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ORIGINAL PAPER

EU DRUID project: results of a questionnaire survey

amongst participants of driver rehabilitation programmes

in Europe

Simone Klipp

Received: 11 May 2009 /Accepted: 12 November 2009 /Published online: 27 November 2009# European Conference of Transport Research Institutes (ECTRI) 2009

Abstract

Purpose This study was one part of the research activitiesof work package 5 Rehabilitation of the integrated EUDRUID project (6th Framework Programme). It aimed atgathering information about the cognitiveaffective and

behavioural processes that participants undergo whileattending driver rehabilitation (DR) programmes. The

primary objective was to analyse the outcomes of groupinterventions for alcohol offenders in order to assessany cognitive, motivational and behavioural modifica-tions within individual participants and to identify therelevant variables which initiate and support this change

process.

Methods The general methodological concept of the studywas a prospective cohort design of participants of group-

based European driver rehabilitation programmes, carriedout via a participant feedback questionnaire survey. In total

N=7.339 DUI offenders in 9 European countries (Austria,Belgium, France, Germany, Great Britain, Hungary, Italy,

Netherlands and Poland) participated in the survey.Results The results indicate that DR participants feel suchprogrammes provide strong support for their cognitive andbehavioural change processes. The findings suggest thatparticipants feel encouraged to establish new behaviouralgoals and the commitment to stick to them. At the same

time, the participants ratings emphasise the important roleof the course leader in encouraging such changes.Conclusions The findings of this explorative questionnairesurvey are promising. Although it is impossible to draw any

conclusions regarding long-term behavioural changes or

effects on recidivism rates, participants of DR coursesexpress positive feedback on completion of the programme.The positive outcomes of the study can motivate decision-makers to launch DR measures and to regard them as anessential part of a comprehensive countermeasure systemagainst DUI.

Keywords DUI . DWI . Driver rehabilitation .

Transtheoretical model . Programme evaluation . DRUID

1 Introduction

Driving under the influence of psychoactive substancesremains one of the main causes of serious and fatal trafficinjuries in the EU [15]. Driver rehabilitation (DR) is one

possible countermeasure for drivers under influence ofalcohol (DUI) and drivers under influence of illicit drugs(DUID). Thereby, the term driver rehabilitation comprisesspecific secondary interpersonal prevention measures thatfocus on attitudinal and behavioural changes of DUI/DUIDoffenders. It includes post-licensing measures for differentdriving-under-influence offender groups, but also coversmeasures for driving license applicants with an official

record related to alcohol and/or illicit drug use. Drinkdriving offenders with a problematic drinking and driving

pattern represent the main target group. Illicit drug drivingoffenders and individuals whose fitness to drive is inquestion due to an alcohol or illicit drug history, are furthertarget groups. The primary aim of driver rehabilitation is toavoid new traffic offences under the influence of alcoholand/or illicit drugs, and/or to re-integrate the individual intothe traffic system without imposing a risk on other traffic

participants [6].

S. Klipp (*)Federal Highway Research Institute (BASt),Bruederstr. 53,51427 Bergisch Gladbach, Germanye-mail: klipp@bast.de

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In the knowledge that sanctions (e.g. license revocation,fines and/or imprisonment) imposed on drivers who havecommitted serious offenses or accidents while beingimpaired due to alcohol and/or illicit drugs do not alwaysresult in behavioural change, the German-speakingcountries took the first initiative to develop DR pro-grammes in Europe in the late 1960s and early 1970s.

Meanwhile, DR programmes for drink driving offendershave been implemented in many European Member Statesand the use of DR programmes for drug driving offenders isalso increasing. Due to specific national situations andtraditions, DR has not developed uniformly in Europe, butall DR programmes share the fundamental aim to modifythe individual problem behaviour and to establish safety-oriented attitudes and behaviours in order to minimize re-offenses in the future. Various recidivism studies havealready revealed the effectiveness of this approach [1, 3, 4,9, 10, 1921, 29, 36].

An extensive body of knowledge and expertise on DR

now exists, but remains fragmented. Hence, DR wasincluded as one specific major research topic of theintegrated EU research project DRUID (Driving under theInfluence of Drugs, Alcohol and Medicines; Project No.TREN-05-FP6TR-S07.61320-518404-DRUID) with theaim to both increase and systematize this knowledge. In afinal step, Europe-wide standards for DUI/DUID interven-tion measures are to be elaborated.

This study was one part of the research activities ofDRUIDs work package 5 Rehabilitation. The aim of thestudy was to gather information about the core elements ofsuccessful interventions for different drivers under the

influence of psychoactive substances. As DR programmesaim at avoiding recidivism, but some participants do not

profit sufficiently from these interventions and tend to re-offend despite participating in a DR measure, the interna-tional research team considered it necessary to analyze thecognitiveaffective and behavioural processes participantsundergo while attending a DR programme. The primaryobjective was thus to assess the outcomes of DR groupinterventions in order to gain insight into change processes,to appraise cognitive, motivational and behavioural mod-ifications within individual participants and to identify therelevant variables which initiate and support the change

process. Thereby, the study did not focus on evaluatingsingle programmes, but targeted at gaining a comprehen-sive picture in general.

1.1 General description of European DR groupinterventions

The first group interventions offered in Europe followed theconcept of driver clinics which were applied in NorthAmerica and Canada in the 1960s and targeted recidivous

traffic offenders in general. The first European interventionswhich have been offered target-specific for drink driverssince 1971 were so-called group talks for repeated driversunder the influence of alcohol [40]. Today, at least 77 DR

providers in 12 European countries offer a pool of 87different programmes [24]. Besides some variationsdepending on different national legal frame conditions

(see Section 1.2), the programmes share some commonfeatures [23]. Although the group sizes vary between 6 upto 20 persons and the programme durations range between10 to 40 h, the intervention approach is commonly a

psychological one with educative elements. Hence, most ofthe programmes are led by specifically trained courseleaders, mostly psychologists. As the programme conceptsare target-group specific, alcohol offenders are not mixedwith drug or general traffic offenders in the majority ofcases [24]. Addicted offenders are usually excluded from

participation in such group programmes. Typically, theprogrammes last over several weeks with the same course

leader and the same course participants which provides abasis for effects of group dynamic processes. The typicalcourse schedule runs as follows. The first session focuseson the establishment of an open, trustworthy group climateand the willingness to work on the problem behaviour. Inaddition, the frame conditions of participation, e.g. confi-dentiality and sobriety during the course sessions, areclarified and often fixed in a contract which is signed byeach participant. In this starting session, it is very importantto provide the participants with the opportunity to speak outtheir frustration, anger, shame and reluctance to participate,

but also to clarify the course leaders role as moderator and

facilitator of group discussions as participants are oftenworried to get instructions and lessons from a teacherincluding examinations like in school or driving school.The participants introduce themselves directly or by meansof partner interviews in order to support group cohesion.When the initial phase is finished, first approaches tocontent-related topics are made, e.g. the collection ofrelevant themes that should be discussed during the courseand the collection of the participants ideas about the mainconditions or factors which led to their drink drivingoffence. Based on these suggestions, common goals can

be identified and an agreement on further steps that need to

be taken can be defined easily. Participants often havequestions about their individual situation or next steps tolicense reinstatement. This in turn gives the opportunity toinclude the experiences of the other course participants. Atthe end of the first session, a short feedback of each

participant can provide useful information about the groupclimate reached so far. In the following sessionsthe exactnumber varies according to national regulationsthe mainissues dealt with are directly or indirectly related to the DUIoffence. These include self-estimation of subjective

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The TTM [3234] provides a detailed description of thecognitive, affective and behavioural processes of anintentional change in behaviour. Since its development, it

has been validated in the fields of diagnostic and treatmentof alcohol problems [12, 14, 27]. Moreover, its applicationhas become widespread in the diagnosis of DUI offenders[16, 25, 38, 39] and the evaluation of DUI rehabilitation[26, 31, 35, 37].

The TTM assumes that an intentional change of aproblematic behaviour proceeds via five stages (Precon-templation, Contemplation, Preparation, Action and Main-tenance). Besides, and of even more value for this studysconcept, the TTM postulates ten processes of change that

individuals make use of in progressing from one stage tothe next [13]. These processes were theoretically derivedfrom different types of therapy and encompass the

integrative structure of the TTM, thereby accounting forthe word transtheoretical in the models name. The use ofthese overt or covert activities determines the movement fromstage to stage [13, 32]. Five cognitiveaffective processes(experiential processes) and five behavioural processes can

be distinguished. The cognitiveaffective processes (Con-sciousness raising, Dramatic relief , Environmental re-evaluation, Self-re-evaluation & Social liberation) play animportant role in the earlier stages when an intention tochange is created (motivation). The behavioural processes

Table 1 Structural features of the programmes in different European countries

Legallyregulated

participation

Instanceimposing/

proposingparticipation

Criteria forprogrammeassignment

Mode ofparticipation

Consequences ofparticipation

Austria yes Licensingauthority

BAC > 1.2 mandatory License reinstatement

Belgium yes Publicprosecutor,court

No licensewithdrawal(BAC < 1.6)& offender < 26years

voluntary Reduction of suspensionperiod & othersanctions, avoidance offurther prosecution

France yes Publicprosecutor,court

BAC > 0.8 voluntary &mandatory

Reduction of suspensionperiod, avoidance offurther prosecution orother sanctions

Germany Type I Special advanced driverimprovement courses

yes Licensingauthority

Novice driverswith DUIoffense

mandatory Ongoing validityof the license orlicense reinstatement

Type II Courses for therestoration of the fitness to

drive

yes Licensingauthority

Prior driverassessment

voluntary License reinstatement

Type III Courses to apply forreduction of the suspension

period or to prepare for themedical psychologicalassessment

no voluntary Reduction of suspensionperiod possible,increased chances to

pass subsequentassessment

Great Britain yes Court Suspensionperiod 12months &offender 17years

voluntary Reduction of suspensionperiod

Hungary yes Court Prior driver assessment

mandatory License reinstatement

Italy no Assessment centre

Prior driverassessment

mandatory License reinstatement

Netherlands yes Licensingauthority

BAC > 1.3%,BAC > 0.8for novicesdrivers &recidivists

mandatory Ongoing validityof the licence

Poland no Prison BAC > 0.5 voluntary Reduction of theprison term possible

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(Self-liberation, Stimulus control, Counter conditioning,Helping relationships & Reinforcement management) aremore important in the later stages, representing theimplementation of an intention (volition) and translationinto concrete behaviour (action).

The second theoretical concept, the Diamond of Change[8], describes certain key elements that are supposed to

initiate and to contribute to change processes in DR groupinterventions. These key elements basically originated fromoutcomes of evaluation studies in psychotherapy andaddiction research as well as from personal long-standingexperience as leaders of DUI/DUID group courses. Find-ings from a prior EU ANDREA Project (Analysis of DriverRehabilitation Programmes) [2] also provided relevantinput.

The following five key elements, or contributing factors,are considered to be important and to initiate the motiva-tional and behavioural change in the participants of DRcourses: I = Individual; this key element is defined as the

participants self-acceptance and self-efficacy; PTR = Partic-ipanttrainer relations; meaning the interpersonal relation-ship between the DR participant and trainer; PPR =

Participantparticipant relations; this element concerns theinterpersonal relationship between the course participants;C = Contents; defined as the modules of the DR-measure;M = Methods; this element takes into account the ways andmeans in which the contents are presented and how thecourse is conducted. As all five factors are seen to be keyelements of equal importance interacting with each other andintertwined in a complex way, the structure of a diamondwas chosen to illustrate this and the name Diamond of

Change was created (see Fig. 1).As a consequence, the feedback questionnaires consisted

of items with statements mirroring the different changeprocesses. The items were developed on the basis ofGerman and English versions of the TTM-related ques-tionnaires SOCRATES [30], RTCQ [18], URICA [28] andPOCA-G [11]. Within each item one of the corners of theDiamond of Change was always presented in order toidentify the factor which contributed to the specific

processes (contributing factors). Thus the items consistedof two elements: the contributing factor (mainly at the

beginning of the sentence) and a statement representing

the process that may have been undergone, e.g. Throughthe way the course was conducted (method) I see some ofmy troubles in a different way (self-re-evaluation).Participants were asked to mark their agreement with theitems on a Likert-type scale with four possibilities (agreecompletely, agree mostly, disagree mostly, and disagreecompletely). Besides the concept-related items, an overallevaluation of the course was requested (very good, good,

poor, very poor). In addition, a series of questions on socio-demographics and offense-related variables such as blood

alcohol concentration (BAC), prior DUI convictions andprior DR course participation were included. The surveyinstrument was improved within two test runs and the finalversion was translated into several languages [German(German and Austrian), English (British), French (Frenchand Belgian), Dutch (Dutch and Flemish), Hungarian andPolish]. As the focus of the study was not on evaluating single

programmes, but also in order to fulfil the ethical requirementsregarding anonymization and data protection imposed by theEU Commission for the DRUID research, the specific

programmes were not coded on the questionnaires.The data collection lasted from August 2007 until

January 2008. The questionnaires were distributed to theparticipants after they had received their certificates ofattendance at the end of the final group session. For data

protection reasons, and also to avoid answers biased bysocial desirability, the participants sealed the questionnairesin envelopes after filling them out. Subsequently, the courseleader collected the envelopes and the providers sent them

to the research team.

2.2 Sample description

In total N=7.339 DUI offenders in 9 European countries(Austria n =1,646, Belgium n =103, France n =686,Germany n=2,351, Great Britain n=1,022, Hungary n=657, Italy n=140, Netherlands n=501 and Poland n=233)

participated in the questionnaire survey. The mean age ofthe DUI sample was 34 years old (SD=12.6) with 10.7%

being female. The average BAC of the sample was 1.43(SD=0.58). Nearly 60% of the survey participants lived in

small towns and only one fourth completed full secondaryschool education or higher education. Almost one fourthwas detected due to an accident and approximately thesame amount were recidivists. Nearly 12% already

participated in a DR programme prior to the current one.Detailed results regarding demographics and offense-related variables for the whole European sample are

presented in Table 2; selected variables are displayed ona country level in Table 3.

2.3 Data analysis

Data processing was carried out by the Austrian RoadSafety Board (KfV). Data were analyzed for the totalEuropean sample. Besides the country variables, allincluded socio-demographic and offense-related data servedas independent variables in the subsequent analyses,whereby the variable educational background was di-chotomized to 0 = no completion of full secondaryeducation and 1 = at least completion of full secondaryeducation (higher education than compulsory and second-ary school attendance).

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influence on the overall course evaluation (recidivism:p=.828; education: p=.221). All results of the analyses of

socio-demographic and offense-related variables as inde-pendent variables are displayed in Table 6.

3.2 TTM processes

The results for the overall means on each scale of the TTMbased on the answering format in the feedback question-naire (1 = agree completely, 2 = agree mostly, 3 = disagreemostly, 4 = disagree completely) reveal that course

participants generally show high agreement on all processscales (see descriptive statistics in Table 4) with theEuropean means ranging from M=1.39 (0.56) to M=

1.92 (0.97). Thereby the participants show highestagreement with the items representing self-liberation,meaning they found the course supportive for their choiceand commitment to change their behaviour. On thecontrary, participants agree less on scales representingenvironmental re-evaluation and dramatic relief. Hence,they experienced the course to be less supportive foraltering the perception and assessment of how the problem

behaviour affects their physical and social environment andlacked emotional involvement somehow. When comparingthe overall sum score means for all cognitive affective

processes to the overall sum score means for all behavioural

processes for the total European sample, it becomesobvious that the participants agree significantly higher (t=43.02; df=7,231; p

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are affirmed by the participants ratings. Thereby, theparticipanttrainer relations is judged to be the mostsupportive factor by the total European sample (M=1.330.52). The methods (M=1.670.77) and the other partic-ipants (M=1.670.70) are considered to be of leastimportance, but still gain relatively high scores foragreement (Table 4). The country comparisons reveal

significant differences between the countries regarding theparticipants ratings of the importance of the differentcontributing factors (p

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Table5

Resultsofmultiplecountr

ycomparisons(posthocSchefftests)

Variable

Multiple

comparisonresults;Countrieswithsign.d

ifferencesp.0

01

(meanD

iff)

Countriesforming

homogenoussubgroups(alpha=.05)inascendingorder

I

II

III

IV

V

Overallcourse

evaluation

GB-A(.19)

GB-B(.30)

GB-D(.37)

GB-F(.21)

GB-H(.38)

GB-I(.49)

GB

PL,A,F,B

F,B,D

B,D,H

D,H,I,

NL

GB-NL

(.50)

A-D(.18)

A-H(.19)

A-I (.30)

A-NL(.31)

PL-D(.19)

PL-I(.31)

PL-NL

(.32)

F-D(.16)

F-H(.17)

F-I (.28)

Transtheoretical

modelprocesses

Consciousness

raising

GB-A(.24)

GB-D(.22)

GB-F(.30)

GB-H(.44)

GB-I(.37)

GB-NL

(.24)

GB,PL

PL,D,NL,A,

B,F

D,NL,A.,B,

F,I

B,F,I,H

H-A(.20)

H-D(.21)

H-PL(.30)

H-NL(.20)

Dramaticrelief

NL-A(.44)

NL-D(.52)

NL-F(.30)

NL-GB

(.42)

NL-H(.29)

NL-I(.55)

I,D,A,GB,F

D,A,GB,F,H

A,GB,F,H,

B,PL

B,PL,NL

D-F(.22)

D-H(.23)

D-PL(.30)

Environmental

re-evaluation

PL-A(.40)

PL-B(.64)

PL-D(.35)

PL-H(.41)

PL-NL

(.53)

PL,F,GB

F,GB,I,D,A,

H

I,D,A,H,

NL

D,A,H,

NL,B

Selfre-evaluation

GB-A(.22)

GB-D(.18)

GB-F(.24)

GB-H(.21)

PL,GB,B,D

,H,

NL,A

GB,B,D,H,

NL,A,F

B,D,H,NL,

A,F,I

Socialliberation

a

GB,A,D,B,

H,

PL,NL,F

D,B,H,PL,

NL,F,I

Cognitiveaffective

processscales

(insum)

GB-A(.16)

GB-D(.14)

GB-F(.20)

GB-H(.27)

GB-I(.23)

GB-NL

(.26)

GB,PL,D

PL,D,A,F,B

D,A,F,BI,

NL,H

H-A(.12)

H-D(.14)

H-PL(.19)

D-NL(.12)

Selfliberation

GB-A(.17)

GB-D(.22)

GB-F(.23)

GB-H(.24)

GB-I(.36)

GB-NL

(.18)

GB,PL,A

PL,A,NL,B,

D,F

A,NL,B,D,

F,H

B,D,F,H,

I

I-PL(.31)

Stimuluscontrol

GB-A(.19)

GB-D(.19)

GB-F(.24)

PL,GB,H,N

L,D,

A

H,NL,D,A,F,I

NL,D,A,F,

I,B

Counterconditioning

GB-A(.22)

GB-D(.27)

GB-F(.30)

GB-H(.27)

GB-I(.38)

GB,PL,NL

PL,NL,A,B,

D,H

NL,A,B,D,

H,F,I

Helpingrelationships

I-A(.32

)

I-D(.33)

I-GB(.42)

I-PL(.39)

H-D(.16)

H-GB(.25)

GB,PL,D,A

,F,

B,NL

D,A,F,B,NL,

H

H,I

Reinforcement

management

NL-A(.31)

NL-D(.30)

NL-GB

(.40)

NL-H(.33)

NL-PL

(.54)

B-PL(.56)

PL,GB,I,H,

A,D

GB,I,H,A,D,

F

F,NL,B

Behavioralprocess

scales(insum)

GB-A(.16)

GB-B(.26)

GB-D(.18)

GB-F(.21)

GB-H(.20)

GB-I(.32)

GB,PL

PL,A

A,D,H,NL,

F,B

D,H,NL,

F,B,I

GB-NL

(.20)

PL-F(.19)

PL-I(.30)

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ones. These results are not surprising, as voluntaryparticipation means that the individuals who decide toattend a course are likely to be highly motivated andexpect it to be beneficial. These advantages are enhanced

by offering obvious reward stimuli which enhanceextrinsic motivation. In this study, British offenders whosuccessfully completed the course gained a reduction in

their suspension period and successful Polish offenderswere very likely to have their prison term reduced.Hence, the steepening incentive effect may even increasefor those participants. In any case, those who decide to

participate voluntarily are intrinsically motivated and mayalso expect advantages for themselves and their future

behaviour. Thus, when they are subsequently asked fortheir opinion on what the programme achieved, they arelikely to evaluate the programme positively in order toavoid negative feelings along the lines of the theory ofcognitive dissonance [17]. Nevertheless, the good to verygood overall evaluations of all European courses show that

even those DUI offenders who participate on a mandatorybasis, and who are often reluctant at the beginning of aprogramme, are convinced of the programmes supportivefunction and express high acceptance on completion of thecourse.

All in all, the findings of this explorative question-naire survey are promising in terms of acceptance.Although it is impossible to draw any conclusionsregarding any long-term behavioural changes or effectson recidivism rates, participants of DR courses express

positive feedback after succeeding the programme. Thefact that this large sample, recruited from various

nations, felt that these courses strongly supported theindividual change processes that are targeted by DRmeasures may at least trigger the implementation of DR

programmes. Furthermore, and considering the fact thatEuropean group intervention programmes for DUIoffenders show an average recidivism reduction rate of45.5% [23], these results should motivate decision-makersin those countries which did not yet establish DR

programmes to launch DR measures and to regard themas an essential part of a comprehensive countermeasuresystem.

Acknowledgements The author would like to thank the followingcolleagues of the DRUID research team who contributed to thisstudy: Birgit Bukasa, Sofie Boets, Eveline Braun, Uta Meesmann,Elisabeth Panosch and Ulrike Wenninger, for all their work and

pleasant cooperat ion. Thanks are also due to Elisabeth Ponocny-Seliger for her assistance with data management and to all

participating providers in Europe for their highly appreciatedefforts to contribute to this research. I further acknowledge thefunding of the EU DRUID project by the European Commission asthe realization of this study would not have been possible withoutits support.

(meanD

iff)

I

II

III

IV

V

Diamondofchange

contributingfactors

Individual

GB-A(.19)

GB-B(.30)

GB-D(.18)

GB-F(.23)

GB-H(.27)

GB-I(.30)

GB,PL

PL,D

D,A,F,NL,

H,I,B

GB-NL

(.25)

PL-F(.20)

PL-H(.25)

PL-NL

(.22)

Methods

GB-A(.31)

GB-D(.36)

GB-F(.28)

GB-H(.44)

GB-I(.37)

GB-NL

(.32)

GB,PL

PL,F

F,A,NL,B,

D,I,H

PL-D(30)

PL-H(.38)

Contents

GB-F(.17)

GB-NL

(.23)

GB,PL,D,I,

A,

H,B,F

PL,D,IA,H,

B,F,NL

Participantparticipant

relations

GB-H(.21)

GB,B,D,A,

NL,

F,H,PL

D,A,NL,F,H,

PL,I

Participanttrainer

relations

GB-D(.15)

GB-H(.23)

GB-I(.41)

I-A(.34)

I-D(.27)

I-F(.31)

GB,A,PL,F,NL,

D

A,PL,F,NL,D,

B,H

I-PL(.31)

I-NL(.28)

A-H(.16)

a

Thehighestp-valuewasp=.002f

orcountrycomparisons

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