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Traffic Medicine and Psychology Unit, Institute of Forensic Medicine, CMU Avenue de Champel 9, 1211 Geneve 4, Switzerland
Every year, we examine individually (psychological and medical exam) nearly 150 DWI repeat offenders (at least two convictions for driving with a BAC above 0.8o/oo) and 100 drivers under suspicion of drug addiction. Based on our experience, we can state these persons belong to two subgroups which differ from one another essentially in one criterion: the capacity or the incapacity to decide to consume (drug, medicine, alcohol) or not. If the incapacity is established, we have to aim at a deep modification of the way of life and it is illusory to hope any change by a short term action around the theme of driving: a medical, psychotherapeutic treatment or residential care is necessary. In this case, the person is not a driver who needs rehabilitation, he is someone who needs treatment of his addiction. If the driver is able to control in a certain measure his consumption, the problem might be tackled by the angle of rehabilitation and focused on the driving.
In this perspective, the detection of alcoholism in cases of drunken driving is a crucial problem because it allows orientation toward fundamentally different interventions. We have conducted a study on all drunken driving recorded by the police in Geneva during one year (about 950 cases). The measure of a biological marker of alcoholism (GGT) allowed us to characterize DWI committed by alcoholic drivers (BAC, age, sex, recidivisms, moment of the week or of the day,...). We can estimate more than a third of DWI were committed by alcoholic drivers and their profile can be defined.
In the State of Geneva, Switzerland, there is no rehabilitation program for drivers found to be driving under the influence of alcohol or drugs. Available measures are: penal procedures leading to a fine or imprisonment, driving licence suspension through administrative procedures. In the latter case, if the driver is considered fit to drive, according to medico-psychological criteria, the duration of the suspension is calculated according to the severity of the offence and of past records: there are no conditions to restitution. If the driver is considered as unfit to drive, the duration of the suspension is not fixed: it is up to the person concerned to request restitution of his driving licence when he feels ready. This request will be once again examined with respect to medico-psychological criteria. The role of the expert in traffic medicine and psychology is to define criteria of inability and criteria of restitution (time and conditions). Legal bases exist to enforce rehabilitation programs on recidivist drivers, but these do not yet exist in Geneva.
In studying the literature, it is often difficult to understand if a rehabilitation program used in a country has an educational or a therapeutic goal. Nevertheless, a strict definition of the option seems crucial. Moreover, the problem of rehabilitation does not concern only alcohol drinkers. If we talk about driving under influence, or driving while intoxicated, we accept the idea that alcohol is not the only concern: drugs and medicine are also to be taken into account. We are not sure that alcohol consumption is the best model to build suitable actions that would be generalizable. And we are not sure that drug consumption has to be considered as a different phenomenon from alcohol consumption.
The population concerned with rehabilitation is very heterogenous and the first step is to caracterize it. The object of the rehabilitative action is the relationship between consumption and driving. A concept which is obvious when we talk about consumption or about driving is the notion of control. Why not use it as classification axis ?
The control may apply first on consumption. If someone is unable to refrain from consuming when he decides, we have to believe that at one time or another he will drive under influence or with withdrawal symptoms. We consider therefore this kind of consumption is a case of inability to drive because of control loss which suggests toxicodependance. Any modification of the way of life must be accompanied by a profound modification from a psychological point of view.
The control may also apply to the decision to drive after having drunk. This is a typical case in social drinking. Desinhibition due to the effect of alcohol, cannabis or cocaine then affects the power of deciding his behaviour. If there is no dependancy, adjustment of behaviours may avoid risky situation.
The other cases of driving under influence without loss of control should be classified into lack of knowledge inducing wrong attitudes or into attitudes of denial.
We think that the split between ability and inability, and by extention between different rehabilitation strategies, is to be based on keeping or losing the control of consumption. If the control is kept, modification of behaviour and attitudes may be reached by an educational approach. If the control is lost, an effective action calls for a therapeutic approach.
In all cases, the problem arises for drugs and medicines as well as for alcohol. In all cases, driving hould be forbidden. In all cases too, the question of rehabilitation in traffic will be raised at one time or another.
The modification of attitudes or the completion of knowledges belong to an educational approach. If someone keeps control on his behaviour, he is able to apply these modified attitudes and knowledges. But an accurate definition of the goal of the program is crucial. It is not enough to say that the goal of the program is to reduce recidivism: this is just an intention. The elaboration of a goal must include description of behaviours to be induced, conditions in whitch these behaviours must appear, and criteria of judgement allowing to consider the program as completed.
The main object of the program would be the relationship between the effects of the products and driving safety. Should we imagine the same program to deal with driving under influence of alcohol, cannabis, medicine such as benzodiazepine, or even cocaine? Why not since these products are often taken in association and the same attitudes in relation to traffic safety are developed.
Helping someone to recover the control of his consumption must be a therapeutic process where duration is an unavoidable component. But inability is not definitive and not exceptional.
Inability is not definitive because whatever the severity of addiction, recovery is possible, even if the term of recovery has a special meaning and may be disputed (Alcoholic Anonymous or Narcotic Anonymous, for instance, do not accept the term of recovery). The way to prove it must be open to everyone. And everyone must receive informations on the orientation which allows him to evolve. From an ethical, moral and also legal point of view, we cannot consider inability as definitive, therefore methods of rehabilitation should be planned.
Inability is not exceptional and does not concern only a tiny minority of the DWI population.
In case of driving while under the influence of a drug such as heroin, it is frequent that there is a toxicodependence and consequently an inability. With respect to alcohol, inability because loss of control of consumption in case of drunken driving is not a marginal phenemenon. We can illustrate this thesis.
We have conducted a study on all the cases of drunken driving recorded by the police in the State of Geneva during one year. We will not give all the details but only some results because this study will be published in the Journal of Preventive Medicine. The State of Geneva is essentially a residential area. Population is 390,000. Each year near 1000 drunken driving cases (BAC above 0.8o/oo) are recorded. In blood samples taken at the time of the offence, we measured GGT (gamma glutamyl transferase) the most widely used marker of alcoholism. In 31% of the cases, pathological values were recorded and are a strong index of usual alcohol abuse. Among these drivers, average BAC is 2.19o/oo whereas it is 1.77o/oo for the others. For BAC above 2.5o/oo (in 20% of the cases), the proportion of drivers presenting abnormal values of the marker is above 50%, reaching even 100% when BAC is 3.4o/oo. We also noted that among the recidivist drivers (22% of the total) 46% have abnormal values of GGT. To reinforce the idea that the drivers with abnormal marker values have lost control of their consumption, we noted that they were arrested especially in the middle of the day (from 9 a.m. to 9 p.m.) and in the middle of the week and not only, like social drinkers, during the night and during the week-end.
With regard to people referred to our institute for expert assessment in traffic medicine and psychology, we examine each year about 100 drivers convicted of drug consumption and 150 recidivist drunken drivers. The drivers convicted of drug consumption are or were, in 90% of cases, heroin addicts. The others were found to have a social and controlled consumption of cannabis, cocaine or ecstasy. Among recidivist drunken drivers, 37% have pathological values of GGT but 60% have or have had alcoholic habits to such an extent that we can talk loss of control of consumption. Among these, alcohol use is reactional (dramatic events, depressive episode,...) in one quarter of the cases. The other 40% are social drinkers who, even when they have some alcoholic habits, have not lost their self-control.
Supported by this data and with reference to the literature, we estimate that approximatively, one third of drunken drivers (with a BAC above 0.8o/oo) and one half of the recidivist drunken drivers are unfit drivers because an uncontrollable alcohol consumption. These people, like drug addicts, can be regrouped under the term of substance dependance and, as such, must be directed to a therapeutic type of action.
The aim of traffic medicine and psychology is essentially to diagnose unability, to guide people to a therapeutic solution, and to evaluate treatment progress. However the therapeutic process itself is beyond their competence. This process is handled by specialists in alcohology, in drug dependence, in psychotherapy, or even in general medicine: in fact it is the concern of specialists in private or institutional therapy. The physician, the psychologist, the therapeutic institution, must be free to treat the patient according to their therapeutic options with a minimum of external pressure. The unfit driver has to give up his status as a driver to become a patient. Only after an evolutionary process in treatment will he recover his status of driver to be evaluated as such. The traffic physician or traffic psychologist has to elaborate ability and inability criteria and communicate these criteria to the driver he examines and to the therapists who cure him. He has, afterwards to examine the evolution by studying the new equation driver-consumer without prejudice on the therapeutic tools. The strict separation between the roles of the evaluator and the therapist seems to us crucial.
We are confronted with people who may have good knowledges and correct attitudes with regard to traffic safety but who cannot apply them. Education is not the right approach since it is the way of life that must be changed. A therapeutic approach will not have strong effects if it is programmed, standardized and forced. Nevertheless it is true that for some, treatment will be followed only with a more or less admitted target to recover the right of driving. In this case, even without compulsory treatment, external motivation is more important than the internal necessity of a radical modification of the way of life. Duration plays then a decisive role since the new way of life must become a network stong enough to remain, and must bring about advantages obvious enough to compensate the tendancy to return to the previous way of life.
In conclusion, we think that there is only one way of rehabilitation for unfit drivers who have lost control of their alcohol or drug consumption: a medical, psychological or institutional treatment, or at least a framework of this kind. It must be free from the pressure created by compulsory programs oriented towards driving ability. Moreover, it must last long enough to allow a reconstruction of a new pattern of life.