Treatment or prison: service user and staff experiences of drug treatment and testing orders

AIMS AND METHOD The drug treatment and testing order (DTTO) is a treatment option imposed 
by courts and the first multi-agency initiative in the treatment of substance 
misuse in the UK. We used separate focus groups for service users and staff 
involved with DTTOs in Hertfordshire to qualitatively investigate their 
experiences of the orders. Interviews were recorded and analysed using 
grounded theory methods. RESULTS Analysis highlighted areas of concern related to the central issue of 
forced treatment, which was more challenging for staff than for service users. 
The area of most concern was multi-agency collaboration. CLINICAL IMPLICATIONS Multi-agency initiatives require extensive liaison across agencies.

The drug treatment and testing order (DTTO) is a treatment option imposed by courts and the first multiagency initiative in the treatment of substance misuse in the UK. We used separate focus groups for service users and staff involved with DTTOs in Hertfordshire to qualitatively investigate their experiences of the orders. Interviews were recorded and analysed using grounded theory methods.

RESULTS
Analysis highlighted areas of concern related to the central issue of forced treatment, which was more challenging for staff than for service users. The area of most concern was multiagency collaboration.

CLINICAL IMPLICATIONS
Multi-agency initiatives require extensive liaison across agencies.
The long and enduring relationship between crime and illegal drug use has been well documented (Hall et al, 1993). The results of follow-up studies indicate that drug treatment does facilitate the reduction of acquisitive crime in offenders addicted to illicit drugs (Gossop et al, 2000).
The drug treatment court model of tackling the drug-using offenders was initiated in Florida in 1989 (Harrison & Scarpitti, 2002). At present, similar models are being tested in several countries (La Praine & Gliksmanl, 2002;Makkai, 2002). In England and Wales, Bean (2002) noted that the importation of the drug treatment court has not been possible because of legislative difficulties. Once the legal framework was in place for the drug treatment and testing order (DTTO) in 1998, a pilot project involving three sites was initiated. Since October 2000 DTTO services have been implemented throughout the UK. In 2005 the DTTO was replaced by the drug rehabilitation requirement. Another multiagency service, the drug intervention programme (DIP), was implemented the same year.
The DTTO concept of 'either treatment or prison' is designed to facilitate treatment access for individuals trapped in the vicious circle of crime to fund drug use, but this can be challenging for professionals working in the field. This study aims to generate data that will explore the dilemma of treatment or prison from the service user and staff perspectives.

Methodology
This is a qualitative study, in which separate interview groups for DTTO service users and staff in Hertfordshire were conducted between March and June 2004. The sampling frame was all service users attending and all staff working within DTTO services in Hertfordshire (an area that includes both urban and rural populations). All clients attending DTTO services were invited to participate through advertising posters in clinical areas and personal invitation by their keyworkers. Members of staff were invited with a personal invitation sent by post. Unstructured interviewing was employed for data collection, and grounded theory techniques were used for analysis. The aim of this approach is to build a theory from information grounded in qualitative data gathered from a range of settings and to take account of how reality is viewed by participants themselves. It adopts the socially constructed nature of reality and it is accepted that there are multiple realities, or ways of knowing, all of which are relevant to the argument in question. The group interview format was adopted because it allows for interaction between group members, as well as for enrichment of the data within an appropriate social context.
The study was approved by the local research ethics committee. All participants were asked to consent to participate in the study, assured that all identifying information would be confidential and that participating in the study would not affect their treatment (as service users) or their professional role (in the case of staff).

Interviews
Interview format for service user and staff groups was the same and took place at their treatment programme or work environment respectively. The sessions were tape-recorded. Two members of the research team facilitated each group, one of whom led the session while the other kept notes. Neither researcher was directly clinically involved with the participants. Participants were asked to reflect on their experience of the order and to say their name each time they made a contribution to the discussion. There was limited prompting by the researchers if participants did not reflect on the issue of 'treatment or prison'. All group sessions lasted a maximum of one and a half hours.

Participants
Six service user groups were formed (two groups per programme) with a maximum of eight people per group. A total of 29 clients (46% of the total population in DTTO treatment at the time of the study; 24 male) took part in the project. The representation of the different localities was equal. The minimum experience of the order was of 2 weeks of assessment and the longest of 13 months, with a mean of 4.7 months. For 19 clients it was their first order (see Table 1).
Three groups for staff (one per structured programme) were formed, involving eight (five female and three male) drug counsellors/workers (100% of the staff from the structured programmes). Two probation officers (female) from one team and one consultant psychiatrist (female) were also interviewed. Because of the small numbers of those in professional groups, results should be interpreted with caution. Drug counsellors/ workers had similar qualifications. Six had counselling training and qualifications, one had accredited training in psychotherapy, and two had a diploma in addictive behaviour. Three staff members were recovered users. Their work experience ranged from less than 1 year to 20 years. Two members have been involved from the initial set-up of the programme while the others have worked with DTTO clients for between 2 and 12 months. Both probation officers had qualified recently and had limited experience with DTTO clients although one of them had worked with clients with mental health and substance misuse problems prior to her qualification. The consultant psychiatrist had several years' experience in the field of substance misuse and previous experience with DTTO clients.

Data analysis
The interviews were coded and concepts were generated from the data by two researchers independently. These concepts were then discussed and used to generate more abstract conceptual categories with a view to synthesising, explaining and understanding the data, and identifying patterned relationships within it.

Different expectations
Service users had different expectations about the order. Some did not know what to expect, others mentioned 'getting medication' and 'getting clean', without being able to expand or put these into context. The main motivation for some was to stay out of prison. Some service users had clearer expectations: 'getting advice and support on how to stop taking drugs, develop structure and build a new life'.
The order was a new experience because it provided more than traditional services. Goals became clearer with time. Regular attendance was considered crucial as this was seen to be the way to get to know and trust the keyworker, understand the process of the order and belong to a group.
'Well initially it was to get clean. Then as I began it I discovered stability and that's when I realised what I wanted.
I am now thinking about the year ahead. To me DTTO is structure and stability as long as you comply with it.'

Forced treatment and motivation
The participants of one group commented on their positive and beneficial experience from the early days of the order when staff did everything for them. Most groups felt that rules were important and people who were not motivated needed to understand this. It was felt that motivation improved with time, as the benefits of the treatment were realised. The role of personal responsibility was also identified by most people as important irrespective of the support provided by services.
'If it wasn't for a court order a lot of people would not come because when it comes to admitting that you want help there's not a lot of people that will ask for help.' 'In a way I suppose being forced to come here with a court order was maybe a good thing. If the public could access it I don't think they would come so . . . being forced is a good thing.' 'You can have all of the other parts of the order, but no matter what you have, it is no good if you are not motivated to change'.

Clear communication between agencies
One point that was raised as being of particular importance was clear communication between staff from different agencies and service users. It was felt that the rules and expectations should be explained clearly from the beginning of the order. Communication between the different agencies was considered to be an ongoing problem because service users were often given mixed messages about the aims, rules and importance of the different components of the order.
'You hear different things from different people. I know they're trying to work it out too but it's hard for us.' 'Make it one or two places only that you have go to instead of running all over the place.' Staff Forced treatment Staff discussed in detail the issue of forced treatment. Their experience was that it takes a lot of effort on their side to overcome this therapeutic obstacle and enable clients to come voluntarily. It is difficult to find the right balance between a therapeutic environment and a court order.
'In many ways it came across as a way of purely avoiding going to prison. I [drug counsellor] was expecting people to attend with an enormous resistance to any form of therapy'. 'I [drug counsellor] didn't realise just how difficult it was going to be to balance the therapeutic element with the fact that it is a court order'.  Up to 3 months  5  8  13  3-6 months  8  1  9  More than 6 months  6  1  7  Total  19  10  29 'It is a treatment, but also an order, [that] causes conflict.' [probation] Improvement with time Staff felt that clients were suspicious because of the link with probation. It was acknowledged that staff concerns when they first started were influenced by clients' experiences and vice versa. There was, however, a gradual development of trust between service users and staff. The experience of the order has changed and become more positive over time. Probation staff commented on how little they could influence the structure of their roles, and how they felt 'pushed into it'. They concluded that it was a learning process and felt that they developed their own style.
Inter-agency communication A major topic of discussion was that of collaboration across disciplines and agencies. There was a lot of anger expressed towards probation services and magistrates because of the lack of understanding about addiction and recovery, and lack of respect for inter-agency boundaries.
Most staff emphasised that poor communication between agencies was the biggest problem in the smooth running of the order. The victims of poor communication and difficult dynamics between agencies are the service users. Medical staff expressed the complaint that they were not really involved in the order, but included simply because 'we are needed to prescribe'. They suggested that the experience of multi-disciplinary work that has been prevalent for several years within mental health and statutory addiction services could be expanded to include multi-agency working.

Clear communication with clients
Providing clear information to clients regarding the nature of the multi-agency set-up and respect for confidentiality was felt to be necessary to reduce suspicion from service users. Staff emphasised the importance of clear rules in all aspects of the order including expectation regarding drug use, criteria for vocational training and stages of the order.
'It is important to know each stage they will be going through when they start the order'.
'Clients feel that they are caught in the middle'.

Discussion
To our knowledge, this is the first study of the experience of service users and staff of DTTOs. The aim was to explore the issue of forced treatment. By eliciting views and experiences of the participants in a detailed and authentic way, and by following the basic principles of grounded theory as introduced by Glaser and Strauss in 1967 (Hayes, 1998), data analysis revealed a number of associated issues. The dilemma of 'treatment or prison' seemed to be more challenging for staff than for service users. It was suggested by service users that the fact that the order was enforced by the courts could be very productive, as it afforded them the opportunity to engage and benefit from the therapeutic environment. It seems that the conflict between forced treatment and personal responsibility is something that can be worked through once service users are engaged. It appears there was a reciprocal influence: service users progressed when working relationships between the different agencies improved. At the same time, staff became more enthusiastic and dedicated when they realised that, despite the difficulties and shortfalls of the order, a good number of service users were benefiting from it.
The quality of the multi-agency collaboration seemed to be the biggest issue of concern for all participants. The contributing agencies have different philosophies and approaches to the problem of drug-related crime. Clear instructions, boundaries and expectations were highlighted as crucial. Good liaison to enhance interagency communication is critical for a successful service, but is time-consuming. Therefore, the challenge remains with the professionals and the dilemma is rather 'can we work together?' than 'treatment or prison?'Although the way the DTTO operates has changed since this study was conducted, most of the issues discussed and highlighted by service users and staff are relevant to the new formats of the court orders as well as the drug intervention programmes.