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Motivation from Without

Motivation from Without. Keith Humphreys Professor of Psychiatry, Stanford University Visiting Professor of Psychiatry, King’s College London Research Career Scientist, VA Health Care System knh@stanford.edu. Presented at 2012 NDASG, Llandrindod Wells, Wales.

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Motivation from Without

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  1. Motivation from Without Keith Humphreys Professor of Psychiatry, Stanford University Visiting Professor of Psychiatry, King’s College London Research Career Scientist, VA Health Care System knh@stanford.edu Presented at 2012 NDASG, Llandrindod Wells, Wales

  2. 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

  3. Johnny, if you don’t clean up your room right now there is a 40% chance that a month from now, I will ground you for two years! Criminologist James Q. Wilson’s analogy for how we respond to criminal offenders

  4. New paradigm

  5. Exemplars of the New Paradigm • Physician Health Plans • HOPE Probation • 24/7 Sobriety

  6. 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

  7. 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

  8. 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.

  9. The World of Probation • Low social capital offenders • More serious co-occurring problems • Overwhelmed staff • Unclear rules, inconsistent rewards and punishments

  10. HOPE Probation for Drug-involved 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

  11. 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

  12. 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.

  13. 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

  14. 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 arrestand certain, modest punishment (1 night in jail) • Nearly self-sustaining financially because offenders pay for own testing

  15. Alcohol-Impaired Motor Vehicle Fatalities/Vehicle Miles Traveled Source: U.S. National Highway Safety and Transportation Agency

  16. 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

  17. 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

  18. 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

  19. 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

  20. Thank you for your attention!

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