Rapid evidence review: Alcohol interventions and the criminal justice system

This review sought to identify, screen, and review peer-reviewed journal articles published between 2000-2019 that report alcohol outcomes from interventions seeking to reduce alcohol use as a primary or secondary objective. Interventions were delivered within the criminal justice system (CJS) or to people accused of, or sentenced for, crimes.

Abbreviated sets of search terms were entered into two search engines (PubMed and PsycInfo). Searches sought to identify interventions delivered at five points within the CJS:

1. Pre-arrest, arrest, and police custody;
2. Courts and sentencing;
3. Probation and parole;
4. Prison; and
5. Resettlement and aftercare.

The search strategy was iterative, evolving as searches progressed. Identified gaps led to the addition of a sixth domain:

6. Offence- and offender-focused interventions.

Due to the distinctive needs of women and young people, data for these two groups were extracted (and are reported) separately. After duplicates were removed 4,901 titles and 701 abstracts and full-texts were screened. Five systematic reviews were also reference-mined to identify studies of potential relevance. The state of the current evidence base is assessed with reference to 48 papers from 44 comparative studies. Only studies with comparison groups are reviewed in the main body of this report¹.

A descriptive synthesis of evidence was planned, informed by the findings of other recent reviews which have identified studies using heterogeneous outcome measures applied to heterogeneous interventions. In this context, meta-analysis would be impossible; this expectation proved well-justified.

Overview

This review identified a lack of substantial, robust and consistent evidence relating to reductions in alcohol use from any intervention type of any intensity delivered to any group at any stage of the CJS. This noted, a handful of robust evaluations identified treatment effects in some interventions. These included:

• Collaborative behavioural management (probation; men and women);
• Automated telephone risk assessments (probation);
• Motivational interviewing as an adjunct to domestic violence programmes (courts);
• Judicial supervision (drug courts);
• Acceptance and Commitment Therapy (women’s prisons)
• Therapeutic communities (prisons); and
• Dialectical behavioural therapy (women, post-release).

These were isolated examples. Each was supported by just one or two evaluations, sometimes conducted in the same setting and by the same research team². However, they may indicate promising directions for future interventions and research.

Additionally, a larger proportion of papers reporting outcomes for women offenders (as opposed to those reporting on men, young people, or amalgamated mixed-gender cohorts) identified positive treatment effects. The two mixed-gender studies that reported women’s outcomes separately³ also reported that women made greater alcohol-related treatment gains than men. This suggests that gender may be important.

This review also identified examples of interventions less frequently associated with positive treatment outcomes, based on a larger body of evidence:

• Brief interventions (<3 hours of face-to-face psychosocial intervention) were evaluated by twelve studies. Three (25%) reported clear and substantive reductions in alcohol use.
• Motivational interviewing underpinned thirteen interventions. Four (31%) were associated with clear and substantive reductions in alcohol use.

For most other types, intensities, and durations of intervention, closer to half of all publications reported clear and substantive reductions in alcohol use.

Risks of bias

Studies’ assessed risk of bias did not appear to play an appreciable part in distorting reviewed findings:

• 56.5% of studies with a low risk of bias (13 of 23) reported no effects.
• 50.0% of papers with a moderate risk of bias (5 of 10) reported no effects.
• 54.5% of papers with a high risk of bias (6 of 11) reported no effects.

No appreciable patterns of bias likely to affect the conclusions of this review could be found in any reviewed area, for any reviewed group, or for any kind of intervention of any duration.

Stages of the criminal justice system

No substantial, robust and consistent evidence could be found for interventions delivered in any stage of the CJS.

1. Two papers evaluating interventions within, or arising from, police custody focused on different initiatives. Their findings are inconclusive.
2. Twelve papers evaluated a wide range of initiatives based in court or delivered as a sentencing option. As a body of reviewed evidence, these publications provide little support for any particular treatment approach. However, a handful of studies indicate there may be value in further evaluations of judicial monitoring in drug courts and alcohol interventions appended to domestic violence interventions.
3. Sixteen papers evaluated a range of psychosocial approaches to prison treatment. As a body of reviewed evidence, these publications provide little support for any particular treatment approach. However, two studies (conducted in one setting) indicate there may be benefit in further evaluations of therapeutic communities.
4. Ten papers evaluated a range of (predominantly case management) interventions within the probation or parole setting. As a body of reviewed evidence, these publications provide little support for any particular treatment approach. However, two robust evaluations suggest potential benefits in further evaluations of automated telephone risk assessments and collaborative behavioural management.
5. Four papers evaluated resettlement or aftercare interventions. Their findings are inconclusive.
6. Three papers evaluated interventions engaging people at any stage, or at nonspecific stages, of the CJS. Their findings are inconclusive.

Young people

No substantial, robust and consistent evidence could be found for interventions delivered to young people.

• Four papers reported on interventions for young people. They approach heterogeneous interventions. Their findings are inconclusive.

Women

No substantial, robust and consistent evidence could be found for interventions delivered to women.

• Twelve papers reported on interventions for women or reported women’s outcomes separately. They approach highly heterogeneous interventions and, taken as a body of reviewed evidence, provide little support for any particular treatment approach.
• However, a handful of studies point to potential benefits in conducting further evaluations of acceptance and commitment therapy (prisons), dialectical behavioural therapy (resettlement) and collaborative behavioural management (probation).

Additionally, studies that engaged both men and women were reviewed as men’s interventions. This may mask additional gendered effects: just two of the ten evaluations that only engaged men identified clear and consistent treatment effects, with seven identifying none. (See section 8. Women, for details). Succinctly, then, it appears that gender may play a significant in alcohol interventions within the CJS.

Types of intervention

No substantial, robust and consistent evidence could be found for any broad category of intervention (e.g., pharmacological or psychosocial):

• Papers reporting on interventions categorised as case management, pharmacological, practical and psychosocial were divided in roughly equal proportions between those identifying treatment effects, and no treatment effects.
• None of the papers reporting on (a diverse set of) sentencing options (N=3) or practical resettlement support (N=3) reported positive outcomes.

Specific model of intervention

No substantial, robust and consistent evidence could be found for any theoretical framework structuring an intervention; though a preponderance of papers identified no effects arising from motivational interviewing.

• Fourteen papers reported on interventions structured according to the principles of motivational interviewing. A majority (7 out of 13) identified no treatment effect, and two more reported predominantly ‘no effect’ findings.
• No other approach was evaluated by more than three studies.

Intensity of intervention

No substantial, robust and consistent evidence could be found for any theoretical framework structuring an intervention; though a preponderance of papers identified no effects arising from brief interventions.

• Twelve articles evaluated brief interventions. Of these, 7 (58.3%) identified no effects and 2 (16.7%) reported predominantly ‘no effect’ findings.
• All other varieties of treatment intensity (moderate, high, constant and long-term, variable) were divided in roughly equal proportions between identifying treatment effects, and no effects.

Motivational interviewing and brief interventions

The preponderance of ‘no effect’ motivational interviewing and brief intervention papers did not appear to be directly related. Five of 9 brief MI interventions (45%), and 3 of 5 longer interventions (60%), reported no effects.

To mix metaphors, this review has identified some potentially promising seeds amidst a generally muddy canvas. Some approaches, evaluated by a handful of studies, offer some promise. However, the papers reporting them were all too often derived from just one study, just one setting, or just one research team. Other interventions or approaches were evaluated somewhat more but appear less promising. This was particularly the case for interventions focused exclusively on men; brief interventions; and interventions based on motivational interviewing.

A core challenge in identifying treatment effects is the heterogeneity of reviewed studies. Few approaches have been repeatedly implemented and evaluated in a way that permits treatment effects for alcohol use to be identified. Newbury-Birch et al. (2016; 2018) note that this is partly due to the difficulties of following up imprisoned cohorts following release, and this is clearly true of prison-based interventions. However, interventions in other contexts and domains evidenced similar difficulties.

Whilst acknowledging these difficulties, some recommendations can be made regarding research.

• Firstly, women’s outcomes should be reported. Female offenders and treatment seekers differ from men in terms of their needs (e.g. Corston, 2007; Covington, 2011) and treatment outcomes (e.g. Grace, 2017; Kennedy et al., 2012:56). In this review, 19 of 21 mixed-sex studies reported no women’s outcomes. This creates a real gap in research knowledge.
• Secondly, there is potential for a review of the impact of alcohol interventions on offending outcomes. 285 papers were excluded from this review because they reported no alcohol outcomes. Many of these instead drew on routinely collected offending data. Whilst this was beyond the reach of this study, these papers have the potential to add significantly to understandings of the relationship between alcohol and crime, and the social benefits of alcohol interventions within the CJS.
• Thirdly, the lack of treatment effect for men identified in this review would benefit from more attention.

This review also supports two recommendations for policy and practice.

• Firstly, many offenders have very high levels of need. Those leaving prison – even from intensive treatment programmes – may be facing imminent homelessness (e.g. Lloyd et al., 2017). In this context, it is perhaps unsurprising that brief interventions may struggle to deliver substantive outcomes (Newbury-Birch et al., 2018). A clear fit between needs and treatment intensity has the potential to pay dividends; but delivering light-touch interventions to seriously marginalised populations may be optimistic.
• Secondly, interventions within this review mostly targeted a single stage of the CJS. Few interventions followed an individual as they progressed through the CJS, and even fewer followed them for a considerable period of time. This can create a ‘cliff-edge of support’ on release (Lloyd et al., 2017). There may be real benefit in designing interventions that meaningfully follow individuals over the course of a treatment journey, even if this involves working through across multiple stages of the CJS (see, for example, Olson and Rozhon, 2011).

1 When searches were first conducted, a decision was made to include studies with no comparison group to secure a broader overview of the literature and of interventions / evaluations being delivered. As the review progressed, it became apparent that studies with no comparison group could not meaningfully be included in any synthesis of findings that described the efficacy of treatment. The risks of bias are too great. To this end, only comparative studies are reported on in the main body of this report. However, studies with no comparative element are descried in Appendix 3, and all studies are described in the narrative summary of papers (Appendix 4). These sections include reports on 18 additional papers from 17 additional studies.
2 E.g., Therapeutic communities were evaluated by three publications arising from two studies in the same setting (Sullivan et al., 2000; McKendrick et al., 2006; Van Stelle et al.);
3 Polcin et al., 2018; Friedman et al., 2011; Johnson et al., 2011.