Criminal justice referrals constitute a large proportion of admissions to substance abuse treatment facilities in the United States. During 1998, for example, 45 percent of admissions to treatment solely for an alcohol use disorder originated as referrals from the criminal justice system (SAMHSA, 2000).

Individuals who are arrested for driving while intoxicated (DWI) or driving under the influence (DUI) accounted for roughly one-quarter of those referred to alcohol treatment from criminal justice sources (SAMHSA, 2000). In addition, an unknown but probably large number of individuals refer themselves to treatment in anticipation of court proceedings for a pending DWI or DUI.

Clients who are referred to alcohol treatment following a DWI pose unique challenges for treatment professionals. Such clients may be disinclined to admit problems or to consider behavior change (Lincourt, Kuettel, & Bombardier, 2002). Many are angry about being ordered by the court to receive a substance abuse evaluation and are fearful of the consequences they would face for failing to comply with the treatment provider’s recommendations.

A significant proportion of DWI offenders do not meet standard diagnostic criteria for alcohol abuse or alcohol dependence (Stasiewicz, Nochajski, & Homish, submitted) but may be thought of as problem drinkers, in that they have either experienced negative consequences of their drinking or drink in ways that increase their risk of experiencing such consequences (Sobell & Sobell, 1993).

Evidence indicates that brief interventions are as effective as longer-term treatments for individuals with less severe alcohol problems (Zweben & Fleming, 1999). Thus, problem-drinking DWI offenders may be ideally suited for brief interventions targeted at increasing motivation to change drinking behavior that puts them at risk for experiencing future alcohol-related problems, including DWI recidivism. In this article, we describe an approach to working with DWI offenders that is consistent with the principles of motivational interviewing — a brief intervention that has been found to be effective in bringing about change in people with alcohol problems, including alcohol-abusing criminal offenders (Miller & Rollnick, 1991; 2002).

Motivational interviewing
Motivational interviewing (MI) involves the application of a set of therapeutic methods designed to enhance clients’ intrinsic motivation to change by helping them explore and resolve ambivalence (Miller & Rollnick, 2002). These methods include open-ended questioning, reflective listening, and use of affirmations, summarizing the client’s comments as they pertain to behavior change, and evoking “change talk.” The skillful application of these methods helps to create a therapeutic approach that is empathic, collaborative, and aims to elicit (or evoke) the client’s intrinsic motivation for change. Thus, MI stands in contrast to existing assessment and treatment approaches for DWI offenders, which tend to be more educative, less collaborative, and less likely to focus on eliciting the client’s motivation for change (Wells-Parker, Bangert-Drowns, McMillen, & Williams, 1995).

Efficacy of motivational interviewing with criminal justice populations
Recent studies have evaluated the use of MI as an intervention designed to address substance use in mandated clients (Lincourt et al., 2002) and domestic violence offenders (Easton, Swan, & Sinha, 2000). In addition, the intervention has been evaluated with substance-abusing clients in probation settings (Harper & Hardy, 2000) and in correctional settings (Ginsburg et al., 2002; Stein & Lebeau-Craven, 2002).

In a single-case study design, Mann & Rollnick (1996) evaluated the use of motivational interviewing with a non-substance abusing sex offender. In these studies clients who received MI had higher rates of treatment attendance and completion (Lincourt et al., 2002); increased motivation to take steps to change their substance use (Easton, Swan, & Sinha, 2000); greater rates of alcohol-problem recognition (Ginsburg, Weekes, Boer, & Moser, 2001); and rated MI more favorably than standard care (Stein & LeBeau-Craven, 2002). Collectively, the studies reviewed above suggest that MI is an efficacious approach to treatment for alcohol and other drug problems, and that MI may be useful in work with offender populations. In this article, we present our experiences developing and implementing a MI-style feedback session to be used by clinicians who perform substance abuse evaluations with DWI offenders.

In adapting MI for use with DWI offenders, we have focused on addressing change both in criminal behavior (e.g., driving while intoxicated) and in substance use behavior (e.g., overall frequency of heavy drinking). Thus, our first goal has been to give clients the opportunity to examine factors that potentially could increase their risk of driving while intoxicated and/or being arrested again for DWI. Our second goal has been to increase the extent to which clients who engage in harmful patterns of alcohol use feel concerned about those patterns and feel motivated to make a change in their drinking behavior. For those clients identified by our comprehensive assessment as having a more serious current problem with alcohol, a third goal has been to utilize MI to facilitate their engagement in more intensive treatment.

Many brief interventions involve providing feedback to individuals in order to promote health behavior change. The most widely used approach related to motivational interviewing is one in which the client is given feedback based on individual results from standardized assessment measures (e.g., Drinker’s Check-Up; Miller, Sovereign, & Krege, 1988). A key purpose of providing feedback is to facilitate the development of discrepancy and/or the making of comparisons that promote behavior change (DiClemente et al., 2001).

The MI-based feedback session used in our project contains four major sections that occur sequentially: opening statements; eliciting information/developing discrepancy; presentation of feedback; and future directions. Below, we address each section separately and provide examples of client-therapist dialogue to illustrate how therapeutic goals are met using an MI-style framework.

The therapist has two main goals during the initial phase of the session — first, to clear up any misconceptions or concerns the client may have about the therapist acting as an agent of the court; and second, to anticipate and minimize any inclination toward resistance that the client is likely to bring in to the session.

With regard to the first goal, it is important to inform the client about the type of information that will be shared with the referring agency (U.S. Department of Health and Human Services, 1999). The therapist provides the client with accurate information regarding the relationship between the treatment agency and the court, and lets the client know what type of information will be released (e.g., need for treatment, treatment completion). In addition, the therapist informs the client that any information released must be accompanied by a written consent for release of information that adheres to federal confidentiality regulations. Finally, the therapist ensures that the client understands the choices that he or she has regarding the information to be released and the consequences (if any) of those choices (e.g., risk of non-compliance with a court mandate).

Although a motivational interviewing perspective acknowledges that the therapist plays a role in eliciting client resistance, we have observed many DWI offenders who “walk in the door” with high levels of resistance, for reasons discussed above. Therefore, our second goal during the opening phase of the situation is to initiate rolling with the resistance. That is, rather than waiting for the client to express resistance behavior, the therapist opens with an empathic statement that essentially reflects several of the most common resistance statements encountered when working with DWI clients. These points of resistance are offered as possible topics for discussion during the feedback session, and as a way to express empathy by giving the client the feeling that the therapist has some understanding of the client’s experience with receiving a DWI.

This is an adaptation of the “agenda setting” approach of behavior change counseling, in which clients are provided with a menu of options to choose from that includes topics of importance for discussion (Rollnick, Mason & Butler, 1999). Beginning the session this way (i.e., rolling with resistance from the outset) serves three important purposes: it gives the client a sense of control by providing him or her with the opportunity to choose the initial topic of discussion; it establishes rapport by acknowledging some of the experiences the client has been through; and it provides an opening for the client, rather than the therapist, to initiate discussion of key topics (e.g., negative consequences experienced; the client’s view of his or her drinking), thus reducing the risk of resistance. This way, the therapist brings up possible points of resistance and rolls with them. Consistent with the spirit of MI, this strategy is both client-centered and directive, and encourages the client to take control of the topic. A sample statement is provided below:

Therapist: There are probably a lot of things we could talk about today, such as the legal consequences of receiving the DWI, the inconvenience and expense it has caused, the way society portrays a person who gets a DWI, or the idea that getting a DWI means that you have an alcohol problem. These are a few of the things that other people who have received a DWI have experienced. What has this experience has been like for you?

In response to this open-ended question, clients will usually mention the inconvenience (i.e., the expense, loss of license, loss of work) and/or embarrassment of receiving the DWI. Others may minimize the experience or be reluctant to comment or provide additional information. By initially taking the focus off the client’s alcohol consumption and placing it on the person’s experience with the DWI, we strive to validate the client’s experience. This opening statement also demonstrates to clients that the therapist is not trying to change them, tell them what to do, or place restrictive demands upon them. By approaching client resistance in this way, we have found that the client usually will make the first direct statement about alcohol consumption. Once this happens, the therapist is free to inquire about alcohol consumption with less danger of eliciting client resistance, because the topic already has been introduced by the client.

Eliciting Information/Developing Discrepancy: During this phase of the feedback session, the therapist elicits information from the client about the day of the arrest. The discussion focuses on the client’s alcohol consumption that day, and on the events leading up to the arrest.The two main goals of this phase are to understand the client’s view of the DWI (e.g., reasons for drinking more than usual or for making the decision to drink and drive) and to begin developing a discrepancy between the client’s perceived level of risk involved with drinking and driving and the actual risk involved.

By eliciting information from the client about the day of the DWI arrest, the therapist gradually introduces the idea to the client that there may have been risks that the client was unaware of that contributed to the DWI. For example, the therapist may begin to develop a discrepancy between the client’s subjective feeling of not being intoxicated and the client’s awareness that his or her blood alcohol level rises above the threshold for DWI during a typical night of drinking.

Presentation of Feedback: As discussed earlier, motivation for change may increase when people perceive a discrepancy between their current behavior and important personal goals. Personal feedback of results from objective assessment measures can contribute to helping clients realize they are not where they want to be with regard to their drinking or risk for DWI. The process of providing feedback also permits the elicitation of self-motivational statements that reflect the client’s intentions to change. In the project described herein, personalized feedback included information about the client’s alcohol use, risk for developing an alcohol problem, and risk for DWI recidivism.

The general approach to providing feedback is to provide each client with his or her own Personal Feedback Report (PFR), which includes the client’s scores on a set of measures related to the problem area (in this case, drinking and risk for recidivism). Each score is accompanied by an explanation, as well as a comparison of the client’s score with normative data or some other interpretive information. The therapist hands the client a copy of his or her PFR along with a pamphlet designed to help the client understand his or her own PFR (see Miller et al., 1995, for examples of PFR-related materials).

When working with DWI offenders, our basic approach is to help the clients understand what the assessment results mean and to elicit their reactions to the information. The therapist frames the feedback as new information that may be useful in helping the client evaluate his or her risk for the development of an alcohol problem and for receiving another DWI. The therapist specifically avoids using the information to “prove” that the client has an alcohol problem or to pressure the client to accept some prescribed course of action. The therapist reviews each section of the PFR and provides the information necessary to help the client understand what his or her score means.

The PFR includes information about the client’s alcohol consumption, blood alcohol concentration (BAC) for the heaviest day of drinking during a typical week, and the person’s level of risk for developing an alcohol problem and for DWI recidivism. With regard to risk for developing an alcohol problem, the PFR focuses on three factors: tolerance level, other drug use, and family history of alcohol problems. Higher levels on any of these factors indicate an increased risk. With regard to risk for DWI recidivism, the PFR focuses on two factors: the person’s score on the Research Institute on Addictions Self-Inventory (RIASI, Nochajski et al., 1995), a self-report measure that has been found to predict DWI recidivism; and the person’s number of prior DWI arrests. Higher scores on either of these two indicators are associated with a greater risk of receiving a future DWI offense.

Following the presentation of the feedback, the therapist summarizes key information. An example of a summary statement is provided below.

Therapist: So we have talked about factors that put people at higher risk for experiencing future alcohol-related problems, such as receiving another DWI. Factors that increase your risk include an inability to trust how intoxicated you feel, unsafe levels of alcohol consumption, and your comfort level with taking risks. It seems like you’re starting to look at things a little differently now. What are your thoughts at this point?

Client: Well, before I came here, I didn’t think that my drinking was putting me at risk for getting a DWI. It would be really hard to give up drinking, but I don’t want to go through this again. Is there something else I could do?

In this example, the therapist focuses on those factors that increase the client’s risk for experiencing future alcohol-related problems. The intention is to increase the client’s motivation to take steps to reduce his/her level of risk. The client’s response opens the door for the therapist to review ways for the client to reduce the risk of experiencing future harmful consequences related to drinking. In the last phase of the feedback session the therapist focuses the discussion on the future and on steps that the client can take to reduce the risk of harmful, alcohol-related consequences.

Future Directions: The first step in making the transition to discussing the client’s future plans is to summarize the individual’s current situation. The therapist pulls together the client’s reasons for thinking he was at low risk prior to the DWI and what the client has since learned about personal characteristics that put him/her at a higher level of risk for experiencing future problems.

Therapist: We have spent time looking at perceived risk and actual risk and it sounds like you have learned some new information about your level of risk that you may not have been aware of before. Looking forward, how might this new information affect your decisions about drinking and driving?

Client: Well, I won’t drive after drinking again.

Therapist: Not driving after you have had any amount of alcohol would eliminate the risk of another DWI. What might you do differently if, in the future, you found yourself in a situation similar to the one that preceded your DWI arrest?

The therapist’s question leads to a discussion about what the client could do differently in future drinking situations. The client’s discussion of plans to make specific changes allows the therapist to support the client’s self-efficacy. It can be helpful for the therapist to structure this discussion by asking some specific questions aimed at eliciting details of the client’s plan for reducing the risk of future alcohol-related problems. This process is similar to that of completing a Change Plan Worksheet with the client (see Miller, Zweben, DiClemente, & Rychtarik, 1995) and is useful in helping to clarify the client’s plan for change and the perceived consequences of changing or not changing. During this process, the therapist can give voice to the inclination a client might feel to drink in certain risky situations and can, thus, give the client an opportunity to reaffirm his or her commitment and intention to change.

It is important to note that the client’s plan for reducing risk may include additional treatment for an alcohol problem. Ideally, such decisions would be made by the client after receiving personalized feedback about his or her alcohol use and alcohol-related problems. However, with certain individuals, the therapist may need to advise the participant about the benefits of additional treatment if he/she appears not to be deciding in that direction. This must be conducted in a persuasive, but not coercive manner, consistent with the overall spirit of MI. (i.e., “It is your choice, of course. I want to tell you, however, that I’m worried about the choice you’re considering, and if you’re willing to listen, I’d like to tell you why I’m concerned ...”)

When making a treatment referral, the client may become defensive or resistant. Should this occur, the therapist may address the resistance using one or more MI strategies (e.g., roll with resistance).

Conclusion
The material presented in this article addresses an important individual and societal need — namely, to reduce the harmful consequences of alcohol use, including recidivism, in convicted DWI offenders. As mentioned earlier, DWI offenders may be disinclined to admit problems or to consider behavior change. In our clinical research program, we found the principles of MI (i.e., express empathy, develop discrepancy, roll with resistance, support self-efficacy) to be well-suited to guiding our work with DWI offenders. By applying these principles, we found clients were less resistant and more open to receiving information about ways to reduce their risk of recidivism.

We also found it useful for the therapist to put aside any preconceptions that he or she may have about the characteristics of people who receive DWIs, to recognize that DWI offenders are very sensitive to being labeled as problem drinkers, and to focus on the client’s perception of the DWI as an atypical event which has resulted in extremely inconvenient consequences. Importantly, we capitalize on the client’s motivation to avoid another DWI, and use the feedback session to increase the client’s awareness of factors that increase the risk for future alcohol-related problems. By developing discrepancy between the client’s perception of risk and a more accurate appraisal of the risk involved, the intention is to increase the client’s motivation to change risky alcohol consumption. The procedures described in this paper also serve to “prepare” DWI offenders for additional alcohol treatment, if the counselor determines that such treatment is needed.

Preliminary data from our clinical research program demonstrate the feasibility and acceptability of the MI approach and suggest that the intervention influenced several key target behaviors. For example, 99 percent of participants completed both sessions, and based on the treatment acceptability ratings; 25 percent found the MI feedback session “somewhat helpful”; 48 percent found it “very helpful”; and 18 percent found it to be “one of the most helpful sessions” Following the feedback session, 65 percent of participants reported feeling “fairly motivated” or “very motivated” to make a change in their drinking behavior.

At an 18-month follow-up interview, DUI recidivism rates derived from official records were quite low, with only three offenders (3.1 percent) rearrested since the initial assessment. This figure compares favorably to the results of two other investigations of rehabilitation outcome, both conducted in New York State, which reported rates of DWI recidivism to be more than double (7 percent) those found in our sample (Dowling & McCartt, 1990; Nochajski, 1999).

Although the results from a test of our MI-based feedback session are encouraging, an evaluation of the relative effectiveness of this intervention is needed. In the meantime, we have shared our experience in the hope that others will try out the MI approach with DWI offenders and other criminal justice populations.

Paul Stasiewicz, PhD (stasiewi@ria. buffalo. edu) is a Senior Research Scientist and Clinic Director at the Research Institute on Addictions, University at Buffalo, The State University of New York.

David Herrman, MSW is a therapist in the chemical dependency outpatient program at Buffalo General Hospital.

Thomas Nochajski PhD (tnochajs@ria. buffalo.edu) is an Associate Professor in the Deparment of Social Work at the University at Buffalo, The State University of New York.

Kurt Dermen PhD (Dermen@ria. buffalo.edu) is a Senior Research Scientist at the Research Institute on Addictions, University at Buffalo, The State University of New York.

Acknowledgement:
We wish to thank therapists, Sam Gonzalez, Terri Jandzinski, Beth Kogut, and Eugenia Riollano, for their valuable input throughout the treatment phase of this project.

References
DiClemente, C. C., Marinilli, A. S., Singh, M., & Bellino, L. E. (2001). The role of feedback in the process of health behavior change. American Journal of Health Behavior, 25, 217-227.
Dowling, A. M., & McCartt, A. T. (1990). Evaluation of the New York State drinking driver program. Report submitted to the New York State Department of Motor Vehicles.
Easton, C., Swan, S., & Sinha, R. (2000). Motivation to change substance use among offenders of domestic violence. Journal of Substance Abuse Treatment, 19, 1-5.
Ginsburg, J., Mann, R., Rotgers, F., & Weekes, J. (2002). Motivational interviewing with criminal justice populations. In W. R Miller and S. Rollnick (Eds.) Motivational Interviewing: Preparing People for Change (333-346). New York: Guilford Press.
Ginsburg, J., Weekes, J. R., Boer, D. P., & Moser, A. E. (2001). Motivational interviewing: Enhancing treatment readiness in alcohol-abusing offenders. Poster presented at Annual Convention of the American Psychological Association, San Francisco, CA.
Lincourt, P., Kuettel, T. J., & Bombardier, C. H. (2002). Motivational interviewing in a group setting with mandated clients: A pilot study. Addictive Behaviors, 27, 381-392.
Mann, R. E., & Rollnick, S. (1996). Motivational interviewing with a sex offender who believed he was innocent. Behavioural and Cognitive Psychotherapy, 24, 127-134.
Harper, R., & Hardy, S. (2000). An evaluation of motivational interviewing as a method of intervention with clients in a probation setting. British Journal of Social Work, 30, 393-400.
Miller, W. R. & Rollnick, S. (1991). Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press.
Miller, W. R. & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change. New York: Guilford Press.
Miller, W. R., Sovereign, R. G., & Krege, B. (1988). Motivational interviewing with problem drinkers: II. The Drinker’s Check-up as a preventive intervention. Behavioural Psychotherapy, 16, 251-268.
Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1995). Motivational enhancement therapy manual: A clinical research guide for therapists treating individual with alcohol abuse and dependence. (Project MATCH Monograph Series, Volume 2). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.

This article is published in Counselor,The Magazine for Addiction Professionals, February 2006, v.7, n.1, pp.26-32.

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