prisoners. London: HM Prison Service. HM Prison Service/Department of Health (2004) Alcohol treatment/interventions: Good practice guide. London: HM Prison Service Drug Strategy Unit. Josephs RA & Steele CM (1990) The two faces of alcohol myopia: attentional mediation of psychological stress. Journal of Abnormal Psychology 99 115 26. Lang E, Stockwell T, Rydon P & Lockwood A (1995) Drinking settings and problems of intoxication. Addiction Research 3 141 9. McMurran M (2005) Drinking, violence, and prisoners health. International Journal of Prisoner Health 1 25 9. McMurran M (2006) Controlled drinking goals for offenders. Addiction Research and Theory 14 59 65. McMurran M (2007a) Alcohol and aggressive cognition. In: TA Gannon, T Ward, AR Beech & D Fisher (Eds) Aggressive Offenders Cognition: Theory, research and practice. Chichester: Wiley. McMurran M (2007b) What works in substance misuse treatments for offenders? Criminal Behaviour and Mental Health 17 225 33. O Boyle M & Barratt ES (1993) Impulsivity and DSM-III personality disorders. Personality and Individual Differences 14 609 11. O Donnell J, Hawkins JD & Abbott RD (1995) Predicting serious delinquency and substance use among aggressive boys. Journal of Consulting and Clinical Psychology 63 529 37. Pernanen K (1991) Alcohol in Human Violence. Guilford. Pihl RO & Hoaken PNS (1997) Clinical correlates and predictors of violence in patients with substance use disorders. Psychiatric Annals 27 735 40. Singleton N, Farrell M & Meltzer H (1999) Substance Misuse among Prisoners in England & Wales. London: Office for National Statistics. Room R & Rossow I (2001) The share of violence attributable to drinking. Journal of Substance Use 6 (4) 218 28. WHO (2002a) Reducing Risks, Promoting Healthy Life. Geneva: World Health Organisation. WHO (2002b) World Report on Violence and Health. Geneva: World Health Organisation. Hoaken PNS & Pihl RO (2000) The effects of alcohol intoxication on aggressive responses in men and women. Alcohol and Alcoholism 35 471 7. 7