Substance abuse is a major problem in the general population as well as in prisons and the wider criminal justice system Roberts, Hayes, Carlisle Shaw, 2007. In recent years an increasingly greater proportion of prison inmates are mentally ill, have substance use disorders and other chronic health problems (Lowinson, 2005). In understanding the connection between substance use and criminal behaviour it is important to recognise the range of behaviours to which each of these refers to. Substance use refers to a wide range of psychoactive substances which can be taken in a variety of ways resulting in different effects on the individual. Criminal behaviour also refers to a range of activities with different targets which subsequently result in a varying level of harm to their victim (McMurran, 2008). In the following essay the focus is largely on substance abuse and the relationship to those offenders with mental and personality disorders as well as those with intellectual disabilities, concluding with a section on treatment services.
There are many proposed systems for diagnosing and classifying substance-use disorders. The two which are most widely used are: the International Classification of Diseases-10 (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) (Salloum & Lezzich). The main five diagnostic categories within the ICD-10 and DSM-IV are: Intoxication, harmful use, dependence, withdrawal, and substance-induced psychosis. Although these five diagnostic categories are widely accepted, there does appear to be some controversy in how these phenomena are explained. For example, implicated in dependence or addiction are a wide range of behavioural, emotional, genetic, cognitive, neurological, social and cultural factors where often their importance and contribution to the diagnosis is disputed by professionals in the field (McMurran, 2008).
Diagnosis of substance use disorders is primarily conducted using structured interviews. They are structured in that they contain a broad range of questions that directly relate to the diagnostic criteria for any given psychiatric disorder (Williams, 1992). The diagnosis of substance dependence according to the DSM-IV requires that an individual meets three out of nine possible criteria over a 12-month period (Craig, 2005). One diagnostic method which is widely used and provides a comprehensive assessment of substance abuse disorder (Williams, 1992), is the structured clinical interview for DSM-IV (SCID-IV, Spitzer 1996). Not only does this provide a comprehensive diagnostic assessment enabling a broad picture of the client’s symptoms, it also allows mental health professionals to exercise their clinical judgement (Craig, 2005). One further diagnostic tool designed for assessing the severity of a range of different substances as well as the severity of a series of different substance disorders is the substance dependence severity scale (SDSS). The SDSS has shown to have high reliability and internal consistency and is unique in that it assesses the frequency and severity of symptoms; something that other diagnostic tools have failed to do (Miele et al, 2000).
Before beginning to examine the relationship between substance abuse and offending it is important to consider the prevalence of drug use among the general population. In the 2011/2012 crime survey for England and Wales it is reported that an estimated 8.9% of adults aged 16-59 had used some form of illicit drug within the last year. Further to this it was also reported that one in three adults (36.5%) had taken an illicit drug in their lifetime. It is important to recognise that, as this is a household survey, these figures do not take into account groups such as the homeless or those living in institutions such as prisons. This is important to consider as these are two groups who would potentially have a very high rate of drug use and problematic drug use behaviours. With regards to alcohol use overall the survey indicated that 61% of the recent incidents of drug use within the last year also involved drinking alcohol at the same time, thus showing a reasonably high rate of simultaneous poly-substance use. Key research has shown there is a difference between male and female offenders when it comes to substance abuse and offending which therefore has important implications for the design and implementation of treatment programmes (Palmer, 2006). Findings have indicated that there is a strong association between substance use and an elevated risk of offending in women (Byrne & Howells, 2002), however it has been suggested that men and women differ greatly in their motivations for drug use (Lengan &Pelissier, 2001)
Recent research has indicated that there are certain individual characteristics that, when combined together, can lead to an increased risk of developing problems with substance misuse. One study using a qualitative piece of research suggested that being male, young, having a borderline/mild intellectual disability (ID), living independently and having a mental health problem were all found to be risk factors for developing a “substance related problem” ( Taggart, McLaughlin, Quinn, Milligan, 2006). The co-occurrence of mental disorder and substance misuse is of great interest to forensic mental health professionals in that these two combined together in an individual could lead to an increase in the risk of crime, in particular the risk of violent crime, but importantly it could interfere with effective treatment. Those individuals diagnosed with a mental illness use substances for the same reasons as other people, such as mood management, alleviating boredom, pressure from peers, however they are more likely to be prone to low moods, may live in neighbourhoods where substances are more available or less likely to be lucratively employed. Contrary to this the stress-vulnerability models of schizophrenia assert that some people are more psychobiologically vulnerable to mental illness and stressors, such as substance use, which can then be a trigger for various psychiatric disorders (McMurran, 2008).
One investigation looking at the relationship between substance abuse, mental illness and violence came from Swanson et al (1994) who examined a subset 7,000 members of the general public studied longitudinally. Results concluded that the overall likelihood of violence was low throughout the whole sample however mental illness did increase the likelihood of violence, for example for those with schizophrenia. The results from this study found that those people who abused alcohol and drugs were nine times more likely to have been seriously violent in the past year; however it was those with both mental illness and substance abuse problems who were thirteen times more likely to have been seriously violent in the previous year. Studies such as Hodgins et al (1999), which have used clinical samples, have indicated a strong relationship between substance abuse and violence in people with affective disorder rather than those with schizophrenia. However when considering these statistics it is important to recognise that most people with a mental illness are not violent and are not hospitalised, therefore sampling hospital patients alone will provide a biased picture about the relationship between mental illness and violent crime (Brennan et al, 2000).
Violent behaviour among individuals with severe mental illness has become a significant focus in community-based care. Swartz et al (1998) studied the effect of substance abuse and medication non-compliance with the risk of serious violence among people with severe mental illness. The findings showed that the combination of alcohol abuse and medication non-compliance were significantly associated with serious violent acts in the community, importantly this was after clinical characteristics were controlled for. These results indicate a need for more targeted community interventions whereby mental health and substance abuse treatment are integrated (Swartz et al, 1998).
Research has shown Comorbid Substance use disorders (SUDs) and major mental disorders (MMDs) increase the risk of homicide in individuals. Putkonen, Kotilainen, Joyal and Tiihoen (2004) used a nationally representative sample of men with MMD who had attempted or committed homicide. 78% of the mentally ill homicide offenders were diagnosed with schizophrenia, 17% with schizoaffective and 5% with other psychosis. A lifetime SUD was detected in 74% and alcohol use disorder in 72%. Among those with a dual diagnosis (MMD and SUD) about two-thirds had PD or anti-social personality disorder (APD) indicating that for the prevention of serious violence by persons with MMD there is a need for effective treatments for those with a dual diagnosis or those who have a history of APD (Putkonen et al).
There are many theories that have attempted to explain the link between alcohol and crime, in particular the relationship between acute alcohol consumption and aggressive behaviour, which has proven to be a complex phenomenon (Chermack & Giancola, 1997). The Anxiolysis Disinhibition Model proposes that in situations in which aggression is present or has the potential to occur, anxiety is also present. Therefore in situations where aggression is likely and alcohol is also present those who have been drinking alcohol feel less anxious than those individuals who haven’t consumed alcohol and therefore more likely to engage in aggressive behaviour (Levav, 2009). However the Expectancy model provides a different explanation for this higher level of violent behaviour in those who have consumed alcohol. Dermen & George (1989) investigated the role of alcohol expectancy as a moderator of the relationship between self-reported frequency of aggression and drinking habits. The findings showed that the frequency of physical aggression was significantly higher for those who were expecting alcohol to increase aggression compared to those who either expected no difference or a decrease in physical aggression. Research on the existing literature on the alcohol and aggression relationship has highlighted that it is a highly complex and influenced by a wide range of developmental, psychological and alcohol related risk factors as well as contextual influences. Being aware of these factors allows for the development of appropriate and effective treatment programmes for individuals with alcohol and violence problems (Chermack et al).
In general there is little evidence to suggest that illicit drugs are uniquely associated with the occurrence of violent crime. In the 1991 National Criminal Victimisation survey findings showed that one fourth of criminals were under the influence of alcohol, whereby less than 10% of these were reported to be under the influence of illicit drugs. This is supported by further data on those individuals arrested for violent offenses where it was found that only 5.6% offenders were under the influence of illicit drugs at the time of their offenses (US Bureau of Justice Statistics, 1992). Studies looking at drug and alcohol involvement of homicide offenders and victims also support the notion that alcohol is, overwhelmingly, the substance most frequently associated with violent behaviour (Fendrich et al, 1995). One limitation common in much of the research into substance abuse and violence is that many researchers fail to take into account how this relationship may vary as a function of drug type. For example there is little evidence to suggest a link between heroin and violence (Parker & Auerhaun, 1998) with only 1.5%-5.6% of heroin users involved in violent crime (Ball, 1991). The most extensive research literature concerning drugs and violence is that investigating the relationship between cocaine and violence (Parker & Auerhaun). There is evidence supporting the association between use of cocaine and violent crime with some researchers suggesting that cocaine-associated violence “may in part be a defensive reaction to irrational fear” which comes from the paranoia cocaine can create (Miller et al 1991). One further consideration that researchers need to take into account is the duration or amount in which the different illicit drugs have been taken. With regards to amphetamines evidence indicates that either prolonged periods of heavy use or extremely high doses can induce “amphetamine-induced psychosis”, which has been described as a reaction virtually indistinguishable to schizophrenia (Fukushima, 1994). However this reaction is extremely rare with nearly all research on this using case studies, thus making these findings ungeneralisable (Paker & Auerhaun).
Personality disorders (PDs) and substance use disorders (SUDs) frequently co-occur both in clinical settings and in the general population (Sher & Trull, 2002). Offenders with PD are of considerable concern, due to the fact that PD is a predictor of serious recidivism (Bonta et al 1998). Coid, Yang, Tyrer, Roberts and Ullrich (2006) looked at the prevalence and correlates of PD in a sample from the general population. Findings indicated that drug use and PD occur more often than alcohol use and PD, whereby the link between alcohol and crime being strongest when combined with cluster B PD. Verhuel et al (1995) provided a comprehensive overview of the prevalence of PDs among patients with a substance use disorder. The two most prevalent PDs among patients with SUDs are antisocial personality disorder (ASPD) and borderline personality disorder (BPD), with reported estimates of 22% for ASPD and 18% for BPD. Although most attention on comorbidity between PDs and SUDs focuses largely on ASPD and BPD, there is evidence of other PDs (in particular avoidant PD and paranoid PD) being prevalent among those suffering from SUDs (Sher & Trull, 2002). Research has shown that people with co-occurring personality disorders, in particular ASPD are more likely to drop out of substance abuse treatment, however there is some evidence to suggest that this is more likely to be related to depression rather than PD (Kokkevi et al, 1998).
Borderline personality disorders (BPD) and substance use disorders (SUDs) are two forms of psychological problems which are often diagnosed within the same person. Sher & Trull (2002) found that out of 479 BPD patients 275 received a SUD diagnosis (57.4%). It has been proposed that the personality traits of instability and impulsivity are fundamental to the development of both SUD and BPD, however it is important to recognise that the onset and nature of substance abuse problems is different for males and females with research indicating that men with comorbid SUD and BPD are more likely than women to have multiple rather than single SUDs (Dulit, Fyer, Miller, Sacks, & Frances, 1993).
There is a considerable amount of evidence to suggest an association between substance abuse and violence in PD offenders, with alcohol intoxication being a specific area of concern (Corbett et al, 1998). However it is important to recognise that some individuals report that the use of substances actually reduces their likelihood of offending, in particular violent offending, as some substances can have a calming effect on strong emotions (Khantzian, 1997). Conversely it is critical to highlight that this effect may diminish or reverse as the individual’s tolerance to the substance develops (Tennant & Howells, 2010).
Investigating the relationship between intellectual disability (ID) and criminal offending is problematic for two main reasons. Firstly because of the problems that occur with the definition of “ID” and secondly because much crime goes unreported or undetected and therefore studies can only include those who are involved in the criminal justice system ( Holland, Clare & Mukhopadhyay, 2002). Individuals with disabilities are a growing population that confronts multiple intellectual and psychosocial disadvantages (Chapman, 2012), however given these disadvantages they experience the level of offending from this vulnerable group is strikingly low (Holland et al, 2002). One study (McGillivray & Moore, 2001) looked at a group of 30 individuals with mild ID, whose offending behaviour had resulted in their involvement in the criminal justice system, with a matched comparison group of 30 non-offenders. Not only did the results indicate that those individuals with mild ID regularly consumed alcohol and used illicit drugs, the data also indicated a link between substance abuse and criminal behaviour in this population. In support of these findings, a descriptive study was conducted of the recidivism of 75 offenders with ID who had served a sentence in a segregated unit. The aim of the study was to identify those factors which placed an offender at a higher risk of reoffending. The results showed a recidivist rate or 41.3% with the variables of substance abuse, unemployment and psychiatric history being identified as major causes of recidivism (Klimecki, Jenkinson & Wilson, 1994). However, although there is fairly little research in this area, it has been concluded that compared to substance abusers without ID, ID substance abusers are less likely to receive or remain in treatment (Chapman, 2012) which could provide an explanation for the above findings.
There is a large body of research on the treatment of substance abusing offenders in prisons, with more than half of prisons inmates having significant substance abuse problems and require treatment services. Many offenders have not previously received adequate mental health, substance abuse or other health care services and reach prison with pre-existing conditions and a range of other critical care needs (Lowinson, 2005). Fazel et al (2006) conducted an extensive review exploring the relationship between substance abuse in various medical and criminal settings and compared this to substance abuse in the general population. It was concluded that substance abuse was higher in prison populations that in the general population. Importantly it was found that for female prisoners the differences were more noticeable than for male prisoners, whereby drug dependency was up to 13 times higher than for the general population for females and 2 to 10 times higher for men. This highlighted that not only was there a need for more treatment services in prison settings, treatment for females should be a priority. However these figures are from North America alone and therefore a wider review gathering data from a larger section of the population would need to be completed before adequate recommendations could be made regarding treatment services (Robert, Hayes, Carlisle & Shaw, 2007).
With research showing that there is a great need for treatment services for substance abusing offenders it is paramount to establish what kind of treatment will be the most effective and provide the best results. Perry et al (2006) carried out a review which explored whether court based interventions, secure establishment-based interventions and community-based interventions for those drug abusing offenders reduce drug use and importantly whether this then subsequently leads to a reduction in criminal behaviour. Results indicated that therapeutic communities and aftercare seemed to be the most effective interventions. Regardless of this fact one important finding to come out of this review is that there is not one single best treatment method suitable for all individuals and that many factors must be taken into consideration when deciding upon the most suitable course of treatment for an offender with a substance abuse problem (Robert et al, 2007).
In 2002 The Home office released an updated drug strategy which set out actions to ensure that future generations would never have to face the dangers that drugs present today. As a response to this Holloway et al (2005) reviewed the literature on the effectiveness of criminal justice programmes which aimed to reduce drug related crime and those drug treatment programmes which may inadvertently have a positive effect on drug related crime. Meta-analyses found all drug intervention programmes in the UK to be effective in reducing drug related crime with the higher intensity programmes being 50% more likely to reduce drug related offending behaviour than their low intensity equivalents. With this in mind it is important to recognise one key findings of the review which indicated that treatment programme outcomes are related to demographic characteristics of the individual and therefore the effectiveness of treatments will be more or less effective depending on these characteristics (Robert et al, 2007).
Several clear conclusions can be drawn from the extensive literature review concerning the relationship between substance abuse and offending. Substance use may increase the likelihood of criminal behaviour in a number of ways depending on which individual is taking what substance in what context and in what way. Underlying personality traits may be a key explanatory factor for mentally ill and personality disorder patients alike. Substance misuse needs to be targeted in all forensic mental health populations and special consideration needs to be taken to ensure this issue is not avoided because it is seen to be outside the responsibility of forensic mental health services (McMurran, 2008).