Screening, clinical assessment, and determining a client's readiness for treatment represent the beginning of the treatment process. The elements of each of these activities are detailed at length in this chapter.
The goals of screening criminal justice offenders for alcohol and other drug (AOD) problems are to identify potential candidates for treatment intervention as early as possible in their criminal justice processing and to interrupt their cycles of addiction and crime. The screening process can begin when a police officer responds to a complaint or makes an arrest. At an initial screening, a few quick and simple questions are all that are needed. Basic, simple, and direct questions can yield useful answers. Not asking them will yield no information. Simple questions might include:
Did you ever do anything while drinking or using drugs that you regretted later?
Have you ever gotten into a fight because of your drinking or drug use?
After this initial point of contact, there are several more points where either formal or informal AOD screening can be conducted as AOD users move through the criminal justice system. These points include: in the jail or the lockup, at arraignment, at pretrial investigation, at meetings with prosecutors and public defenders, in interactions with various officers of the court and representatives of the criminal justice system, and at probation violation hearings. These officials can be made aware of their potential impact on AOD abuse treatment, and taught basic screening techniques. Despite the lack of nationwide uniformity in the various agencies and institutions that comprise the criminal justice system, similar techniques can be applied systemwide, and can effectively identify a large number of offenders for further assessment -- which is the point of screening.
The use of AODs is pervasive in today's criminal justice population. Study results vary, but most suggest that up to 80 percent of the street crime in this country involves AOD use. Offenders may use AODs and/or steal to feed drug habits, and violence often results from AOD abuse and during drug deals. Nearly half of all traffic fatalities involve the abuse of alcohol. There are high correlations between AOD abuse and certain public health problems. Moreover, AOD screening can be an opportunity to screen for diseases such as tuberculosis (TB), hepatitis, and HIV infection and other sexually transmitted diseases. Thus, as increasing numbers of AOD abusers are screened and treated, the potential exists to reduce associated crimes, deaths, and accidents.
Because arrestees are often in a state of psychological crisis, arrest can be an excellent stage for screening. Arrestees are often anxious, depressed, and frightened. The negative consequences of their AOD abuse are often obvious and severe, and hard for the arrestee to deny. At this point, offenders may offer information about their AOD abuse. Once released from the criminal justice system, their concern for the gravity of their situation will usually fade.
From the standpoint of public safety, the pretrial phase, when the largest number of potential abusers are in the system and under control, provides the greatest potential for early identification. Without identification and intervention, most AOD-using offenders will rejoin the general population with little or no knowledge of their AOD abuse problem or resources that exist to assist them.
An initial screening is useful in separating those who are likely to be addicted from those who are not. Screening does not require extensive training. It begins with being aware, and includes listening and noticing behavior and actions.
Screening interviews should be done in private. Offenders have a right to privacy and to confidential handling of all information they provide.
Most users are likely to abuse several drugs. Sometimes the AOD involvement is obvious. The smell of alcohol may be readily apparent; a suspect's behavior may be bizarre or disoriented; drugs may be evident on the scene. Sometimes the AOD involvement is less obvious. Episodes of domestic violence or fighting among friends may involve AOD abuse that is hidden from sight. However, police officers can learn to look for signs of AOD use and to trust their instincts, intuition, and judgment about the possible role of AODs. They can pass their impressions on to the next criminal justice official handling the case. Ongoing communication and data-sharing are important aspects of the screening process. Screening is not a single event, but a continuous process that can be repeated by a variety of professionals in a variety of settings.
A number of basic screening instruments are available, such as the CAGE questionnaire, which has four simple questions to look for potential alcohol involvement. More indepth screening and assessment can be done by using the Michigan Alcoholism Screening Test (MAST) or the Offender Profile Index (OPI). Several of these instruments are included in the appendices to this document. Certain biological measures such as Breathalyzer, blood-alcohol, and urine tests are also important screening tools.
Screening is a hierarchical, although flexible, procedure. If it errs, it should err toward the false positive. The idea is to rule out people without problems, and raise the index of suspicion regarding others. A positive screening, at any point in the process, is a trigger for a more formal and thorough AOD use assessment.
Those involved in the screening process can include police officers, city and county jail employees, defenders, probation officers, magistrates, prosecutors, hearing officers, and counselors. Screening can be conducted in the lockup, the probation office, the prosecutor's office, the detective's interviewing room, the arraignment or hearing officer's courtroom or chambers, and the jail or prison orientation room.
It is the function of criminal justice system officers, at all points of the process, to pass on information they have obtained from the AOD screening procedure. Although screening does not have to involve much paperwork, information should be documented in written form in a case file, even if a client does not go on to criminal prosecution, so that it can be acted upon in cases of subsequent arrest. It helps if a standardized format is used so that it will be understandable to people in justice and treatment who refer to it in the future.
If a client acknowledges having an AOD problem and recognizes the extent of the problem, much has been accomplished -- for this represents the end of the screening, a signal to initiate further AOD assessment. If he or she denies AOD involvement, the screener should look for evidence in major life areas, including:
Relationship of the current charge to AOD use
Recent or current AOD use
Past treatment history
Health problems (including the presence of HIV infection, TB, hepatitis B)
Criminal justice system history
History or evidence of mental illness
Results of urine, breath, or blood testing
Problems with family, social integration, employment, housing or financial instability, or homelessness.
Screening can be done with a minimum of special training by almost any criminal justice official. Screening education strategies can vary, based on the need and/or point in the system. The orientation to the process can be included in routine training and ongoing staff development. This orientation should be done systemwide, so that everyone from the arresting officer to the judge knows the importance of screening and the screening decision, and what screening decisions mean. Screening should be a fairly "seamless" process. That is, screeners should be fully integrated in the process and not be seen as adjuncts to the overall process. In fact, to a large extent, the degree to which screening is integrated with other processing activities will determine its success in the criminal justice system.
Screening is possible at every contact point in the criminal justice system. Screening at an early point in the system does not preclude screening further down the line. Screeners should understand that their own impressions may change, even in the short time in which they have contact with a client. Many abusers use more than one drug, and various effects and withdrawal symptoms may become evident at different times, causing a variety of unanticipated behaviors. Screeners should be trained to expect the unexpected. Offenders' behavior and motivation to admit to AOD abuse also fluctuates; consequently, screening at all points in the system is likely to identify potential candidates for assessment despite their earlier denial of use.
Screening instruments are the objective arm of the screening procedure, providing uniformity, quality control, and structure to the process. Some instruments may be more appropriate than others in certain settings. Among the more commonly used instruments are the CAGE questionnaire, the MAST, and the OPI.
The CAGE questionnaire is a simple but effective test designed to screen for alcohol abuse. It consists of four questions:
Have you ever felt the need to Cut down on your drinking?
Do you feel Annoyed by people complaining about your drinking?
Do you ever feel Guilty about your drinking?
Do you ever drink an Eye-opener in the morning to relieve the shakes?
Studies reveal that two "yes" answers to the CAGE questionnaire will correctly identify 75 percent of the alcoholics who respond to it and accurately eliminate 96 percent of nonalcoholics. Modifying the CAGE questionnaire for other drugs involves simply substituting "drug use" for "drinking" in the first three questions, and asking for the fourth question, "Do you use one drug to change the effects of another drug?" or "Do you ever use drugs first thing in the morning to `take the edge off'?"
The MAST is a frequently used test that is more detailed than the CAGE questionnaire. The MAST consists of 25 questions and can be used during longer interviews or in holding and confinement situations. It is a commonly used indicator of alcoholism. The MAST is included in Appendix C.
The OPI measures the client's drug use severity as well as his or her "stakes in conformity" within a variety of contexts: family support, education, and school involvement; work, home, and correctional history; psychological and treatment history; drug use severity; and HIV-risk behaviors. It can be administered in about 30 minutes by an experienced probation officer, counselor, or other trained clinician. It includes a straightforward grading guide to help interpret the seriousness of an AOD abuser's problem. A day of training is required to be able to administer it, and a training manual is available. The client's numerical score has a corresponding treatment recommendation. The OPI is reproduced in Appendix C.1
The goals of assessment are to gather information about the client and to describe how the treatment system can address his or her AOD-abuse problems and the impact these problems have on the client's life. The assessment process is descriptive as well as prescriptive. It identifies the client's individual strengths, weaknesses, and readiness for treatment, and recommends a level of services appropriate to address the client's problems and/or deficits.
Typically, an assessment is conducted in a 2- to 3-hour procedure, although this can vary. In most cases, assessment involves a combination of clinical interview, personal history taking, biological testing, and paper-and-pencil testing. Depending on the methods used, the assessment may require more than one session.
Assessment has a number of specific goals and purposes:
To determine the extent and severity of the AOD abuse problem.
To determine the client's level of maturation and readiness for treatment.
To ascertain concomitant problems such as mental illness.
To determine the type of intervention that will be necessary to address the problems.
To evaluate the resources the client can muster to help solve the problem. Typical resources include family support, social support, educational and vocational attainment, and personal qualities such as motivation that the client brings to treatment.
Assessment can be done by an independent assessment group (such as a systemwide central intake unit or an independent Treatment Alternatives to Street Crime program) or by the same professionals who will be providing treatment if it is determined that the type of intervention they provide is appropriate for the particular client.
The assessor should be a qualified human services professional with demonstrated competence in AOD programs, such as an addiction counselor, a licensed social worker, or other trained clinician. A cre-dentialed and/or certified alcoholism, substance abuse, r chemical dependency counselor should be available. It is desirable that each individual assessor work in a licensed or certified setting to ensure that there are adequate resources and a multidisciplinary approach, to take advantage of the collective wisdom of the agency. Ongoing training and supervision are critical to ensure the skill level and accountability of the service providers.
The assessment process should include a broad variety of components that will yield an evaluation of the client that is as comprehensive and holistic as possible. The assessment should provide the information required to recommend the most appropriate course of treatment. Areas that should be investigated in the assessment include:
Archival data on the client, including -- but not limited to -- prior arrests and contacts with the criminal justice system, as well as previous assessments and treatment records
Patterns of AOD use (see below)
Impact of AOD abuse on major life areas such as marriage, family, employment record, and self-concept
Risk factors for continued AOD abuse, such as family history of AOD abuse and social problems
Available health and medical findings, including emergency medical needs
Psychological test findings
Educational and vocational background
Suicide, health, or other crisis risk appraisal
Client motivation and readiness for treatment
Client attitudes and behavior during assessment.
As this listing of professionally accepted data and criteria suggests, the assessment process must be driven by specific data and criteria. For example, in considering the patterns of AOD use, the assessor should determine the presence or absence of such signs and symptoms as:
Tolerance (High tolerance suggests that a client has a history of heavy drinking or drug use.)
History of physical withdrawal symptoms
Episodes of uncontrolled drug or alcohol use, binges, or overdoses
Use of AODs for "self-medication" of painful and unpleasant emotions
Attempts to hide use
Physical signs of drug use, such as needle track marks, emaciation, and alcohol odor
Positive drug test results
History of attempts to quit AOD use
Family dysfunctioning relative to AOD abuse
History and onset of drug use
Drug use behavior (e.g., does client use drugs alone? For sex? To go to work?)
Method of administration, including injection, snorting, smoking, or drinking.
Assessment instruments are standardized tools that are productively used in tandem with the personal history data obtained by the clinician in formulating a clinical impression. Instruments provide another data source for the assessor to use in evaluating the client.
Instruments are an integral part of any assessment. Their results should be used in conjunction with good clinical judgment. There is no single litmus test applicable to all situations and all clients. It is recommended that practitioners review available instruments, and then use, combine, and/or adapt them to suit their own assessment and planning needs.
The following instruments, while they may have some limitations, can provide useful and valuable information.
The Addiction Severity Index (ASI) is perhaps the most widely used assessment instrument. It can be administered in about 60 minutes by a trained counselor. The premise of the ASI is that addiction must be evaluated within the context of problems that may have contributed to or resulted from AOD use. It collects data to estimate the client's level of discomfort in seven areas: alcohol use, medical condition, drug use, employment, financial support, illegal activity, family and social relations, and psychiatric problems. It incorporates both the client's and the assessor's assessment of his or her needs and priorities. A copy of the ASI is reproduced in Appendix C.
This battery combines identification, classification, and treatment assessment instruments with personality profiles and measurements of specific offender needs. It is composed of four instruments: the Alcohol Dependence Scale, the Offender Drug Use History, the Client Management Classification interview, and the Megargee offender typology derived from the Minnesota Multiphasic Personality Inventory (MMPI). The battery provides sound data that can move with the offender through the entire correctional system. It determines not only treatment needs but also the need for specific programs. Two weaknesses of the battery are that the MMPI is an expensive tool and the
Alcohol Dependence Scale is copyrighted, requiring a fee for its use. Another alcohol component can be substituted in place of the alcohol component in the instrument.
This tool was developed by researchers at the Comprehensive Drug Research Center at the University of Miami School of Medicine as part of the National AIDS Demonstration Research Program of the National Institute on Drug Abuse. Primarily focused on assessing HIV risk, it also measures criminal history, legal history, injection drug use, needle use and sharing during incarceration, and sexual activity during incarceration. It is best used in conjunction with other assessment tools. A copy of this instrument appears in Appendix C of this document.
Biological tests can be valuable instruments to determine AOD use, especially when such use is denied by the client. Urinalysis, breathalyzer tests, blood tests, and all other available physical tests should be considered when AOD use is not self-reported. Such tests can be used when a client acknowledges AOD use but may be unclear about exactly what drug or drugs have been used. Therefore, if at all possible, self-reports should be corroborated with biological testing. Given the reemergence of TB in many correctional populations, it is important that testing be done.2 The presence of TB, furthermore, is often an indicator for HIV infection. The cost and timeliness associated with biological testing must be factored into decisions regarding the use of the tests.
The results of the assessment process should be presented in a valid, reliable, and clinically useful document, one that clearly makes its point, can be replicated, and contains data that will be relevant in treatment. A good assessment avoids simplistic formulations that reduce a client to a number, a score, a check list, or a simplistic label.
The presentation of data backing up the assessment should be offered in language that is sufficiently jargon-free to be understood by all relevant personnel, including the client, with only minimal interpretation. Acronyms and abbreviations should be explained when used. In most jurisdictions, the client is entitled to access to his or her record, and the client and his or her attorney should be able to read and understand it.
The screening and assessment instruments provide data on each area surveyed. These data, along with the more extensive history from the clinical interview, need to be fused into a narrative document. Any summary assessment needs to relate to its supporting data and show how the data were collected and interpreted. For the purposes of a court, many judges are comfortable with just a summary paragraph of assessment and do not want to be inundated with extra information. But even in a condensed report, there should be at least three definable, well organized sections:
An introduction, explaining how this assessment came to be, who ordered it, and why.
A section on methodology, explaining how the data were collected, what tests were used, and how the results were interpreted.
A straightforward presentation of the data, relating to the various content areas suggested above (see Components of Assessment) without interpretation, followed by a clinical impression and recommendations. This is essentially a strategic management plan. It should include recommendations for additional referrals or assessment, when necessary.
The narrative document should include a defensible paragraph or two explaining how and why the assessor has reached his or her conclusions. For example, writing only that "Mr. Jones is an alcohol abuser" is insufficient. A more useful rationale for the conclusions reached might be:
We met with Mr. Jones and determined, based on his life circumstances and personal observations, that he is having trouble with alcohol. His third marriage is ending, and he cannot keep a job more than 9 months. He misses work because of his drinking. He came to his interview smelling of alcohol. The test results confirmed the initial impressions. We believe he definitely has an alcohol problem, and appropriate treatment should be provided.
A client may refuse to cooperate with the assessment process, refuse to provide information, or provide information that is intentionally or internally inconsistent and contradictory. That might result in a "cannot assess" report. But there may be other, more hidden problems than simple recalcitrance. The client may not know or may be unable to relate the answers to the questions that he or she is being asked. Recognition of this may trigger a need for further assessment to ascertain if mental illness, brain damage, or other organic indicators might explain the clinical picture. Assessors should realize that getting to the bottom of this client's problem may be more than their program can handle, that they may be dealing with another condition in addition to an AOD problem, and that a more sophisticated neuropsychiatric workup is needed.
The results of the assessment can be useful to a number of different individuals and agencies. However, in many cases, results cannot be presented to anyone -- including the judge or referring criminal justice representative -- without the signed consent of the client, in accordance with Federal confidentiality regulations. Once a client is asked to sign a release, he or she should know the precise reason for the release and understand what is covered in it.
The client is also entitled to know what recom-mendations are made in the assessment report. It is important that the judge know if the client does not agree with the determinations and recommendations of the assessment. In most States, clients are entitled to a second opinion, although they usually have to pay for it themselves. Chapter 6, Legal and Ethical Issues, includes a full discussion on confidentiality and client consent.
Quality assurance and improvement are important in any treatment system. Quality assurance is defined by the Joint Commission on Accreditation of Healthcare Organizations as the ongoing activities designed to objectively and systematically evaluate the quality of client care and services, pursue opportunities to improve the quality of client care and services, and resolve identified problems.
There are two types of quality improvement: internal and external. Both are recommended. External review tends to be a one-time or intermittent evaluation, while internal review should be an ongoing process, with each review providing a foundation for subsequent reviews. In external quality assurance, an outside source, such as an independent contractor or a State licensing agency, conducts the evaluation. It is recommended that external reviews be conducted on a yearly basis to ensure the integrity of the process.
Internal review is done by both peer and supervisory personnel and can be a relatively quick and informal process designed to weed out flagrant problems. A more formal internal review is a self-study that should be done routinely as required by State or local regulations and should include an audit and a survey of assessments to see if any patterns are suggested. This survey can be used to set certain goals for the agency; for example, when one instrument shows up repeatedly in assessments, all staff members should be taught to understand the instrument.
A client is ready for treatment when he or she perceives and accepts the need for treatment in order to achieve personal change. Readiness for treatment has to do with a client's insight into his or her own condition, a willingness to effect change, and the appreciation that prior attempts at effecting change have not yielded desirable results, at least not consistently.
Readiness can be prompted in two ways: by circumstances or extrinsic pressures such as loss (of job, family support, money, etc.) or fear (of incarceration, violence, health risks including overdose, or even suicide). Intrinsic pressures or motivation bring a client closer to readiness. These pressures include guilt, self-hatred, and despair; weariness with the drug-related lifestyle; and a feeling that life can be better. Note that simply acknowledging the need for personal change does not necessarily imply readiness for treatment. Rather, people with AOD problems may seek treatment alternatives, such as self-change; getting help through friends, relationships, religion, and employment; or geographic relocation as a way to stop AOD use.
Readiness can be measured both by subjective impression and objective quantification. One scale measures readiness for treatment (and other factors) on a 1-to-5 scale, asking for responses to statements like, "I am sure that I would go to jail if I don't come to treatment," "I am worried that my spouse will leave me if I don't come to treatment," and "I feel that my AOD use is a very serious problem in my life" (De Leon and Jainchill, 1986).
Increasing someone's readiness for treatment begins with the assessment process, during which the assessor should not just record information, but also feed back impressions to the client. For example, "You say you don't have a drinking problem. Well, how about those five marriages? How about those six jobs in 2 years? How about the fact that you're on probation for your third DUI? Don't you think any of this indicates a drinking problem?"
Among clients mandated to treatment from the criminal justice system, it is unusual for a client to be genuinely enthusiastic about entering treatment. Most clients are not ready, do not want to be in treatment, and do not like it. Usually, though, they see treatment as a more attractive alternative than incarceration. This is not necessarily totally negative. Research data have suggested that coerced treatment can be as effective as voluntary treatment, if not more so (Leukefeld and Tims, 1988). In the language used by Alcoholics Anonymous, "Bring the body, and the mind will follow." Indeed, one of the typical traits of the AOD abuser is denial, the inability or unwillingness to recognize the significance of a problem. Only after a client is in treatment can the subject of denial receive the direct and systematic attention it requires. Excluding people from treatment merely because of a lack of readiness, based on denial, would mean that the treatment process would never begin for many. It is essential to link clients who exhibit denial to the most appropriate program that will address the denial problem. Indeed, addressing denial is an integral aspect of treatment.
Not all clients, of course, are reluctant to enter treatment. Many men and women view treatment as an alternative to incarceration, job loss, or losing custody of their dependent children.
Clients are less likely to drop out of treatment if they understand the treatment process and if they've been prepared for assuming the role of patient. A strong incentive to keep clients in treatment is the knowledge that they will benefit from the treatment, not only for AOD abuse, but also for other problems and issues in their lives.
Research indicates that readiness for treatment is strongly associated with an individual's perception of needing assistance in the process of personal change, compared to alternative options (De Leon and Jainchill, 1986;Collins and Allison, 1983). These researchers' work with the Circumstance, Motivation, Readiness, and Suitability Scales suggests that retention in treatment may be related to an individual's understanding of treatment options.
The task of assessing individuals' readiness for treatment is related to their perceptions of the severity of their AOD abuse problems; their understanding of what treatment options are available, compared to the alternatives; the extent of their ambivalence about a need for personal change; and, in the case of a nonvoluntary participant, what measures can be employed to create a motivational crisis that makes them amenable to treatment.
AOD-involved offenders may be referred to a program for assessment and/or treatment as a result of a court order or another compulsory effort requiring compliance. Often their motivation for change does not correspond to their desire to comply with these compulsory measures in order to avoid negative consequences. As noted earlier, research has demonstrated that coerced treatment is at least as effective as voluntary treatment, suggesting the importance of connecting even nonmotivated AOD-involved offenders with assessment and treatment resources.
Most AOD abusers experience a stage of ambivalence about changing their destructive patterns of behavior (Shaffer, 1992). An increased awareness of the impact of destructive behavior on every aspect of an individual's life is required to shift ambivalence toward an acceptance of responsibility for behavior change. Programs that employ the results of a comprehensive assessment to inform the AOD user set the stage for promoting treatment readiness. The resultant shift of perception, coupled with the motivational crisis created by coercion into treatment, leads the way for further efforts toward motivation and eventual retention in the process of treatment and recovery.
The previous discussion notes the common reality for AOD abuse treatment -- most recipients of services are not voluntary participants. For years, treatment professionals and paraprofessionals believed that a person needed to "hit bottom" in order to be "ready for change."
Today, it is recognized that people can be ready for treatment without "hitting bottom" and that many people can receive benefits from treatment even if they aren't completely ready for treatment. One of the major constructs currently recognized for under-standing the process of addiction and recovery is the Developmental Model of Recovery. According to this model, several tasks are involved in working through the ambivalence associated with the first stage in the process of recovery, which Gorski calls the Transitional Stage (Gorski, 1991). Developing motivating problems, which refers to behaviors resulting in "hitting bottom," and accepting the need for abstinence and help are a few of these tasks. Clinicians can identify an individual's position along the process of recovery by assessing which stage- specific tasks must be resolved. The primary focus of the transitional stage is recognizing the addiction and developing the motivation to become abstinent.
Generally a client can be considered "ready" for treatment when he or she wants to be, sees AOD abuse treatment as a way to become drug or alcohol free, and recognizes that he or she cannot do it alone without professional assistance. But readiness is not often so clearcut. In reality, readiness for treatment is a question of degree, not absolutes. Even more important than readiness are linking clients with the appropriate level of service, and using inducements and the leverage of the criminal justice system to maintain them in treatment, with the expectation that their own changing perceptions will soon keep them in treatment of their own volition.
1 The OPI and a copy of its training materials are reproduced in: Inciardi, J.A., ed. Drug Treatment and Criminal Justice. Newbury Park, CA: Sage Publications, 1993. 2 CSAT convened a consensus panel to design and recommend two screening instruments, which are now being tested. One is for AOD-abuse staff to screen for possible infectious disease in AOD clients. The other is for public health workers to screen clients for AOD abuse.
Site Map
Help
Account
Cart
Home
