This chapter presents an overview of screening and assessment for alcohol and other drug (AOD) abuse problems. It first defines these processes and clarifies how assessment differs from the classification of offenders as performed by the criminal justice system. This is followed by descriptions of the basic elements of a comprehensive assessment. Next, the chapter details the training and qualifications needed by professionals who perform clinical screening and assessment. A rationale is offered for increased coordination between criminal justice and AOD abuse treatment programs and guidelines for building successful linkages. The chapter concludes by reviewing several special issues involved in the assessment of criminal justice clients and the selection of treatment options for these clients. These issues are explored in greater detail in Chapters 4, 5, and 6.
The term classification is used by the criminal justice system to refer to the process by which a jail, prison, probation, parole, or other criminal justice program assesses both the security risk represented by the individual offender and, ideally, the individual's need for social services.
In its broadest sense, classification is the process in which the educational, vocational, treatment, and custodial needs of the offender are determined. In theory, it is a system by which a correctional agency reckons differential handling and care, and fits the rehabilitation and security programs of the institution to the requirements of the individual (Inciardi, 1993).
In practice, many criminal justice programs attempt to assess and meet the human service needs of offend-ers, but this assessment is subordinated to the need to maintain security and to protect the community.
A clinical screening is a preliminary gathering and sorting of information used to determine if an individual has a problem with AOD abuse, and if so, whether a detailed clinical assessment is appropriate.
The screening may be performed by personnel from the criminal justice system, a treatment program, or a linkage system such as Treatment Alternatives to Street Crime (TASC).1
The limited availability of funds for clinical assessment necessitates this screening process. Screening also filters out individuals who have medical, legal, or psychological problems that must be addressed before they can participate fully in treatment. A screening program should connect individuals with these and related problems to a specialized social service program tailored to meet such primary needs. Assessment for the specialized program will occur at the special program site.
Eligibility criteria for AOD abuse treatment programs vary. This is true in part because treatment programs provide services that are appropriate for some patients but not others. Similarly, patients have specific needs that may or may not be met at a specific program. In some cases, a treatment program screens out an individual but refers him or her to another treatment program that can provide the specialized assessment and treatment that the individual needs.
The screening process consists of asking a few questions designed to:
Identify the existence of an AOD use problem
Identify individuals with a history of violent offenses or severe medical or psychiatric problems
Identify individuals who have severe mental retardation
Identify individuals who would not for any reason be eligible for release to treatment or accepted by a treatment program.
Most importantly, however, the screening process is designed to determine who can benefit from treatment and which general category of treatment (for example, long-term versus short-term; residential versus outpatient; drug-free, etc.) is most appropriate for each client.
Current practices of clinical assessment evolved from the classification schemes found in correctional systems and prison reception centers. A clinical assessment is the collection of detailed information concerning the client's substance use, emotional and physical health, social roles, and other areas that may reflect the severity of the client's abuse of alcohol or other drugs, as a basis for identifying an appropriate treatment regimen. The clinical assessment is performed by trained treatment professionals. The primary purpose of clinical assessment is to develop a picture of the client's substance abuse pattern and history, social and psychological functioning, and general treatment needs. With the benefit of this detailed portrait, the treatment program can prepare an appropriate clinical response.
A second function of assessment is to initiate the process of treatment. The assessment can serve this function only if the interviewer succeeds in actively engaging the client in the assessment process. In a clinical assessment, the individual is confronted with the consequences of his or her substance abuse and challenged to see that the continuance of this behavior represents a personal choice. Together, the client and the clinician determine the behavioral changes that the client wants to make. The recommendations of the assessment are later reviewed with the client, who then decides whether to consent to treatment.
The many dimensions of the clinical assessment are grouped here under three broad domains -- socio-behavioral, psychological, and physical. In addition to gathering detailed, multidimensional information, the clinician should prepare a summary statement that integrates and interprets the information.
An assessment of clinical risk explores the social world and behavioral history of the individual to gather information concerning the individual's history of AOD abuse, involvement in the criminal justice system, social support and social roles, educational and vocational needs, and spirituality.
The assessor gathers information about how and when the client's use of AODs began, the frequency and pattern of use, the types of drugs used, the client's previous attempts at self-help, previous formal treatment and its results, and patterns of AOD abuse in the individual's family. Given the health risks associated with tobacco smoking and passive exposure to smoke, and given that treatment options exist for nicotine addiction, the assessment should include questions related to nicotine addiction.
The assessment interview should document the client's past involvement in the criminal justice system and current legal charges. Clients may be removed from treatment as a result of a disposition concerning pending charges against them. Thus, information on current charges is necessary for treatment planning.
The clinician should ascertain the extent and quality of social support the client receives. Do the client's family members and friends support his or her treatment and recovery, or do they act as codepen-dents who enable the individual's addiction to continue? The assessment of social roles should also explore the individual's care-giving responsibilities, the place the individual occupies in the structure of the immediate and extended family, and the individual's employment status. In the case of female clients, it is especially important to gather information about their responsibility for taking care of dependents. Clinical assessments often fail to gather this information, but it has great bearing on the form of treatment that is appropriate for many female clients.
Information gathered about the individual's current employment status, level of educational attainment, and marketable skills helps determine the individual's need for education or job training.
Spirituality here refers to a belief in a Higher Power, a general "sense of belonging in the universe," or a sense of community. There is evidence that spirituality plays a positive role in an individual's recovery from alcohol or other drug abuse. Information on spirituality is not gathered for later use in persuading the client to accept any particular religious belief or doctrine. Rather, this information helps match the individual with appropriate services. In fact, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) requires that the organizations it accredits assess the client's spirituality as a part of the clinical assessment.
As noted earlier, the initial clinical screening filters out seriously disturbed individuals in order to refer them to appropriate psychological treatment. A client's serious emotional disorders and disturbances must be treated first, if they are primary, or concurrently, to enable the client to benefit from treatment. The psychological portion of the clinical assessment may likewise identify an individual who should be referred to psychological treatment before receiving treatment for AOD abuse. The clinical assessment also builds a psychological profile of the client that facilitates the provision of treatment. The interview should assess the following:
Levels of anxiety and depression
Personality disorders
Locus of control
Level of psychological development
Organic brain syndromes
Central nervous system function and impairment
History of sexual, emotional, and/or physical abuse
The biomedical portion of the assessment determines the client's general state of medical and dental health and identifies any chronic or acute medical problems, including nutritional deprivation. The assessment also obtains information on the client's history of infectious and contagious diseases, including HIV and tuberculosis. The rationale for the biomedical assessment is threefold. First, this assessment, like the psychological assessment, provides information to help the treatment program staff design the optimal treatment. Second, this assessment makes it possible for the treatment program to refer clients to appropriate medical services. Third, by performing standard medical assessments, treatment programs can gather data that can be used to raise public awareness of the increasingly limited availability of basic health care services.
The assessment should conclude with an integrated summary of critical information and diagnostic impressions concerning the individual and his or her treatment needs. This summary should comment on the individual's general quality of life and level of functioning. It should also set priorities for the treatment of the various problems related to the client's abuse of alcohol or other drugs. Such a summary is required of institutions accredited by the JCAHO.
Any professional staff member of a treatment or criminal justice program can be trained to conduct the initial clinical screening. To perform an indepth clinical assessment, an individual needs training, professional experience working with substance abusers, and an intuitive or learned ability to engage the client's active participation. With appropriate training, ex-offenders and other people recovering from AOD abuse can become very effective clinical interviewers for some segments of the overall clinical assessment process.
To conduct the psychological and sociobehavioral portions of the assessment reliably, the interviewer must have sufficient professional training and clinical experience. The interviewer must also be able to communicate the findings of the assessment concisely and accurately to the client and all other relevant parties. Appropriate professionals for this task include psychologists, social workers, certified substance abuse or addiction counselors, and clinical nurse specialists. The individual's understanding of the assessment process is as important as the type of professional credential he or she holds. The biomedical portion of the assessment should be conducted by a licensed medical professional with training in diagnostic skills, such as a physician, physician's assistant, nurse practitioner, or nurse clinical specialist.
Training for all portions of the clinical assessment, including the medical assessment, should build several kinds of skills: 1) the ability to establish rapport; 2) the ability to conduct nonjudgmental, nonthreatening interviews; 3) the ability to succinctly document information throughout the assessment and in the integrated summary; and 4) cultural competence. Specific training should also be given for the use of any specific assessment instrument.
To provide consistent information for individual treatment planning as well as program evaluation and systemwide service planning, it is important for programs to use standard assessment instruments. It
is also appropriate for programs to develop additional clinical instruments to meet their particular needs. Standard assessments should not be the sole means of assessing a client's needs. Rather, they should be used in combination with the interviewer's structured, clinical, and intuitive assessment of the client.
Coordination between treatment and criminal justice programs makes assessment and treatment programs more effective. Criminal justice decisions regarding treatment can be more appropriately made, and are more acceptable to treatment personnel, when consultation between the two groups has occurred. It is important for treatment and criminal justice staff to understand the goals of both systems. Policies and practices in the criminal justice system are more likely to support the goals of treatment when consultation has occurred, and vice versa. Finally, scarce resources for the treatment of AOD abuse are put to the best possible use when they are used after consultation between the two systems.
Criminal justice and treatment systems cannot achieve enhanced coordination simply by reaching a formal agreement to collaborate. To encourage a team approach to treatment assessment, referral, and case management, the two systems need to develop or strengthen arrangements that support linkages at the institutional level and in the management of each client's treatment. In addition, cross-training can maximize the effect of both systems' screening and assessment efforts and minimize the need for duplication of effort.
At the institutional level, the team managing coordination between the two systems should include the director of probation or prison director, judges, prosecutors, representatives of the defense bar where appropriate, and the treatment director. Led by this team, the two systems should collaborate to develop broad statements of working policies that specify the principles and rationales guiding the new collaborative relationships. In particular, those documents should provide details on the following:
The needs and goals of each institution
The means by which these needs and goals will be met, with suggested timeframes
Guidelines for sharing information at the various stages of the assessment and treatment process,
within the framework of consent regulation
Guidelines for providing a continuum of care that makes it possible to match the particular treatment needs of a client with a specified level of treatment, often at transitional points in the correctional process. For example, when the client is transferred from prison to a community correctional program, he or she may be able to enter an outpatient treatment program.
The management team for each client should include a representative of each institution involved (for example, the probation officer and a treatment counselor). Criminal justice personnel must be included in the individual case management team at each stage of the treatment process, beginning with the clinical assessment.
The case management team should reach formal agreement on the answers to the following questions:
What are the goals and timeframe for treatment?
What guidelines will govern the kinds of information that will be shared? (For example, will the parole officer expect the treatment program to report if the offender relapses to drug use?)
What process will be followed to reach decisions concerning such questions as whether pretrial release, probation, or parole should be revoked; when treatment should be considered a failure; and how personnel in both systems will respond in the event of specific treatment problems?
The intent of these recommendations is not to create new bureaucratic systems, but, rather, to use existing agencies and personnel to achieve close coordination among systems. The use of coordinated case management teams is necessary to make efficient use of scarce resources and to increase the effectiveness of case management. Increased coordination does not require new personnel, but only new training of existing personnel in all systems.
Professionals working in systems that link treatment and corrections must be aware of a broad range of special issues in assessment related to clients' gender, culture, ethnicity, sexual orientation, educational level, religious affiliation or spirituality, and other such sociocultural characteristics. Issues related to a number of these characteristics are discussed below.
The person performing the assessment must be able to tailor the interviewing process to the client's levels of literacy, verbal communication, and listening skills. The person performing the assessment needs to establish sufficient rapport with the client to make sure that the client understands the questions asked and the information being shared. The interviewer should avoid presupposing the client's literacy level based on social class, race, or ethnicity. The interviewer should also be aware that a client's inability to read or write does not make the client unable to take an active part in the assessment. For some clients, it may be necessary to substitute an oral interview for a paper-and-pencil assessment.
It may be necessary to perform the assessment in the primary language of the individual, which may not be English. Assessors should avoid the assumption that a speaker of any given language can also read that language. The client may not be functionally literate in any language. Another part of the staff member's sensitivity to language should be an awareness that the client may need to communicate in "street language." The assessor should be attentive to the kind of vocabulary that the individual client feels most comfortable using. To the extent possible, concepts should be stated in lay language, even street language, if appropriate, but not professional or clinical jargon.
Using appropriate language is an essential part of making a true connection with the individual, so that he or she becomes engaged in the assessment process. While good assessment may be largely an intuitive process, specific assessment skills can be taught. Training can be provided in nonjudgmental interviewing techniques, rapport building, sensitive probing, and multicultural sensitivity.
For appropriate assessment, it is critical that culturally and linguistically competent staff are available. The assessor must be aware of the importance of the client's cultural identity and the extent of his or her acculturation into the dominant culture. Some programs attempt to draw on traditional cultural strengths of the individual in specific ways; these may be appropriate for the individual who has a strong identification with his or her culture of origin, but it may be inappropriate for other individuals of the same group. It is necessary to gain some sense of the meaning that the individual's culture holds for him or her personally, rather than relying on presuppositions.
The client's culture has many potential implications for the process of the assessment. Some cultures view direct questioning as inappropriate. Therefore, individuals from this type of culture may view the assessment process as highly intrusive. A goal of the assessment process is to understand the client's world from his or her own cultural perspective.
The importance of making appropriate inferences from information about an individual's culture makes it imperative that programs involved in assessment exert a strong effort in good faith to hire assessors representative of the populations they serve. When qualified professionals from these cultural groups are not on staff, treatment programs can seek to employ counselors or support staff from these groups, in order to create a diverse multicultural program environment.
For effective assessment and placement, it is necessary to recognize that institutional and individual discrimination may exist in the criminal justice system and other institutions, and that bias can negatively affect classification, screening, and assessment.
In the last decade, the growth in women's prison populations has been dramatic. According to the Bureau of Justice Statistics, the average daily population of women confined in local jails rose by more than 95 percent, as compared with only a 50 percent increase in the male jail population. The need for sensitivity to gender issues is apparent.
Treatment programs should guard against perpetuating institutional sexism -- institutional policies and practices that systematically ignore the special diagnostic, assessment, and treatment needs of women. They should also be aware that female clients may not have received a full exploration of findings that suggest treatment need. For example, many current assessment tools were developed specifically for male clients. These instruments tend to explore factors related to men's traditional roles such as performance in the workplace. (The Addiction Severity Index now includes modified severity indexes for women, as well as sections on living arrangements and relationships that are more sensitive to women's lives than previous versions. Instruments need to be tailored in this way for men and women.) Furthermore, women's abuse of AODs may go unnoticed because women are less likely to have contact with employers or others who would press them into treatment. Fear of the male offender is another impetus for the criminal justice system to refer men to assessment and treatment while neglecting the assessment needs of women, who may be viewed as less threatening to society.
Misdiagnosis can occur if the person performing the assessment has preconceptions about the kinds of psychological dysfunction that women are likely to present. For example, physicians or psychologists may misread symptoms of alcoholism as symptoms of depression. Rates of depression for male alcoholics are comparable to the rate for males in the general population, but female alcoholics are significantly more likely to have a diagnosis of depression than either women in the general population or male alcoholics. Professionals performing medical assessments must be aware of physical differences in the ways that the abuse of AODs is manifested in men and women. Some research suggests that there may be differences in the way alcohol is processed in men and women.
A complete biopsychosocial assessment includes nonjudgmental questions designed to assess the individual's sexual orientation, the individual's understanding of and attitudes toward his or her own sexual orientation, and the family and social supports available to the gay or lesbian client. This information has implications for the etiology of AOD abuse, for related mental health issues, and for the placement of the individual in treatment. Some treatment programs, because of their institutional culture, may not be appropriate for homosexual, bisexual, or lesbian clients.
Questions intended to explore the individual's sexual orientation should be framed neutrally. For example, "How do you identify yourself -- as gay, lesbian, bisexual, heterosexual . . . ?" Clients may be at varying stages in exploring and defining their sexual identity. Asking questions in an open-ended way gives clients the opportunity to explore their sexual identity in the course of the assessment and treatment.
As public funding has declined, treatment programs concerned about their economic survival have often become biased against the poor. A common assumption is that in allotting limited treatment slots, treatment programs should sacrifice the treatment of the poor. The many common negative stereotypes about the poor and their motivations contribute to this bias. Programs that are committed to providing services to the poor must recognize that indigent people may require more intensive services because they have not had access to adequate food, shelter, or medical treatment.
The person performing the assessment should be respectful of all religious affiliations and of the nonreligious client. The assessor should be sufficiently familiar with the beliefs and practices of various religious groups in the community to avoid offending the client and to refer the client, when appropriate, to a treatment program that can make use of the client's spirituality or religious belief as a strength. As mentioned earlier, belief in a Higher Power or a sense of "belongingness" within one's family and the universe has a positive association with effective treatment. Working together with corrections, treatment personnel should also serve as advocates for religious freedom in prison as a part of treatment services in prisons.
The assessment process should include an assessment of any physical disabilities. The physically handicapped client must be placed in a treatment program that is physically accessible. Some clients will be screened out of placement in a particular treatment program if it is inaccessible; others will not be screened out but will need some accommodation for their special needs. This is an important part of the treatment match; the assessor should take care to gain specific information about what the disabled client can and cannot do for himself or herself, in order to place the client in a workable setting.
The primary risk factors for HIV infection that should be assessed include the frequency of drug injections, the sharing of drugs and injection equipment, the use of bleach to sterilize needles, the number of sexual partners, patterns of condom use, sex-for-drug exchanges, and a history of sexually transmitted diseases. Given that more than one-fourth of individuals who have been diagnosed with AIDS are drug injectors, all assessments performed should include an evaluation of the client's risk of contracting HIV. For women and people of African-American, Hispanic, and Caribbean origin, drug injection or sexual relations with a drug injector are principal risk factors for HIV transmission. One of the purposes of this evaluation is to develop a plan for reducing the client's HIV risk behavior.
Treatment professionals working with criminal justice populations have a particular responsibility for addressing the AIDS epidemic, for several reasons. First, analysis indicates that the criminal justice system comes in contact with the portion of the AOD-abusing population that is most at risk for HIV infection. Second, there is a disproportionately high incidence of HIV seropositivity in prisons. Third, because the prison population is captive, treatment programs have an opportunity to assess HIV risk and encourage preventive measures.
It is important to emphasize that risk behaviors, as well as HIV status, should be assessed. However, HIV testing should not be mandatory, for several reasons. First, the decision of an individual to learn his or her HIV status is a private one that requires pretest and post-test counseling. Second, knowledge that an individual is HIV-positive can threaten his or her access to services, personal safety in the prison environment, and access to medical insurance. Third, massive HIV testing clouds the issue because the focus of HIV prevention efforts should be on reducing risk, not identifying individuals' HIV status. Fourth, mandatory testing would override confidentiality regulations and violates some State laws.
When symptoms of AIDS are discovered during the course of a medical assessment, HIV testing may well be indicated. Individuals diagnosed with HIV infection or AIDS should be referred to appropriate counseling and medical services.
As noted earlier in this chapter, assessment is the first step in the treatment process. Assessment is a good place to begin educating the client about the risks and consequences of HIV infection. It is imperative that clients who engage in high-risk behaviors be referred to programs that emphasize ongoing risk reduction education.
1 For a discussion of TASC, see Inciardi, J.A., and McBride, D.C. Treatment Alternatives to Street Crime (TASC): History, Experiences, and Issues. Rockville, MD: National Institute on Drug Abuse, 1991.
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