ALCOHOL AND CRIME: TREATMENT AND REHABILITATION

Providing treatment for persons who have committed crimes and who also have alcohol problems seems a straightforward subject for description and analysis. The approach should presumably center on the description of circumstances when criminals with alcohol problems do or do not receive treatment for these problems, factors affecting this differential use of treatment, and a review of evidence of the effectiveness of these interventions.

These issues will be dealt with in this entry, but they are not its primary focus. By contrast, the intersection of crime, alcohol problems, and treatment for alcohol problems offers unexpected opportunities for understanding the conceptual relationships between alcohol and crime. These understandings extend well beyond the somewhat tedious question of how drinking might "cause" crime. This intersection of three distinctive empirical phenomena also provides contextual understanding of the construction and implementation of social policy in Western nations.

The starting premise is that all alcohol problems are grounded in behavior that is "continuous" with crime, which provides a context for viewing why or why not treatment is readily provided to a wide range of persons with alcohol problems. According to Durkheimian theory (Erikson), crime is a constant in human societies. Important differences are found, however, in how and when crime is defined and acted upon in different structural and cultural circumstances. By contrast, neither alcohol problems nor their "treatment" are universal across different social structures. While it has been observed that alcohol is used in nearly all human societies, the notion of its "problematic" status is not a cultural universal (Macandrew and Edgerton).

Many dimensions of crime are dealt with exhaustively in this encyclopedia, but for present purposes it is significant to state simply that crime is more or less (but not perfectly) continuous with deviant behavior in everyday life. This is a basic Durkheimian perspective. If this continuum between deviance and crime is assumed, then crime is logically a subcategory of deviance. Where, however, is the "break" on the continuum wherein deviance becomes crime? It is useful in this entry to view the difference between deviance and crime as residing in three factors: the extent of norm violation, social visibility, and formalized social reaction.

Norm violation

Crimes are socially constructed in law. Law is implemented through the cataloging of certain behaviors as requiring formalized social reactions ranging from warnings, through arrests, trials, punishment, and ultimately to banishment or execution. The content of a criminal code may in large part describe the moral structure of the society wherein it is developed and implemented.

Crimes are, however, a subcategory within a broader set of phenomena called norm violations, or acts of deviance. All crimes are norm violations, but not all norm violations are crimes. Viewed historically, norm violations may move in and out of the category of crime, and an understanding of such shifts can be important in the analysis of social structure (Gusfield; Beauchamp). As described below, alcohol problems have been viewed as crimes in various ways at different points in American history, but in recent decades they have been almost wholly shifted to a noncriminal categorization.

Social visibility and formalized reactions

With the exception of those who perform socially invisible criminal acts known only to themselves but who "turn themselves in" due apparently to the weight of conscience, the vast remainder of criminals commit acts that are socially visible. The acts become visible through impacting others, through being viewed by others, and by being reported in some fashion. Acts in the broader category of deviant behavior of which crime is a part need not be socially visible. Their impact upon others may be unknown or ambiguous, others may not view the behavior, or social decisions may be made by affected or observing others that no advantage will be served by reporting the behavior. Without such reporting, the pathway to a formalized social reaction ends.

It is an axiom of sociology that there is a great deal of deviant behavior in society that does not have visible social consequences. Some of this deviance may prove, in retrospect, to be nascent crime, but in many other instances events of deviant behavior pass unnoticed and are absorbed into the ongoing flow of social life (Black). This distinction between deviance and crime is drawn out to establish the continuity between crime and deviance. This should set the stage for considering the conceptual status of alcohol problems, and in turn lead toward an understanding of the social meaning of "treatment."

Alcohol problems as double deviance

Central to this entry is the assertion that all alcohol problems spring from deviance, this being independent of medicalized and moral conceptions that may be attached to alcohol problems. As mentioned, alcohol problems have been subject to shifting definitions and categorizations across cultures and over history, experiences well documented in the history of American society. Colonial historians have observed that eighteenth-century drinking in the American colonies was far more extensive than drinking patterns known in subsequent periods, that drinking was woven into the fabric of nearly all phases of personal and social activity, and that "alcohol problems" were largely unknown, with the exceptions of grossly destructive behavior associated with drunkenness, and of persons who were unable to work and were community wards because of their excessive drinking (Rorabaugh).

As is well known, alcohol soon emerged as a social problem of major proportions, part of a massive set of social and ideological changes in the new republic occurring in the 1820s and 1830s. Interpreters have seen this period as one of the emergence of multiple social problems, not necessarily because of increased prevalence but because of transformed definitions. As part of these changes, alcohol consumption became problematic in America (Clark; Lender and Martin). Problem definitions began with labeling the consumption of liquor or "ardent spirits" as physically and mentally destructive, allowing, however, for the consumption of beer, cider, and wine.

After several decades, all alcohol consumption came to be seen as personally damaging and socially dangerous, and the temperance movement essentially defined all drinking as deviant. Eventually national Prohibition came to be seen as the solution to this alleged morass of problems, and it was enacted in 1920, leading to the distinctive definition of all alcohol-related activities within the conceptual arena of crime.

When Prohibition was repealed in 1933 (for a complex set of reasons still being debated), the definition of alcohol consumption within a criminal conception became obviously untenable. One set of responses moved toward the enactment of a great many rules as to when, how, and by whom alcoholic beverages could be consumed. A second set of responses set about to differentiate between problematic and nonproblematic drinking.

It was in this new area of research that the conception of the disease of alcoholism emerged (Jellinek summarizes these developments). Alcoholism was not defined by the consumption of a set amount of alcohol, but by behavioral patterns wherein persons completely "lost control" over their drinking. Such behavior often could be observed in terminally ill individuals who drank constantly, ate little, manifested severe psychiatric symptoms, and usually died or were permanently disabled due to organ damage. Other types of alcoholics could remain abstinent for considerable periods, but manifested this "loss of control" once drinking began again.

While there was consensus regarding the gravity of this behavioral syndrome, it was clear that any kind of effective intervention would have to address the problem at a considerably earlier stage in its development. Over several decades a well-organized campaign promoted the definition of alcohol problems into the medical arena and out of the criminal arena. Alcoholism as a crime was formally "decriminalized" in the 1960s, and by the 1970s the study of alcoholism as an illness was assigned to a federal research and treatment agency that ultimately became a unit of the National Institutes of Health.

Thus, from the beginning of the nineteenth century, when alcohol problems were barely recognized, there was a rapid shift toward viewing such problems as sin, then as crime, only to transform them into medical disorders by the last quarter of the twentieth century. These rapid and complex definitional changes have never been fully institutionalized in American culture, with the consequence that there are mixtures of definitions and ambivalences about how problems should be managed. These confusions have considerable implications for the likelihood that criminals will receive treatment for their alcohol problems.

One of the manifestations of these confusions is in the "double deviance" definition of alcohol problems. Alcohol problems are defined not by the amount of alcohol consumed or the pattern by which it is consumed, but by the problems in role performance that can be linked to the individual's drinking. Problem drinkers are essentially defined by how much trouble they have gotten into in association with their drinking. Double deviance arises in this way: one or more acts of deviance define an alcohol problem, which in turn defines the individual's drinking behavior as deviant. Persons who repeatedly engage in these patterns of behaviors are seen as unresponsive to negative feedback, and thus "alcohol dependent." Behavioral repetition by alcohol-dependent persons easily segues into "alcoholism."

While role performance impairment appears to be consistent with (in medical language) differential diagnosis at the individual level, it is clear that this definition is almost wholly dependent on social events. While self-diagnosis and self-referral of persons with serious alcohol problems is not unknown, it is very exceptional. Definitions of poor performance emanate from the judgments of significant others surrounding an individual, and thus are a "paradigm case" of socially defined deviance. The crucial understanding is that a problem drinker must also be a social deviant, placing all persons defined as problem drinkers on a continuum with criminals who have alcohol problems.

The prominence of deviance in treatment paradigms

In addition to facets of "crime" surrounding the definition of alcohol problems, there is also clear evidence of "punishment." Despite the widespread usage of medicalized language to describe the behaviors of persons with alcohol problems, they are punished in everyday life by social rejection, loss of friends, marital dissolution, job discipline, or job loss. Sometimes this occurs as part of the rehabilitation process, such as divorce following treatment or the loss of a job associated with treatment entry. Rarely do cries of social injustice arise when an alcohol-troubled person suffers these consequences. While these observations of punishment may seem pedestrian, their importance lies in the fact that alcohol problems are formally defined as medical issues. Crime and punishment are usually held to be independent of disease and medical care.

By linking admission of guilt and repentance to progress through the program, facets of punishment are embedded in the steps of Alcoholics Anonymous (AA), the most prominent mode of treatment for alcohol problems in the United States, and the modality that forms the basis for the vast majority of professionalized treatment programs for alcohol problems. It is important to keep in mind that passage through the twelve steps of AA should be sequential, and that there are no prescriptions regarding how far one must go in the sequence and still be an AA member in good standing. (A desire to stop drinking is, in fact, the sole requirement for membership.) In the eighth step AA members "made a list of all persons we had harmed and became willing to make amends to them all." Although seemingly simple, this step actually encompasses three distinct behaviors (making the list, overcoming resistances to approach others, and deciding to approach all such injured persons). These acts are concrete: writing, deciding, and encompassing a potentially vast array of others. Once this step is accomplished, the individual may move on to the ninth step, wherein he makes "direct amends to such people wherever possible, except when to do so would injure them or others." These expected reparations certainly place the AA member on a continuum with individuals with alcohol problems who have committed criminal acts.

Two further points elaborate this conception. First, there are a multitude of reasons for associating the emergence and social acceptance of the medical model of alcoholism with the invention and diffusion of AA (Beauchamp; Kurtz; Roman). The content of the eighth and ninth steps of the fellowship's program do, however, assert significant deviance with the alcoholic career. It is noteworthy that the eighth step does not suggest the optional possibility of "IF we have harmed others" wherein one might skip to subsequent steps. Herein lies substantial institutional evidence of the intertwining of the definition of alcohol problems and social deviance, well before the emergence of criteria in the American Psychiatric Association's Diagnostic and Statistical Manuals.

Second, the ninth step appears to be intertwined with the eighth step in that it seems illogical that one would become "willing" to make amends to "all" and then do nothing. This possibility must have been recognized by the founders of AA. It is evident that separate "packaging" of these potentially stress-filled and painful sets of actions very likely increases the probability that the reparative actions will be taken.

AA is the dominant modality in the treatment of alcohol problems, but the past few decades have seen the rapid emergence of professional research interest in addiction treatment, much of which has challenged the somewhat single-minded approach of AA and twelve-step programming in general. Prominent among the research-based strategies is the classification of alcohol and drug programs through the Addiction Severity Index (ASI), developed by a team of researchers at the University of Pennsylvania (McLellan et al., 1992a, 1992b). The ASI and a more recent inventory used with clients, the Treatment Services Review (TSR), are centered on the assumption that persons with addiction problems bring a multitude of problems to the treatment setting, including medical, psychological, familial, occupational, legal, and financial problems.

The authors of these inventories assert that most treatments fail because they focus only upon the addiction problems and such treatment typically ignores the accumulated consequences of deviant behavior associated with the development of alcohol problems. The ASI and TSR are focused on assessing clients across all of these problem areas and coordinating treatment services in each needed area in order that full rehabilitation may result. The more serious the alcohol problems, the higher the scores on the ASI and the greater the needs reflected in the TSR.

While the AA steps and the ASI/TSR approaches to addiction treatment have vastly different institutional origins and assumptions, they are remarkably similar in their emphasis upon the deviance that has accompanied the development of alcohol problems. Both approaches argue that successful treatment outcomes will not occur if only the problem of addiction is addressed. In very different ways, both point toward the necessity that problem persons address a range of difficulties in role performance that have been generated across most areas of their lives. In so doing, both approaches demonstrate the vast difference between the medicalized conception of alcohol problems and parallel conceptions associated with other disorders, their treatment, and expectations for recovery.

Why offer treatment to criminals with alcohol problems?

There are three contemporary justifications for the offering of treatment to persons with alcohol problems, all of which contrast to an earlier social welfare justification wherein treatment was offered because it was the morally correct choice. In the first of the contemporary justifications, the offering of treatment is essentially compelled by acceptance of the notion that alcohol problems are intermingled with alcohol dependency, and alcohol dependency is a medical or health problem. Sick persons deserve treatment and persons with alcohol dependency are sick persons.

The second justification is centered on social investment. This idea centers on the occupancy of significant social roles by persons with alcohol problems. Role occupancy in turn indicates that others are dependent upon the focal individual, allowing that in some circumstances this dependence may be symbolic and obligatory, such as the deference that is offered to the needs of elderly family members even though their "productivity" may be strictly symbolic at present but historically significant. Thus treatment is offered through allocating the resources owned by different interest groups, typically families or employers.

The third justification is focused on recidivism. Criminals with alcohol problems are seen as double deviants in a sense different from that used here, namely that there is a causal interdependence between their substance use and their criminality. While it is widely asserted that drinking facilitates crime, the element of differential association with bad company that accompanies drinking and illegal drug use is a secondary facilitating factor. Thus some data indicate that successful treatment of criminals' substance abuse problems will have a desirous effect on recidivism (Pearson and Lipton).

How are criminals linked to these justifications? Looking first at the illness-entitlement idea, it may be difficult to view criminals with alcohol problems as "sick." By definition, they have already received a cardinal label of criminality that implies "bad," not sick. "Bad" is the marker for imputing responsibility for deviant behavior, and the administration of the label "criminal" immediately excludes the possibility of an illness label. Thus, with the "sick" label absolving responsibility and the "bad" label imputing responsibility, "sick" and "bad" have a very difficult coexistence as labels for the same individual.

Thus the administration of criminal labels creates a logic-based resistance to the placement of a sick label on a criminal with alcohol problems. This is not to say, however, that the criminal justice system denies that alcohol problems exist among criminals. Instead, the alcohol problem is seen as something that may interfere with an individual's eventual return to society, as well as a possible contributor to recidivism, but it is clearly not the individual's cardinal problem, which is his or her criminality. There may be no reluctance in agreeing that a criminal's alcohol problem is secondary, or even lower in priority, but there cannot be the administration of a cardinal label wherein the criminal is seen as sick and thus deserving treatment.

Turning to the social investment justification, it is important to examine the role occupancy of the criminal. By being placed in prison, he or she occupies the prisoner role, and may be part of different social networks within the prison. Occupancy of social roles outside the prison is nonexistent or, at best, suspended. It is very rare for employers to hold open job positions for individuals while awaiting the completion of their incarceration. While fathers and mothers, as well as husbands and wives, may be deeply missed by their significant others during their incarceration, the demands of these vacant roles must be filled by others or not filled at all for the duration. Thus the social investment justification for providing treatment for alcohol problems is largely missing.

As mentioned, a principal goal of most prisons is the reduction of recidivism. Recidivism can also be understood in the terms of social roles. An individual who is a recidivist must return to a previous role in the community involving criminal behavior, or adopt a new criminal role configuration, for without such role occupancy, there can be no repeat offenses. Because roles in families and employment become "closed out" for individuals who are incarcerated (assuming they occupied such roles prior to incarceration), their opportunities following the completion of incarceration may be limited to prior roles involving engagement in criminal behavior. Indeed, this possibility may be enhanced if they were evaluated as particularly valuable in the performance of criminal acts by criminal peers, and these persons welcome them back into roles that may have been "held open" for them.

Given these facts, it is only logical to conclude that the major justification for the offering of treatment to criminals with alcohol problems is the traditional social welfare concept that it is the right thing to do. If this is correct, then it immediately explains why the offering of treatment for alcohol problems to criminals drifts down the list of priorities of what can be effectively carried out in the prison environment. The possibility of allocating resources for the treatment of alcohol problems essentially "competes" with other morally compelling programs, such as addressing criminals' mental health problems, dealing with their physical health, and providing them with skills so that they are attracted to noncriminal work opportunities when their incarceration is completed.

The published literature on the effectiveness of treatment invariably supports three general conclusions. First, that there are not enough available resources to afford the widespread availability of such treatment (Wright); second, that the extent of success in treatment is closely linked with the amount of time that criminals are retained in treatment programs (Farabee et al.); and third, that the long-term impact of this treatment on both recidivism and recovery from alcoholism is contingent on a vast range of factors that are extremely difficult to capture with available evaluation technology (Kinlock et al.; Hiller et al.).

Thus, it might be expected that investment in alcohol problem treatment for criminals would be found in an environment of munificent resources where a range of criminals' problems in living in the world were addressed. This would of course assume that the allocation of resources to alcohol problem treatment effectively competed with the demands and lobbying of other constituencies invested in morally compelling programs.

Conclusion

In conclusion, the relationships between alcohol problems, crime, and treatment may be said to offer conceptual excitement and empirical disappointment. The linkages between the three concepts tell us a great deal about the social and cultural attitudes toward alcohol problems that in turn explain the ways in which treatment is utilized and implemented. Deviant behavior, which is clearly on a continuum with criminal behavior, is an essential component of the definition of alcohol problems, and thus for access to treatment. Within the treatment and recovery process, the client's dealing with the facts of his or her deviance plays a central role.

By contrast, we find that treatment is made available to criminals with alcohol problems on a piecemeal basis at best. While there is evidence that some criminals with alcohol problems respond positively to treatment, there is a poor cultural "fit" between the widespread use of treatment and the administration of several major sectors of the criminal justice system.

Hence the empirical disappointment: While from some perspectives there is a very distinctive need for more treatment for criminals with alcohol problems, their deviance has carried them beyond the point where society regards treatment as a sound investment, or even as an appropriate investment. This is in sharp contrast to the salience of deviance in deciding and directing the administration of treatment to persons with alcohol problems whose behavior "falls short" of the criterion of criminality.

The amount of treatment available to the criminal population is minuscule relative to the apparent need. There is no clear way in which alcohol problem treatment could move up the list of priorities in the administration of criminal justice. Thus there is little reason to expect that the availability of alcohol problem treatment for the criminal population will increase at any time in the foreseeable future.

Paul M. Roman

See also Alcohol and Crime: Behavioral Aspects; Drinking and Driving; Drugs and Crime: Behavioral Aspects; Excuse: Intoxication.

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