Alcohol use is widespread and ingrained in Australian culture, featuring in almost every element of life. Australian culture celebrates excessive alcohol consumption, which is a key contributor to antisocial behaviour in Australian society and plays a clear role in street violence, dangerous driving, family violence, assaults, injuries and accidents (Morgan & McAtamney, 2009).
Governments in Australia are acutely aware of the harms caused by alcohol-related violence and are implementing a range of strategies to address this. Some of these include reducing alcohol availability, tighter licensing and controls, alcohol taxes, cultural change programs, education, harm minimisation and alcohol-related violence treatment programs. Psychologists have a role to play in reducing alcohol-related violence across these strategies, but are particularly critical to the development of behaviour change and treatment programs.
Understanding alcohol-related violence
There is a clear association between alcohol consumption and violent behaviour, however the majority of people who drink alcohol do not become violent (McMurran et al., 2006). Underpinning alcohol-related violence is a complex interaction of factors that are different for each individual and possibly for each violent event (Norstrom & Pape, 2010). Room and Rossow (2001) argue that the degree of intoxication is more significant than overall consumption, and McMurran (2012) found that binge drinkers are more likely to engage in aggressive or violent behavior than dependent drinkers.
There is some evidence that reducing alcohol consumption alone is not the most effective way to reduce alcohol-related aggression and that treatment needs to target the full range of factors at play. These additional factors include:
- Pharmacological effects of alcohol on the cognitive functioning of the drinker, including disinhibition alongside an impaired ability to read and appropriately respond to social cues
- Context in which the alcohol is consumed
- Provocation
- Exacerbation of trait aggression
- Alcohol-related expectancies, i.e., those who believe alcohol makes them more aggressive become more aggressive
- Type of alcohol consumed
- Combining of alcohol with energy drinks.
The ADAPT program
The Alcohol Driven Aggression Psycho-educational Treatment (ADAPT) program is a Victorian government initiative, overseen by the Department of Justice. The program was funded through the Victorian Alcohol Action Plan (VAAP 2008-2013) and targets offenders on community-based orders that have been charged with an alcohol-related violent offence, usually assault. Caraniche, a private psychological consulting firm that specialises in offending behaviour change, was contracted to develop and deliver the program across Victoria.
ADAPT is a 40-hour co-facilitated group program that addresses alcohol-related violent offending. The program is delivered within community corrections offices across Victoria and targets moderate risk male offenders on community-based orders for violent offences committed under the influence of alcohol. ADAPT is based upon cognitive behavioural therapy and was developed in line with the principles of risk, needs and responsivity to maximise program outcomes. The program is structured into 20 two-hour sessions delivered across four distinct program phases.
| Psychologists’ duty to warn |
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Stage 1 – Engagement and motivation
- Introduction
- What do I want from this?
- Is my drinking a problem?
Stage 2 – Violence and alcohol education
- Understanding alcohol and its effects
- Understanding violence
- The demon drink – relationship between alcohol and violence
- The cycle of violence
- Violence in relationships
Stage 3 – Skills development and behaviour change
- The cycle of change
- Consequential and harmful thinking
- Effective anger management
- Identifying triggers and high risk situations – managing provocation
- Managing arousal and emotion
- Communication and negotiation skills
Stage 4 – Self-management
- My offence chain
- Self-management cycles
- My Self-management plan*
- Final session – review and closure
*Participants complete a detailed self-management plan that is reviewed by the participant, the program facilitator and Community Corrections Officer in the weeks after the program.
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Program participants
Since 2009, the program has been delivered 35 times across 12 community corrections locations, 556 offenders were referred for assessment and 423 enrolled in the program. Of those, 332 commenced the program and 70 per cent successfully completed it, which is relatively high for an offender treatment program. Of the 30 per cent who did not complete the program, the main reasons for non-completion were repeated non-attendance, inappropriate behaviour in the group, inability to function effectively within the group (e.g., as the result of psychotic symptoms) or breaching their community-based order.
The participants were primarily moderate risk male offenders aged between 20 and 30 years with an average age of 27. Whilst the majority of the participants had been convicted of an alcohol-related assault, their overall offending profile varied considerably. Forty per cent were first-time offenders, and of the 60 per cent with an offence history, 38 per cent had previously been to prison.
There was a great deal of variation in the use of alcohol by ADAPT participants. While around five per cent reported daily drinking and met the criteria for dependence, the vast majority reported irregular or less than weekly consumption of alcohol. Consistent with the literature, almost one third (28%) reported hazardous drinking levels indicative of a binge drinking pattern, with 23 per cent reaching intoxication whenever they consume alcohol.
Clinical challenges
There is a range of clinical challenges when providing group-based programs to offenders. Community-based offenders are usually directed into treatment and are not motivated to participate. Engaging participants and assisting them to find their own reasons for participation is critical to effective offender treatment. In addition, it is essential to get the group ‘mix’ right. This requires an awareness of external factors that can quickly derail a treatment program, such as: offender politics; collusion between co-offenders; relationships between perpetrators and victims; bullying and intimidation within the group; the hierarchy of offence types; high levels of mental disorder (40% of ADAPT participants self-reported a psychiatric diagnosis); and antisocial behaviour, often directed at facilitators.
The ADAPT program faced an additional set of challenges due to the nature of the group and the fact that all the participants used alcohol inappropriately. Whilst not all were dependent, participants were at risk of attending the group intoxicated, and there was always the risk that offenders could develop social drinking relationships with other group participants. Some of the strategies implemented to manage these risks included the following.
- Careful assessment to determine suitability for the program
- All participants signed a participation agreement that outlined the program requirements which were reinforced via a group rules discussion in the opening session.
- All the programs were delivered within the community corrections office to facilitate ongoing communication between the program facilitators and community corrections officers and manage any unruly behaviour.
- A meal was provided during the break in every session to eliminate the need for participants to leave the building.
Regardless of the effort put into preventing incidents within offender programs, issues still emerge. In a group where all of the participants have demonstrated problems with alcohol, aggression and violence, a degree of aggression within the group is expected and provides an important learning opportunity. Central to the role of the facilitator is striking the balance between supporting the individual’s process of change and ensuring the safety and integrity of the group. This requires taking appropriate steps to support participants who behave inappropriately to assist them to understand their own behaviour and take more responsibility for it, but also knowing when it is time to remove a participant from the program. Most often, a participant would only be removed after several discussions about the behaviour and a joint session between program facilitators, the offender and the community corrections officer.
Findings
Over the three years of program delivery, ADAPT has undergone considerable refinement and review. The administrative procedures have evolved to streamline delivery and the evaluation tools and processes have also been significantly modified. Data from the first three rounds of the program yielded inconsistent results, which was thought to be related to both the measures used and the timing of their administration.
Later results using the self-report Alcohol Related Aggression Questionnaire (ARAQ) and Alcohol Use Disorders Identification Tool (AUDIT) clearly demonstrate that the ADAPT program has positive treatment outcomes on alcohol-related violence. Following completion of the program, participants reported that they were less likely to act aggressively as a result of drinking, were less likely to consume alcohol to facilitate aggression or to blame alcohol for acting aggressively, and were less likely to hold beliefs and attitudes that endorsed alcohol-related aggression. Participants also reported fewer problems with alcohol use, including reduced consumption, dependence and harm.
The value of the program is further evidenced by the feedback of participants. Ninety-six per cent of participants who completed ADAPT rated it as good to very good. Sixty-one percent believed the program increased their understanding of the link between alcohol and violence a great deal and 35 per cent felt this to some degree. Ninety-four per cent of participants reported that ADAPT increased their ability to manage their anger and 93 per cent declared it increased their ability to manage their alcohol use.
Conclusion
The expression of alcohol-related violence involves a range of complex factors such as alcohol expectancies, predispositions to anger, drinking context, social disinhibition and the amount of alcohol consumed. Effective treatment needs to be appropriately targeted and able to differentiate the drivers of alcohol-related violence. When delivering group treatment programs, facilitators need to employ strategies to minimise inappropriate behaviour and manage antisocial behavior whilst working to establish a cohesive group. The ADAPT program is specifically designed around these principles and both program outcome data and participant feedback suggest offenders are making strong gains through participation in the program.
The principal author can be contacted at [email protected]