After reading the Prison-Based Chemical Dependency Treatment in Minnesota: An Outcome Evaluation and Substance Abuse Treatment for Adults in the Criminal Justice System articles, discuss the following in your initial post: What are the pros and cons of su

A Treatment Improvement Protocol Substance Abuse Treatment For Adults in the Criminal Justice System TIP 44 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment www.samhsa.gov CJ r CRIMINAL JUSTICE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857 Substance Abuse Treatment For Adults in the Criminal Justice System A Treatment Improvement Protocol TIP 44 Roger H. Peters, Ph.D.

Consensus Panel Co-Chair Harry K. Wexler, Ph.D.

Consensus Panel Co-Chair Acknowledgments Numerous people contributed to the develop- ment of this TIP (see pp. xi–xiv and appendices D, E, F, and G). This publication was pro- duced by The CDM Group, Inc. under the Knowledge Application Program (KAP) con- tract, number 270-99-7072 with the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (DHHS). Karl D. White, Ed.D., and Andrea Kopstein, Ph.D., M.P.H., served as the Center for Substance Abuse Treatment (CSAT) Government Project Officers. Christina Currier served as the CSAT TIPs Task Leader.

Rose M. Urban, M.S.W., J.D., LCSW, CCAC, CSAC, served as the CDM KAP Executive Deputy Project Director. Elizabeth Marsh served as the CDM KAP Deputy Project Director. Shel Weinberg, Ph.D., served as the CDM KAP Senior Research/Applied Psychologist. Other KAP personnel included Raquel Witkin, M.S., Deputy Project Manager; Susan Kimner, Managing Editor; Deborah Steinbach, M.A., Editor/Writer; Janet Humphrey, M.A., Editor/Writer; Michelle Myers, Quality Assurance Editor; and Elizabeth Plevyak, Editorial Assistant. In addi- tion, Sandra Clunies, M.S., I.C.A.D.C., served as Content Advisor. Catalina Bartlett, M.A., Janet Dinsmore, B.A., J. Max Gilbert, M.A., Annette Kornblum, M.S., Joyce Latham, Helen Oliff, B.A., CEC, Susan Paisner, M.A., and David Sutton, B.A., were writers. Special thanks go to Gary Field, Ph.D., for his consid- erable contribution to this document.

Disclaimer The opinions expressed herein are the views of the Consensus Panel members and do not nec- essarily reflect the official position of CSAT, SAMHSA, or DHHS. No official support of or endorsement by CSAT, SAMHSA, or DHHS for these opinions or for particular instru- ments, software, or resources described in this document are intended or should be inferred.The guidelines in this document should not be considered substitutes for individualized client care and treatment decisions. Public Domain Notice All materials appearing in this volume except those taken directly from copyrighted sources are in the public domain and may be repro- duced or copied without permission from SAMHSA/CSAT or the authors. Do not repro- duce or distribute this publication for a fee without specific, written authorization from SAMHSA’s Office of Communications.

Electronic Access and Copies of Publication Copies may be obtained free of charge from SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729- 6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889, or electronically through the following World Wide Web site:

www.samhsa.gov/centers/csat/csat.html.

Recommended Citation Center for Substance Abuse Treatment.

Substance Abuse Treatment for Adults in the Criminal Justice System . Treatment Improvement Protocol (TIP) Series 44. DHHS Publication No. (SMA) 05-4056. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005. Originating Office Practice Improvement Branch, Division of Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857.

DHHS Publication No. (SMA) 05-4056 Printed 2005 ii Acknowledgments Contents What Is a TIP? ........................................................................................................ix Consensus Panel ......................................................................................................xi KAP Expert Panel and Federal Government Participants ..............................................xiii Foreword ...............................................................................................................xv Executive Summary ...............................................................................................xvii Chapter 1—Introduction ............................................................................................1 Overview ..................................................................................................................1 The Purpose of This TIP .............................................................................................3 Key Definitions ..........................................................................................................4 Audience for This TIP .................................................................................................5 Contents of This TIP...................................................................................................5 Chapter 2—Screening and Assessment ..........................................................................7 Overview ..................................................................................................................7 Definitions of Terms....................................................................................................7 Screening Guidelines ...................................................................................................9 Assessment Guidelines................................................................................................10 Key Issues Related to Screening and Assessment...............................................................13 Areas To Address in Screening and Assessment ................................................................18 Selection and Implementation of Instruments ..................................................................33 Screening and Assessment Considerations for Specific Populations .......................................36 Integrated Screening and Assessment—Sample Approaches ................................................39 Conclusions and Recommendations ...............................................................................40 Chapter 3—Triage and Placement in Treatment Services ...............................................43 Overview ................................................................................................................43 Treatment Levels and Components ................................................................................43 Potential Barriers to Triage and Placement .....................................................................47 Creating a Triage and Placement System ........................................................................47 Compiling Information To Guide Triage and Placement Decisions.........................................49 Conclusions and Recommendations ...............................................................................56 Chapter 4—Substance Abuse Treatment Planning .........................................................59 Overview ................................................................................................................59 Assessing the Severity of Substance Use Disorders ............................................................60 Assessing the Severity of Co-Occurring Disorders .............................................................60 Criminality and Psychopathy ......................................................................................63 Client Motivation and Readiness for Change ...................................................................65 Implementing an Effective Treatment Planning Process .....................................................67 Conclusions and Recommendations ...............................................................................70 Chapter 5—Major Treatment Issues and Approaches .....................................................71 Overview ................................................................................................................71 Clinical Strategies .....................................................................................................72 iii iv Program Components and Strategies .............................................................................84 Conclusions and Recommendations ...............................................................................90 Chapter 6—Adapting Offender Treatment for Specific Populations ..................................93 Overview ................................................................................................................93 Treatment Issues Related to Cultural Minorities ...............................................................93 Women’s Treatment Issues ..........................................................................................95 Men’s Treatment Issues.............................................................................................101 Working With Violent Offenders .................................................................................102 Treatment Issues Based on Client’s Sexual Orientation .....................................................104 Treatment Issues Based on the Client’s Cognitive/Learning, Physical, and Sensory Disabilities ..105 Treatment Issues for Older Adults ...............................................................................107 Treatment Issues for Clients From Rural Areas ..............................................................107 Treatment Issues for People With Co-Occurring Substance Use and Mental Disorders .............108 People With Infectious Diseases ..................................................................................116 Sex Offenders .........................................................................................................119 Conclusions and Recommendations .............................................................................122 Chapter 7—Treatment Issues in Pretrial and Diversion Settings.....................................125 Overview ...............................................................................................................125 Introduction ..........................................................................................................125 Characteristics of the Population ................................................................................126 Treatment Services in the Pretrial Justice System ...........................................................127 Trial and Postverdict Periods.....................................................................................130 Diversion to Treatment .............................................................................................131 What Treatment Services Can Reasonably Be Provided in the Pretrial Setting?......................138 Treatment Issues .....................................................................................................143 Developing Pretrial Treatment Services ........................................................................146 Resources ..............................................................................................................151 Conclusions and Recommendations .............................................................................154 Chapter 8—Treatment Issues Specific to Jails.............................................................157 Overview ...............................................................................................................157 Definitions .............................................................................................................157 Trends ..................................................................................................................158 Treatment Services in Jails ........................................................................................159 Description of the Population .....................................................................................159 Key Issues Related to Treatment .................................................................................163 What Treatment Services Can Reasonably Be Provided in a Jail Setting?..............................166 Coordination of Jail Treatment Services .......................................................................175 Examples of Jail Treatment Programs ..........................................................................183 Research Related to Jail Treatment .............................................................................184 Recommendations for Treatment Providers ...................................................................185 Chapter 9—Treatment Issues Specific to Prisons ........................................................187 Overview ...............................................................................................................187 Description of the Population .....................................................................................187 Treatment Services in Prisons ....................................................................................190 Contents v Key Issues Affecting Treatment in Prison Settings ...........................................................190 What Treatment Services Can Reasonably Be Provided in the Prison Setting? .......................194 In-Prison Therapeutic Communities ............................................................................199 Specific Populations in Prisons ...................................................................................204 Systems Issues ........................................................................................................207 Recommendations and Further Research ......................................................................210 Chapter 10—Treatment for Offenders Under Community Supervision ............................213 Overview ...............................................................................................................213 The Population .......................................................................................................214 Levels of Supervision ...............................................................................................214 Treatment Levels and Treatment Components ................................................................214 What Treatment Services Can Reasonably Be Provided for People Under Community Supervision? .......................................................................................218 Treatment Issues for People Under Community Supervision ..............................................220 Treatment Issues Specific to People on Parole ................................................................226 Treatment Issues Specific to Probationers .....................................................................229 Strategies for Improving System Collaboration ...............................................................229 Sample Programs ....................................................................................................231 Conclusions and Recommendations .............................................................................233 Chapter 11—Key Issues Related to Program Development ...........................................235 Overview ...............................................................................................................235 Reconciling Public Safety and Public Health Interests .....................................................235 Interdependence of Criminal Justice and Treatment Systems .............................................236 Program-Level Coordination ......................................................................................242 Research and Evaluation ..........................................................................................247 Cost Issues.............................................................................................................251 Key Goals of SAMHSA .............................................................................................252 Conclusions ...........................................................................................................252 Appendix A: Bibliography ......................................................................................255 Appendix B: Glossary ...........................................................................................291 Appendix C: Screening and Assessment Instruments ...................................................303 Appendix D: Resource Panel...................................................................................309 Appendix E: Cultural Competency and Diversity Network Participants ...........................313 Appendix F: Special Consultants ..............................................................................315 Appendix G: Field Reviewers...................................................................................317 Index ..................................................................................................................321 CSAT TIPs and Publications ....................................................................................335 Figures Figure 2-1. Screening Guidelines by Domain....................................................................11 Figure 2-2. Screening Guidelines by Setting .....................................................................12 Figure 2-3. Recommended Substance Abuse Screening Instruments ......................................19 Figure 2-4. Instruments for Evaluating Readiness for Treatment ..........................................23 Figure 2-5. Instruments for Screening and Assessing Mental Disorders ..................................25 Figure 2-6. Instruments Examining Psychopathy and Risk for Violence and Recidivism .............32 Contents Figure 3-1. Placement and Triage Strategies ....................................................................50 Figure 4-1. Client’s Recovery Plan (CRP) .......................................................................68 Figure 5-1. Common Thinking Errors ............................................................................75 Figure 5-2. Strategies for Working With Offenders Based on Their Stage in Recovery ...............84 Figure 6-1. Traits of ASPD (DSM-IV) ...........................................................................113 Figure 6-2. Borderline Personality Disorder ..................................................................114 Figure 7-1. Substance Abuse Treatment Planning Chart for Treatment-Based Drug Courts .......134 Figure 8-1. Treatment Components ..............................................................................168 Figure 8-2. Goals of the Treatment and Corrections System in the Jail Setting........................176 Figure 8-3. Targeted Treatment for Special Populations Versus Mainstream Treatment for Larger Populations ..................................................................................178 Figure 8-4. Varied Opinions Regarding Medication Use for Inmates in Jail Treatment Programs 180 Figure 9-1. Reasons for Limitations to Providing Treatment to Prison Inmates.......................191 Figure 9-2. Guidelines for Substance Abuse Treatment in Correctional Facilities ....................192 Figure 9-3. Stay’n Out Program Outcomes ....................................................................202 Figure 10-1. Comparison of Probationers and Parolees ....................................................215 Figure 10-2. Paradigm of Collaboration ........................................................................230 Figure 11-1. CSAT Criminal Justice Treatment Planning Chart ..........................................238 Figure 11-2. Barriers to Effective Treatment ..................................................................243 Figure 11-3. Outcome Information...............................................................................250 Figure 11-4. Definition of Terms .................................................................................251 Advice to the Counselor Boxes Chapter 2 Screening and Assessment ...........................................................................................13 The Need to Rescreen ................................................................................................16 Screening for Detoxification ........................................................................................21 Screening for Co-Occurring Disorders ...........................................................................27 Screening for Trauma ................................................................................................29 Screening for Psychopathy ..........................................................................................30 Screening Specific Populations .....................................................................................38 Chapter 3 Triage and Placement ................................................................................................49 Chapter 4 Mental Health Issues .................................................................................................61 Borderline Personality Disorder ...................................................................................63 Psychopathy ............................................................................................................65 Motivation for Change ...............................................................................................66 Chapter 5 Homelessness ...........................................................................................................73 Criminal Thinking ....................................................................................................74 Family Involvement ...................................................................................................78 Addressing the Coerced Client .....................................................................................80 Establishing Boundaries .............................................................................................81 Establishing Counselor Credibility ................................................................................83 Spiritual Approaches .................................................................................................89 vi Contents Chapter 6 Culture and the Counselor ..........................................................................................95 Treating Female Offenders ..........................................................................................97 Parent Training ......................................................................................................100 Rural Clients, Rural Counselors .................................................................................108 “Good” and “Bad” Drugs ..........................................................................................111 Infectious Diseases...................................................................................................118 Chapter 7 General Considerations for Working With Clients in the Criminal Justice System ...................127 Diversion to Treatment Decision Points ........................................................................128 Information Management During the Pretrial Stage .........................................................130 Operating in a Pretrial Setting....................................................................................143 Addressing the Client’s Immediate Needs ......................................................................144 Chapter 8 Jailed Clients .........................................................................................................165 Cross-Training........................................................................................................179 Chapter 9 Prison Treatment Approaches ....................................................................................198 Heading Off Noncompliance.......................................................................................209 Chapter 10 Recommended Treatment Services for People Under Community Supervision ........................221 Treatment Issues for People Under Community Supervision ..............................................225 Treatment Issues for People on Parole .........................................................................229 Contents vii What Is a TIP?

Treatment Improvement Protocols (TIPs), developed by the Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S.

Department of Health and Human Services (DHHS), are best-practice guidelines for the treatment of substance use disorders. CSAT draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to facilities and indi- viduals across the country. The audience for the TIPs is expanding beyond public and private treatment facilities to include practitioners in mental health, criminal justice, primary care, and other healthcare and social service settings.

CSAT’s Knowledge Application Program (KAP) expert panel, a distin- guished group of experts on substance use disorders and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Drug Abuse Directors to generate topics for the TIPs. Topics are based on the field’s current needs for information and guidance.

After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to be members of a resource panel that recom- mends specific areas of focus as well as resources that should be consid- ered in developing the content for the TIP. These recommendations are communicated to a consensus panel composed of experts on the topic who have been nominated by their peers. This consensus panel participates in a series of discussions. The information and recommendations on which they reach consensus form the foundation of the TIP. The members of each consensus panel represent substance abuse treatment programs, hos- pitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A panel chair (or co- chairs) ensures that the contents of the TIP mirror the results of the group’s collaboration.

A large and diverse group of experts closely reviews the draft document.

Once the changes recommended by these field reviewers have been incor- ix x What Is a TIP? porated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet at www.kap.samhsa.gov. The online TIPs are consistently updated and pro- vide the field with state-of-the-art information.

While each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey “front-line” information quickly but responsi- bly. For this reason, recommendations prof- fered in the TIP are attributed to either Panelists’ clinical experience or the literature.

If research supports a particular approach, citations are provided.This TIP, Substance Abuse Treatment for Adults in the Criminal Justice System , revises and supersedes TIP 7, Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System , TIP 12, Combining Substance Abuse Treatment With Intermediate Sanctions for Adults in the Criminal Justice System , and TIP 17, Planning for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice System . The revised TIP provides the current clinical evidence-based guidelines, tools, and resources necessary to help sub- stance abuse counselors treat clients involved with the criminal justice system. xi Consensus Panel Co-Chair Roger H. Peters, Ph.D.

Professor Department of Law and Mental Health Florida Mental Health Institute University of South Florida Tampa, Florida Co-Chair Harry K. Wexler, Ph.D.

Senior Principal Investigator National Development and Research Institute, Inc.

New York, New York Workgroup Leaders Steven R. Belenko, Ph.D.

National Center on Addiction and Substance Abuse Columbia University New York, New York Nahama Broner, Ph.D.

Senior Research Psychologist Center for Crime, Violence and Justice Research New York, New York Christopher J. Geiger Vice President/Director of Criminal Justice Programs Walden House, Inc.

San Francisco, California Kevin Knight, Ph.D.

Research Scientist Texas Christian University Fort Worth, TexasMichael D. Link, M.C.J.

Chief Division of Treatment and Planning Ohio Department of Alcohol and Drug Addiction Services Columbus, Ohio Henry Jay Richards, Ph.D.

Associate Professor University of Washington Seattle, Washington Sally J. Stevens, Ph.D.

Research Professor Social and Behavioral Sciences Southwest Institute for Research on Women University of Arizona Tucson, Arizona Panelists Elaine Abraham Program Developer/Consultant National Development and Research, Inc.

Chula Vista, California E. Bernard Anderson, Jr., M.S., M.A., NCAC,ICADC, CCS Regional Administrator Correctional Treatment Florida Addictions and Correctional Treatment Services, Inc.

Tallahassee, Florida Annabelle Casas-Mendoza, M.A.

Family Treatment Drug Court 65th District Court El Paso, Texas xii Deion Cash Executive Director Community Treatment & Correction Center, Inc.

Canton, Ohio Kimberly S. Hee, M.A.

Grants Program Specialist Office of the Mayor Criminal Justice Planning Los Angeles, California Mack Jenkins, B.A.

Division Director Adult Court Services Orange County Probation Department Santa Ana, CaliforniaCarl G. Leukefeld, D.S.W.

Director Center on Drug and Alcohol Research University of Kentucky Lexington, Kentucky Erik J. Roskes, M.D.

Director Forensic Treatment and Correctional Services School of Medicine Springfield Hospital Center Sykesville, Maryland Consensus Panel xiii Barry S. Brown, Ph.D.

Adjunct Professor University of North Carolina at Wilmington Carolina Beach, North Carolina Jacqueline Butler, M.S.W., LISW, LPCC, CCDC III, CJS Professor of Clinical Psychiatry College of Medicine University of Cincinnati Cincinnati, Ohio Deion Cash Executive Director Community Treatment and Correction Center, Inc.

Canton, Ohio Debra A. Claymore, M.Ed.Adm.

Owner/Chief Executive Officer WC Consulting, LLC Loveland, Colorado Carlo C. DiClemente, Ph.D.

Chair Department of Psychology University of Maryland Baltimore County Baltimore, Maryland Catherine E. Dube, Ed.D.

Independent Consultant Brown University Providence, Rhode Island Jerry P. Flanzer, D.S.W., LCSW, CAC Chief, Services Division of Clinical and Services Research National Institute on Drug Abuse Bethesda, MarylandMichael Galer, D.B.A.

Chairman of the Graduate School of Business University of Phoenix—Greater Boston Campus Braintree, Massachusetts Renata J. Henry, M.Ed.

Director Division of Alcoholism, Drug Abuse, and Mental Health Delaware Department of Health and Social Services New Castle, Delaware Joel Hochberg, M.A.

President Asher & Partners Los Angeles, California Jack Hollis, Ph.D.

Associate Director Center for Health Research Kaiser Permanente Portland, Oregon Mary Beth Johnson, M.S.W.

Director Addiction Technology Transfer Center University of Missouri—Kansas City Kansas City, Missouri Eduardo Lopez, B.S.

Executive Producer EVS Communications Washington, DC Holly A. Massett, Ph.D.

Academy for Educational Development Washington, DC KAP Expert Panel and Federal Government Participants xiv Diane Miller Chief Scientific Communications Branch National Institute on Alcohol Abuse and Alcoholism Bethesda, Maryland Harry B. Montoya, M.A.

President/Chief Executive Officer Hands Across Cultures Espanola, New Mexico Richard K. Ries, M.D.

Director/Professor Outpatient Mental Health Services Dual Disorder Programs Seattle, Washington Gloria M. Rodriguez, D.S.W.

Research Scientist Division of Addiction Services NJ Department of Health and Senior Services Trenton, New Jersey Everett Rogers, Ph.D.

Center for Communications Programs Johns Hopkins University Baltimore, Maryland Jean R. Slutsky, P.A., M.S.P.H.

Senior Health Policy Analyst Agency for Healthcare Research & Quality Rockville, Maryland Nedra Klein Weinreich, M.S.

President Weinreich Communications Canoga Park, California Clarissa Wittenberg Director Office of Communications and Public Liaison National Institute of Mental Health Kensington, Maryland Consulting Members Paul Purnell, M.A.

Social Solutions, L.L.C.

Potomac, Maryland Scott Ratzan, M.D., M.P.A., M.A.

Academy for Educational Development Washington, DC Thomas W. Valente, Ph.D.

Director, Master of Public Health Program Department of Preventive Medicine School of Medicine University of Southern California Alhambra, California Patricia A. Wright, Ed.D.

Independent Consultant Baltimore, Maryland KAP Expert Panel and Federal Government Participants xv The Treatment Improvement Protocol (TIP) series supports SAMHSA’s mission of building resilience and facilitating recovery for people with or at risk for mental or substance use disorders by providing best-practices guidance to clinicians, program administrators, and payors to improve the quality and effectiveness of service delivery, and, thereby promote recov- ery. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and imple- mentation requirements. A panel of non-Federal clinical researchers, clin- icians, program administrators, and client advocates debates and discuss- es its particular areas of expertise until it reaches a consensus on best practices. This panel’s work is then reviewed and critiqued by field reviewers.

The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have helped to bridge the gap between the promise of research and the needs of practicing clinicians and administrators to serve, in the most scientifically sound and effective ways, people who abuse substances. We are grateful to all who have joined with us to contribute to advances in the substance abuse treatment field.

Charles G. Curie, M.A., A.C.S.W.

Administrator Substance Abuse and Mental Health Services Administration H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration Foreword xvii Executive Summary For men and women whose struggle with substance abuse brings them into contact with the legal system, the personal losses can be enormous: fami- lies can break apart, health deteriorates, freedom is restricted, and far too often, lives are lost. But this is just the beginning of the potential devasta- tion. Personal costs to the victims of crime are immeasurable. The effects of every theft, burglary, and violent crime reverberate throughout the whole community. Economic losses include the costs of arresting, process- ing, and incarcerating offenders, as well as the costs of police protection, increased insurance rates, and property losses.

Strong empirical evidence over the past few decades consistently has shown that substance abuse treatment reduces crime. For many people in need of alcohol and drug treatment, contact with the criminal justice sys- tem is their first opportunity for treatment. A substance use disorder may be recognized and diagnosed for the first time, and legal incentives to enter substance abuse treatment sometimes motivate the individual to begin recovery. For other offenders, arrest and incarceration are part of a recurring cycle of drug abuse and crime. Ingrained patterns of maladap- tive coping skills, criminal values and beliefs, and a lack of job skills may require a more intensive treatment approach, particularly among offend- ers with a prolonged history of substance abuse and crime.

This TIP was developed to provide recommendations and best practice guidelines to counselors and administrators based on the research litera- ture and the experience of seasoned treatment professionals. It covers the full range of criminal justice settings and all the phases through which an individual progresses in the criminal justice system. It addresses both clin- ical and programmatic areas of treatment. The consensus panel defined the areas highlighted below as important in efforts to achieve the treat- ment objectives of recovery and a life in the community for everyone. xviii Executive Summary Screening and Assessment A vital first step in providing substance abuse treatment to people under criminal justice supervision is to identify offenders in need of treatment. In the criminal justice system, screening often is equated with “eligibility,” and assessment often is equated with “suitabili- ty.” To do this effectively, the consensus panel recommends that protocols be developed to determine which offenders need substance abuse treatment, assess the extent of their treatment needs, and ensure that they receive the treatment they need. Obtaining accurate and reliable information during screening and assessment can be a challenge; offenders do not always accurately report drug or alcohol prob- lems. Other collateral sources of information (e.g., drug test results, correctional records) can be combined with self-report information to make referral decisions. For example, in many correctional facilities, urine tests are used to flag the need for treatment—even when an offender denies recent substance abuse.

Many offenders who abuse substances have co- occurring mental disorders that can make treatment more complex. They should there- fore be screened for other psychological or emotional problems. Offenders who are initial- ly assessed as having symptoms of co-occurring disorders should be evaluated over an extended period of time to determine whether these symptoms resolve in the absence of substance use.

A significant number of offenders who abuse substances also have histories of trauma and physical or sexual abuse. Screening and assess- ment of a history of physical and sexual abuse should be conducted routinely, particularly in settings that include female offenders. Staff training is needed to develop effective inter- viewing approaches related to the history of abuse, counseling approaches for addressing abuse and trauma issues, and in making refer- rals to mental health services. Triage and Placement in Treatment Services Information obtained in screening and assess- ment is used to place offenders in the treatment program that is best suited to their needs. More offenders can receive appropriate treatment if a range of substance abuse treatment options is provided in criminal justice settings, particu- larly in institutions and community settings where offenders are supervised for long periods of time. In addition to key information regard- ing substance abuse problems, risk for criminal recidivism, and mental health problems, triage and placement decisions also should consider the offender’s motivation and readiness for change, the length of sentence or incarceration, history of previous treatment, violence poten- tial, and other related security or management issues. The consensus panel recommends that in general, offenders who have moderate-to- high levels of substance abuse problems and criminal risk should be prioritized for place- ment in substance abuse treatment services, rather than in other types of institutional pro- grams.

Treatment Planning After placement, a treatment plan is developed that specifies which services the offender-client needs, at what level of intensity, and which of the available resources (e.g., personal, pro- gram-based, or criminal justice) will be most beneficial. The treatment plan takes into con- sideration the severity of substance abuse- related problems and the presence of co-occur- ring mental disorders because these influence the treatment approach. Also important are factors such as criminal attitudes and psy- chopathy, which may suggest persistent crimi- nality unrelated to the need to maintain a drug habit. The degree to which an individual is motivated and ready for change is another crit- ical factor that will determine whether motiva- tional enhancement interventions, sanctions, or more self-directed treatments are appropriate.

Finally, personal strengths are taken into xix Executive Summary account in planning. The offender should be involved in the treatment planning process.

The most effective treatment programs have the resources necessary for comprehensive assessment and treatment planning activities including adequate staffing, clerical support, and access to computers and management information systems that contain information regarding the offender. Mechanisms for sharing information among agencies will expedite treat- ment as clients move through the criminal jus- tice system. For example, monitoring, consulta- tion, and written agreements are needed to define the types of information that will be shared, with whom, and under what circum- stances. Procedures that ensure the smooth and timely flow of relevant information will enable staff to proceed with treatment without interruption. Effective management informa- tion systems allow for access to clinical infor- mation as well as other offender data. At the same time, however, confidentiality regulations require that clinical information be maintained separately from the corrections or supervision case files, and access to clinical files be restrict- ed to staff who have primary clinical responsi- bilities.

Major Treatment Issues and Approaches Clients under criminal justice supervision share many of the same clinical issues faced by others receiving substance abuse treatment, but some are unique. For example, many offenders have problems with the very issues that brought them to the attention of law enforcement, particularly, criminal thinking and values. These clients often have problems dealing with anger and hostility and have the stigma of being criminals, along with the guilt and shame that accompany this stigma. Their identity as criminals may need to be offset by exposure to more prosocial values and identi- ties such as those of family member and wage earner. Adapting Offender Treatment for Specific Populations General clinical strategies for working with offender-clients include interventions to address criminal thinking and to provide basic problemsolving skills; however, substance abuse treatment approaches should be modi- fied to meet specific client needs. Because of their histories or life experiences, certain popu- lations are recognized as having somewhat dif- ferent treatment needs. For example, people from cultural minorities have had different stresses from those in the majority culture.

Women are more likely to have been trauma- tized by physical and sexual abuse than men and to have urgent concerns about their chil- dren. Offenders with co-occurring substance use and mental disorders need help that inte- grates treatment for both. Other groups with specific needs include older adults, violent offenders, people with disabilities, and sex offenders.

Treatment Issues Specific to Pretrial and Diversion Settings Treatment varies not only because of the specif- ic population to which an offender belongs but also because of a client’s stage in the criminal justice system. After arrest and before trial, a large number of individuals move relatively quickly through the system, and many different agencies are involved with each case and its supervision. If offered, the offender may opt for treatment instead of formal charges, trial, sentencing, incarceration, or to reduce the length of incarceration.

Variations in local prosecution and diversion practices may affect a jurisdiction’s ability to develop criminal justice and treatment link- ages. Not all jurisdictions have established pro- cedures or programs for individuals who abuse substances; those jurisdictions that do have programs to treat offenders often maintain xx such programs with limited resources.

However, the pressure of overcrowded jails and prisons is serving to expand and institu- tionalize programs for drug treatment in pre- trial and diversion settings nationwide. Still, outside of formal drug court and diversion pro- grams, treatment access is limited. Types of treatment used in the pretrial setting are neces- sarily brief and include brief motivational interventions, behavior contracts, and refer- rals to detoxification and other services. A variety of sanctions also are available.

In the pretrial setting, the question of an indi- vidual’s guilt or innocence has not been legally determined. It is vitally important, therefore, to note that treatment should not compromise the due process rights of defendants.

Treatment professionals need to bear in mind the presumption of innocence that exists during the pretrial period. Defendants’ due process rights affect what they are willing to agree to and the type of information that they are will- ing to disclose. Defendants should not be coerced into waiving due process rights, although a court may order substance abuse treatment as a condition of pretrial release.

Treatment Issues Specific to Jails Those incarcerated in jails are undergoing sig- nificant stress related to arrest, the uncertain- ties of their legal situation, and the potential loss of their job or custody of their children.

Appropriate treatment services for these indi- viduals are based on the expected duration of incarceration and the information obtained from screening for a variety of possible prob- lems. Brief treatment (less than 30 days) usual- ly focuses on supplying information and mak- ing referrals but can include motivational inter- viewing. Short-term programs (1–3 months) have the time to work on communication, prob- lemsolving, and relapse prevention skills; intro- duce anger management techniques; and encourage participation in self-help groups.Longer term programs (3 months–1 year) can provide additional skills training, vocational and educational activities, and examine crimi- nal thinking errors. The consensus panel rec- ommends that jail staff implement discharge planning that includes gathering information regarding the need for a range of community services, including housing and health care. Treatment Issues Specific to Prisons The unique characteristics of prisons have important implications for developing and implementing treatment programs. In-prison drug abuse treatment, particularly when fol- lowed by community-based continuing care treatment, has been credited with reducing short-term recidivism and relapse rates among offenders who are involved with drugs. More recently, the sustained effects on longer term outcomes have been documented by studies indicating that 9–12 months of prison treat- ment followed by at least 3 months of communi- ty treatment are needed to produce significant improvement and reductions in recidivism and relapse. Because of the comparative stability of the prison population, several treatment options of differing intensities can be made available. The full range of services can be offered, including comprehensive assessment; treatment planning; placement; group, individ- ual, family, and specialty group counseling; self-help groups; educational and vocational training; and planning for transition to the community. Therapeutic communities (TCs) are among the most successful in-prison treat- ment programs. They are highly structured, hierarchical, and intense interventions lasting a minimum of 6 months. TC participants live together, often separate from the general prison population, and take responsibility for their recovery process. Participants work at increas- ingly more responsible positions as they learn self-sufficiency and become competent. Executive Summary xxi Treatment for Offenders Under Community Supervision Parolees and probationers are both under com- munity supervision; nonetheless, they generally represent different ends of the criminal justice continuum. Whereas parolees are serving a term of conditional supervised release following a prison term, probationers are under commu- nity supervision instead of a jail or prison term. Both parolees and probationers generally can be controlled and managed effectively by a combination of treatment and surveillance while under community supervision at a far lower cost than incarceration in jail or prison.

The level of supervision varies according to individual circumstances, including the terms under which probation or parole was granted.

Offenders under community supervision in urban areas who have substance use disorders have available several levels treatment and supervision, including residential, outpatient, halfway, and day reporting centers. Parolees may have difficulty meeting their basic needs when they are released and benefit from case management services to help with housing and employment. Reunification with family mem- bers and social support may also prove prob- lematic.Relapse prevention is extremely important for those under community supervision. Relapse, which is not unusual, can be met by increased supervision and an intensification of the level of treatment. Likewise, the intensity of supervi- sion and treatment should decrease as the indi- vidual meets treatment goals. For both parolees and probationers, reassessment should be peri- odically conducted throughout the phase of community supervision. Following their contact with the criminal justice system, both parolees and probationers benefit from continuing con- tact with the substance abuse treatment system as a means of reducing relapse and recidivism. Key Issues Related to Program Development Offender-clients will best be served by sub- stance abuse treatment and criminal justice systems that are working together to help them in recovery and in becoming law-abiding citi- zens. This requires leaders in both systems who promote their mutual goals, endorsement for mutual goals from leaders, clarification of the goals, and recruitment of stakeholders in pur- suit of the goals. The challenge for substance abuse treatment practitioners and criminal jus- tice professionals is to work together to provide a coordinated response to ensure that offend- ers’ needs are addressed while protecting pub- lic safety. Executive Summary 1 Introduction In This Chapter… The Purpose of This TIP Key Definitions Audience for This TIP Contents of This TIP When the prison gates slam behind an inmate, he does not lose his human quality; his mind does not become closed to ideas; his intellect does not cease to feed on a free and open interchange of opinions; his yearning for self-respect does not end; nor is his quest for self-realiza- tion concluded. If anything, the needs for identity and self-respect are more compelling in the dehumanizing prison environment. —Thurgood Marshall (Procunier v. Martinez, 416 U.S. 396 [1974]) Overview Research consistently demonstrates a strong connection between crimi- nal activity and substance abuse (Chaiken 1986; Inciardi 1979; Johnson et al. 1985). Eighty-four percent of State prison inmates who expected to be released in 1999 were involved with alcohol or illicit drugs at the time of their offense; 45 percent reported that they were under the influence when they committed their crime; and 21 percent indicated that they committed their offense for money to buy drugs (Office of National Drug Control Policy [ONDCP] 2003). Data from the Arrestee Drug Abuse Monitoring program indicate that in 2000, 64 percent of male arrestees tested positive for at least one of five illicit drugs (cocaine, opioids, marijuana, methamphetamines, and PCP).

Additionally, 57 percent reported binge drinking in the 30 days prior to arrest, and 36 percent reported heavy drinking (Taylor et al. 2001).

The consequences of crime related to substance abuse are substantial.

The Bureau of Justice Statistics reports that in 1999 alone, 12,658 homicides—4.5 percent of all homicides for that year—were drug relat- ed (Dorsey et al. 1999). The emotional costs to people with substance use disorders, their families, and the victims of their crimes are immea- surable. The ONDCP estimates that the total crime-related costs of drug abuse were more than $100 billion in 2000 (ONDCP 2001).

The devastating emotional and financial costs of drug-related crimes have led to a number of strategies to break the link between drugs and 1 crime, including stricter drug laws, “three strikes and you’re out” legislation, increased surveillance, mandatory sentencing laws, and severe penalties for drunk drivers, to name just a few. These approaches have had mixed results, and opinions vary on their useful- ness.

One consistent research finding is that involvement in substance abuse treatment reduces recidivism (a tendency to return to criminal habits) for offenders who use drugs (Anglin and Hser 1990; Harwood et al. 1988; Hubbard et al. 1984, 1989; Knight et al.

1999 a; Martin et al. 1999; McLellan et al.

1983; Wexler et al. 1988, 1999 a; Wisdom 1999). For example, when researchers con- ducted followup studies of clients treated through comprehensive treatment demonstra- tion programs funded by the Center for Substance Abuse Treatment (CSAT), they found substantial reductions in criminal activity, including a 64-percent decrease in arrests (Wisdom 1999). In part because of the reduced criminal activity associated with sub- stance abuse treatment for offenders, treat- ment has also been found to be cost-effective.

According to the California Drug and Alcohol Treatment Assessment study (Gerstein et al.

1994), for example, every dollar invested in treatment saved approximately $7 in future costs.

In response to research demonstrating the success of treatment in reducing criminal activity as well as the cost benefits of such treatment, policymakers over the past two decades have implemented a wide variety of strategies at the Federal, State, and local lev- els. These initiatives are aimed at improving the availability and quality of treatment for offenders. Drug Courts—courts with special unified dockets for individuals charged with crimes who are drug or alcohol involved— serve to divert offenders with substance use disorders away from the criminal justice sys- tem into a supervised treatment plan or to incorporate a coerced treatment plan as part of a judicial sentence. Other programs have been established for people with specialneeds, including individuals with co-occurring mental disorders. At the same time, other ini- tiatives have increased funding for people already in prisons and jails. Examples of such initiatives include • Project REFORM and later Project RECOVERY. These programs, funded in the late 1980s by the Bureau of Justice Assistance (BJA) and in the early 1990s by CSAT, provided technical assistance to 20 States in planning and developing substance abuse programming for prisoners with sub- stance abuse problems (Wexler 1995).

• Residential Substance Abuse Treatment for State Prisoners Formula Grant Program.

This program funds States seeking to devel- op comprehensive approaches to treatment for offenders who abuse substances, includ- ing intensive programs for inmates and relapse prevention training. Further infor- mation is available at www.cfda.gov.

• The National Drug Control Strategy, pre- pared annually by the Office of National Drug Control Policy (1997, 1998, 1999, 2000, 2001). This program has encouraged the development of treatment and rehabili- tation services for offenders who use drugs (e.g., Treatment Accountability for Safer Communities, formerly Treatment Alternatives to Street Crime; drug court programs; prison treatment programs). For further information, go to www.whitehouse- drugpolicy.gov/.

• The BJA, Office of Justice Programs, U.S.

Department of Justice. Formerly known as the Drug Courts Program Office, estab- lished to administer the drug court grant program, the BJA provides financial and technical assistance, training, and program- matic guidance for drug courts throughout the country. BJA offers grants that enable communities to develop, implement, or improve drug courts. Information is avail- able at www.ojp.usdoj.gov/BJA/.

• The Serious and Violent Offender Reentry Initiative . In conjunction with several Federal partners, the U.S. Department of Justice is spearheading this initiative to 2 Chapter 1 provide funding to promote successful rein- tegration of serious, high-risk offenders into the community. The Initiative seeks to address all obstacles to successful reentry, including substance abuse. Information is available online at www.ojp.usdoj.gov/ reentry/learn.html.

In part because of initiatives such as these, the availability of substance abuse treatment for criminal offenders is on the rise. After 3 years of decline in the mid-1990s, the number of inmates in drug treatment programs began rising again in 1997 and 1998 (Corrections Yearbook 1998). A report based on a 1997 nationwide survey of Federal and State cor- rectional facilities (Office of Applied Studies 2000) indicates that 93.8 percent of Federal prisons and 56.3 percent of State prisons pro- vide some form of substance abuse treatment.

Although an increasing number of prisons offer some form of treatment, the actual num- ber of programs and slots remains limited (National Center on Addiction and Substance Abuse at Columbia University 1998; Peters and Matthews 2002). For example, although more than half of prison inmates have a life- time prevalence of drug use disorders (Peters et al. 1998), fewer than 15 percent of inmates receive substance abuse treatment services while in prison (Mumola 1999; Simpson et al.

1999 b). Moreover, while the number of sub- stance abuse programs for offenders is on the rise, so too is the number of offenders in need of services. Substance abuse treatment ser- vices for offenders have not kept pace with the growing need for these services (Belenko and Peugh 1998; Simpson et al. 1999 b).

This TIP highlights some of the best practices and innovative programs created to treat offenders. It describes the unique needs of offenders with substance abuse and depen- dence disorders. Finally, it addresses the challenges counselors and criminal justice personnel are likely to face at every stage of the criminal justice continuum. The Purpose of This TIP This TIP updates and combines three TIPs originally published in 1994 and 1995: TIP 7, Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System (CSAT 1994 d); TIP 12, Combining Substance Abuse Treatment With Intermediate Sanctions for Adults in the Criminal Justice System (CSAT 1994 a); and TIP 17, Planning for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice System (CSAT 1995 b).

The new TIP pre- sents clinical guide- lines to assist coun- selors in dealing with problems that rou- tinely arise because of their clients’ sta- tus in the criminal justice system. These clients have multiple needs; they often have poor health, have histories of trauma, lack job and communication skills, and have edu- cational deficits. A special feature throughout the TIP—“Advice to the Counselor”—pro- vides the TIP’s most direct and accessible guidance for the counselor. Readers with basic backgrounds, such as addiction coun- selors or other practitioners, can study these boxes first for the most immediate practical guidance. In particular, the Advice to the Counselor boxes provide a distillation of what the counselor needs to know and what steps to take, which can be followed by a more detailed reading of the relevant material in the section or chapter.

The events of September 11, 2001, dramati- cally altered the political climate of our Nation and caused a shift in focus from the “tough on drugs” policies previously in place 3 Introduction One consistent research finding is that involvement in substance abuse treatment reduces recidivism for offenders who use drugs. to the war on terrorism. These changes have impacted both the sanctions against people in the criminal justice system and the availabili- ty of substance abuse treatment for those populations. While it is beyond the scope of this TIP to address the implications of these shifts or to predict their ultimate outcomes, the core content of this document reflects the current best practices for providing substance abuse treatment for adults in the criminal justice system.

This TIP aims to provide tools and resources to increase the availability and improve the quality of substance abuse treatment to crimi- nal justice clients. It should assist the crimi- nal justice system in meeting the challenges of working with offenders with substance use disorders and encourage the implementation of evidence-based clinical approaches to treatment.

Other guiding principles of this publication are to • Provide the relevant information that will inform and enable treatment providers to feel more confident in their approach to offender and ex-offender populations.

• Help people in community treatment under- stand the criminal justice system and how it works in step with their treatment services.

• Encourage collaboration between the crimi- nal justice and treatment communities.

• Help readers understand the multiple per- spectives that often lead to confusion and misunderstandings—public safety versus public health, treatment versus corrections, differing client needs, issues of culture and society, and local characteristics of the criminal justice system.

• Provide practical solutions and approaches to complex problems.

Key Definitions In this TIP, the term “substance abuse” is used to denote both substance abuse and sub- stance dependence as they are defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) (American Psychiatric Association 2000). This term was chosen part- ly because substance abuse treatment profes- sionals commonly use the term “substance abuse” to describe any excessive use of addic- tive substances. Readers should attend to the context in which the term occurs to determine the possible range of meanings it covers; in most cases, however, the term will refer to all varieties of substance use disorders described by DSM-IV-TR.

According to DSM-IV-TR, substance abuse is a maladaptive pattern of substance use marked by recurrent and significant negative consequences related to the repeated use of substances. Substance dependence is defined as a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual is continuing use of the substance despite significant substance-related prob- lems. A person experiencing substance depen- dence shows “a pattern of repeated self- administration that usually results in toler- ance, withdrawal, and compulsive drug-tak- ing behavior” (p. 192). A diagnosis of sub- stance dependence can be applied to every class of substances except caffeine.

Treatment is defined according to the Institute of Medicine (IOM 1990), as cited in CSAT’s National Treatment Plan Initiative (CSAT 2000 a, b): Treatment refers to the broad range of [pri- mary and supportive] services—including identification, brief intervention, assessment, diagnosis, counseling, medical services, psy- chiatric services, psychological services, social services, and followup—provided for people with alcohol [and/or drug] problems.

The overall goal of treatment is to reduce or eliminate the use of alcohol [and/or drugs] as a contributing factor to physical, psychologi- cal, and social dysfunction and to arrest, 4 Chapter 1 retard, or reverse the progress of any associ- ated problems (CSAT 2000 a, p. 7). The criminal justice system, as discussed in this TIP, includes four subsystems: pretrial and diversion settings, jails and detention centers, prisons (State and Federal), and community supervision settings. Definitions of other terms relevant to criminal justice and substance abuse treatment are given in appendix B, Glossary.

For the purposes of this TIP, an offender is a person who has been arrested, charged with a crime, or convicted of a crime and under the supervision of the criminal justice system. Audience for This TIP This TIP is written primarily for substance abuse counselors and clinicians who treat clients involved in the criminal justice system or who are under full or partial supervision and for administrators whose programs serve clients under criminal justice supervision. It also will be useful for counselors who work in correctional institutions and those in communi- ty agencies with clients on probation, parole, or pretrial release.

Others who work in the criminal justice sys- tem may also find this TIP helpful. This includes judges and prosecutors; probation and parole officers, case managers, public defenders and other criminal defense attor- neys; jail, detention center, and prison per- sonnel; and people working in pretrial/diver- sion and in probation and parole settings.

Program developers and grant writers will find that this TIP provides information about a variety of programs and resources. Finally, this TIP is of value to anyone concerned with reducing overcrowding in correctional facili- ties, addressing the crimes committed by untreated drug-involved offenders, and meet- ing the challenges that these offenders face on their journey toward recovery. Contents of This TIP The chapters that follow will focus on the fol- lowing areas:

• Chapter 2 focuses on screening and assess- ment of criminal justice clients in the rele- vant domains. It includes a discussion of special concerns (e.g., gender and sexual orientation, literacy, a client’s primary lan- guage, and learning disabilities) and specific populations. See also appendix C, which contains more information on screening and assessment instru- ments.

• Although it is rec- ognized that treat- ment can be effec- tive, it is also clear that different treatment approaches may work better with some clients than with others.

Chapter 3 discuss- es triage and place- ment in treatment services and reviews the com- plex area of treat- ment matching.

• Chapter 4 discusses the available treat- ment options in the criminal justice system. It also presents guidelines for devel- oping treatment plans.

• Chapter 5 addresses the major treatment issues for offenders who use substances.

These include a wide range of themes, including engagement and retention, stigma and shame, the client–counselor relation- ship, and major treatment levels (e.g., resi- dential, nonresidential, outpatient, commu- nity supervised, and self-help and other ancillary services). 5 Introduction This TIP aims to provide tools and resources to increase the availability and improve the quality of substance abuse treatment to crim- inal justice clients. • Chapter 6 describes treatment issues and approaches for special populations for whom modifications in treatment may be appropriate: people of ethnic and racial minorities, women, violent offenders, peo- ple with disabilities, older inmates, people with co-occurring substance use and mental disorders, and sex offenders, among others.

• Chapters 7 through 10 describe the specific treatment needs and strategies for individu- als in particular criminal justice settings.Chapter 7 addresses treatment provided in diversion and other pretrial settings.

Chapter 8 provides a detailed discussion of treatment for offenders in jails and deten- tion centers, while chapter 9 focuses on offenders in prison. Chapter 10 outlines treatment for people under community supervision.

• Finally, chapter 11 discusses the issues related to program development. 6 Chapter 1 7 2 Screening and Assessment In This Chapter… Definitions of Terms Screening Guidelines Assessment Guidelines Key Issues Related to Screening and Assessment Areas To Address in Screening and Assessment Selection and Implementation of Instruments Screening and Assessment Considerations for Specific Populations Integrated Screening and Assessment—Sample Approaches Conclusions and Recommendations Overview Screening and in-depth assessment are important first steps in the sub- stance abuse treatment process; currently no comprehensive national guidelines for screening and assessment approaches exist in the criminal justice system. In the absence of such guidelines, information in this chap- ter can help clinicians and counselors develop effective screening and referral protocols that will enable them to • Screen out offenders who do not need substance abuse treatment.

•Assess the extent of offenders’ treatment needs in order to make appro- priate referrals.

•Ensure that offenders receive the treatment that they need, rather than being released into the community with a high probability of re-offend- ing.

This chapter addresses the issues relevant to screening and assessment and makes recommendations for the appropriate use of screening and assess- ment tools in specific settings. For information on how to use screening and assessment to match the offender to services and to identify an appro- priate treatment plan, see chapters 3 and 4. For more information on spe- cific screening and assessment instruments see appendix C.

Definitions of Terms Information gathered during screening and assessment plays an impor- tant role in identifying offender needs and making appropriate referrals for services. Throughout this TIP, the following definitions are used for screening, assessment, and related terms in the criminal justice setting:

• Screening— A process for evaluating someone for the possible pres- ence of a particular problem. The screening process does not neces- sarily identify what kind of problem the person might have or how serious it might be but determines whether or not further assessment is warranted. Screening does not typically include assignment of DSM- IV-TR ( Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition, Text Revision [American Psychiatric Association {APA} 2000]) diagnoses of alcohol or drug abuse or dependence and may only identify DSM-related problem areas. During the screening process staff members use instru- ments that are limited in focus, simple in format, quick to administer, and usually able to be administered by nonprofessional staff. There are seldom any legal or profes- sional restraints on who can be trained to conduct a screening. • Assessment —A process for defining the nature of a problem and developing specific treatment recommendations for addressing the problem. A basic assessment consists of gathering key information and engaging in a process with the client that enables the counselor to understand the client’s readi- ness for change, problem areas, any diagno- sis(es), disabilities, and strengths. The assessment process typically requires trained professionals to administer and interpret results, based on their experience and training. A clinical diagnosis has important legal ramifications since judges tend to rely on assessments to identify an offender’s needs and risks, and to deter- mine the offender’s disposition.

In correctional settings, “screening” and “assessment” are equated with “eligibility” and “suitability,” respectively. “Eligibility” isdetermined in pretrial and jail settings by screening for offenders who may need sub- stance abuse treatment. “Suitability” for placement in one of several different levels of treatment services is determined by an assess- ment to help identify key psychosocial prob- lems related to referral to treatment and/or supervision. Accordingly, the following con- siderations are suggested:

• Eligibility— Does the offender meet the sys- tem’s criteria for receiving treatment ser- vices? A quick screen, typically applicable in prisons and community corrections set- tings, can determine whether a person war- rants assessment to determine if that person has a drug or alcohol problem.

• Suitability— Is the offender suitable for the type of program services that are available?

An assessment can determine whether the offender is capable of benefiting from treat- ment or responding to a particular inter- vention. The question of suitability arises once it has been determined that offenders meet the eligibility criteria for receiving ser- vices.

In essence, screening and assessment vary based on the goals of the evaluation and the setting where they are used. For drug court and jail settings, a source for operational treatment and criminal justice definitions is the article “Guideline for Drug Courts on 8 Chapter 2 Common Myths About Screening and Assessment Following are several common myths about substance abuse screening and assessment, and the facts that debunk those myths.

• Myth: Screening and assessment are no better than intuition in detecting a person’s need for treat- ment.

• Fact: Objective screening and assessment measures can result in treatment that is better targeted to a client’s needs, resulting in better outcomes.

• Myth: Only a single screening is needed to place people in different levels of treatment services.

• Fact: Accurate evaluation requires a battery of assessment instruments that examine how substance use has affected all the domains of the client’s life. When treatment options are severely limited, how- ever, a basic screening may be sufficient to determine both eligibility and suitability for treatment. Screening and Assessment” (Peters and Peyton 1998).

Screening Guidelines This section presents broad guidelines and con- siderations for developing an effective screen- ing protocol. (See section below for additional guidelines related to assessment protocols.)More specific guidelines based on the criminal justice setting and the characteristics of the population are discussed in later sections.

When creating a screening protocol, coun- selors will need to ask the following questions:

• What is the purpose of the screening?

• What screening tools will be used and under what circumstances? 9 Screening and Assessment •Myth: Untrained professionals can conduct screening and assessments.

• Fact: Although some screenings can be administered and scored without significant training, place- ment decisions are greatly improved when they are made by professionally trained staff. This includes staff with relevant certification in substance abuse treatment, those with advanced professional degrees, and those with specialized training in the use of particular screening and assessment instru- ments. For those screening and assessment approaches that require an interview with the offender, specialized training is also needed in basic counseling techniques such as rapport building and reflec- tive listening. Use of trained professional staff in the triage and placement process helps to minimize the number of inappropriate referrals for treatment.

• Myth: Screening and assessment are always compromised because you cannot trust self-report infor- mation from offenders.

• Fact: Research generally validates the reliability, and to some degree, the validity of information obtained through self-reports. Collateral sources such as the offender’s family and friends can improve the reliability of the information gathered (or “the full picture”). Offenders do supply a cer- tain amount of misinformation in some settings to avoid unwanted consequences, however.

• Myth: All screening and assessment instruments are equally effective.

• Fact: Research shows significant variability in the reliability and validity of different instruments with different populations.

• Myth: Because an instrument is widely used, it must be effective.

• Fact: Many highly marketed and widely used instruments do not have a research base supporting the validity of their use. In fact, some of the widely marketed and used instruments have been shown to be less effective than those available in the public domain.

• Myth: Screening and assessment should not examine the history of physical and sexual abuse and related trauma because this may aggravate the offender’s level of stress and psychological instability, and staff may not be able to deal effectively with the consequences.

• Fact: Screening and assessment of all forms of abuse is essential for both male and female offenders, because it is now recognized that the effects of trauma contribute to many mental disorders. Clinical outcomes are likely to be compromised if these abuse and trauma issues are not explored, and if strategies addressing these issues are not developed and integrated into treatment plans for mental and substance use disorders. However, it is important to emphasize that in screening for a history of trau- ma it can be damaging to ask the client to describe traumatic events in detail. To screen, it is impor- tant to limit questioning to very brief and general questions, such as “Have you ever experienced childhood physical abuse? Sexual abuse? A serious accident? Violence or the threat of it? Have there been experiences in your life that were so traumatic they left you unable to cope with day-to-day life?” Purpose of Screening The first issue to consider is the purpose of the screening. In addition to screening for drug use, counselors may consider screening for other problem areas. For example, given that many infectious diseases are associated with the use of drugs (Varghese and Fields 1999), health screening can be important in identifying offenders in need of healthcare services to ensure that clients receive needed medication and to prevent the spread of dis- ease. Screening to identify special needs for offenders with co-occurring mental problems can improve the effectiveness of treatment. It can identify individuals who may pose a threat to themselves or others, prevent crises, and promote immediate intervention.

Screening content should identify key issues that need to be addressed in placing offenders in treatment. Content can be specific to sever- al domains, including substance use, crimi- nal, physical health, mental health, and spe- cial considerations. Figure 2-1 summarizes the information relevant to each domain.

Screening guidelines will vary by setting. A professional screening of an individual who has just been arrested will include different questions and require different information than a long-term prisoner being considered for parole. For a probationer, screening might be used to determine the appropriate level of supervision; a jail inmate may be screened to assess his or her suitability for treatment. Figure 2-2 (see p. 12) highlights the different screening considerations for each setting.

Selection of Screening Tools In addition to identifying the purpose of screening, the protocol should also identify the screening tools to be used and the condi- tions under which they are used. Basic infor- mation can be acquired from any number of sources, including • Booking records •Self-report/interview information•Results of instruments and surveys adminis- tered •Past correctional records (presentence investigations) •Past treatment records •Police reports •Correctional staff reports (for bail hearings, early release) •Prior offense records (for driving under the influence [DUI], possession, trafficking) •Emergency medical reports •Drug test results (from examination of hair, sweat, urinalysis, Breathalyzer®) Some jurisdictions may be required to use a particular instrument or information source to gather information consistently from all offend- ers, even though corroborative information, such as urine test results, is often available.

Such universal screenings can help route non- violent, low-risk offenders to treatment place- ments in the community so that recovery can begin. A more detailed discussion of selection of screening instruments is provided later in this chapter. Assessment Guidelines The goal of assessment is to gather enough information about clients to describe how the treatment system can address their substance abuse problems and the impact of those prob- lems. An assessment examines how the offend- er’s emotional and physical health, social roles, and employment could be affected by substance abuse (Center for Substance Abuse Treatment [CSAT] 1994 a). In addition, assessments can help identify the factors that could prompt a return to drug use or criminal behavior. These include lack of social support networks, unstable employment history, poor health, criminality, unresolved legal prob- lems, inadequate housing, lack of motivation to change, a history of physical and sexual abuse, mental illness, learning disabilities, and other social and psychological factors.

These factors need to be carefully examined during assessment to plan for potential gaps 10 Chapter 2 11 Screening and Assessment Figure 2-1 Screening Guidelines by Domain Domain Information Substance Use • Substance use history • Motivation and desire for treatment • Severity and frequency of use • Detoxification needs, acute intoxication • Treatment history (e.g., number and type of episodes, outcomes) Criminal Involvement • Criminal thinking • Current offense(s) • Prior charges • Prior convictions • Age at first offense • Type of offense(s) • Number of incarcerations • Prior successful completion of probation or parole drug use offenses • Prior involvement in diversionary programs • History of diagnosis of any personality disorder Health • Intoxication, infectious disease (tuberculosis, hepatitis, sexually transmitted diseases, HIV status) • Pregnancy • General health • Acute conditions Mental Health • Suicidality • History of treatment and prior diagnosis • Past diagnoses • Treatment outcome • Current and past medications • Acute symptoms • Psychopathy Special Considerations • Educational level • Reading level/literacy • Language/cultural barriers • Physical disability • Developmental disability • Learning disability • Health and biomedical record • Housing • Dependents/family issues • History of abuse (victim and/or perpetrator), including trauma experienced as a result of physical and sexual abuse in services that can affect relapse and crimi- nal recidivism.

While assessments are more comprehensive than screenings, their depth and scope varies across settings according to the following fac- tors:

• Amount of time available to conduct the assessment • Physical setting of assessment (e.g., holding pen, booking room, medical unit, reception center, lockup, community/corrections office) • Factors influencing the confidentiality or pri- vacy of the assessment process and the uses of assessment findings•Availability of qualified staff, caseload vol- ume, and interagency cooperation •Availability of financial resources (e.g., staffing, type of assessment chosen) •Availability of treatment options in the community •Number of sources of information The instruments and sources of information used during an assessment are determined by the purpose of the assessment. Jurisdictions may elect the quickest and most efficient approach to assess who goes into treatment.

In other cases, the court may want the great- est amount of information available about an 12 Figure 2-2 Screening Guidelines by Setting Setting Purpose Special Considerations Jails • For early identification, if getting out of jail early • To determine eligibility for drug courts and pretrial diversion programs • For diversion to specialized mental health courts or programs focused on behavioral problems • To determine behavioral management prob- lems and acute needs (including crisis inter- vention) • To identify suitability for placement in jail treatment programs • For classification to different housing unitsLook for previous correctional substance abuse treatment, readiness for treatment, past institutional behavior problems, prior correctional treatment, and court orders.

Prisons • To match time left to serve with time for receiving treatment or for custody level classi- fication • To identify suitability for placement in prison treatment programsLook at prison record, treatment history (including treatment for issues other than substance abuse), and behavior.

Pretrial and Community Supervision• To determine the need for housing, transporta- tion, employment, or economic benefits • To identify suitability for placement in commu- nity treatment programs • To assess for public safety risk and level of supervision needed, pursuant to consideration for placement in diversion programsLook for community or corrections records or collateral information (e.g., information from family members). Chapter 2 offender. In this case, in addition to police, corrections, and medical records, an assess- ment should include family and other collat- eral sources for historical information.

The following guidelines pertain to assessment protocols:

• Purpose —In pretrial or diversion settings, assess for linkage to the community and placement to different types of services.

• Content —In all settings, deepen the infor- mation obtained from previous screenings (psychopathy, antisocial).

• Source —In pretrial or diversion settings, seek more expansive collateral information from family and social service staff. In jails, prisons, or community supervision settings, correctional officers and/or collateral offenders may be additional sources of information.

Once a screening has identified the need for treatment, assessments should be conducted before offenders are given permanent place- ments. Assessments feed into treatment plan- ning, decisions about treatment intensity and services needed (e.g., treatment planning and matching), and re-entry and continuing care plans. Key Issues Related to Screening and Assessment The distinctions between screening and assess- ment are defined above. This section highlights key issues relevant to both.

Accuracy of Information Accuracy of screening and assessment infor- mation is clearly dependent on the honesty of the offender. It is critical to administer screening and assessment instruments in a way that encourages honest answers. The consequences of honest and dishonest responses should be clarified, and the setting for the screening can be important in this regard (Knight et al. 2002). Some factors that contribute to greater accuracy of responses include using collateral information, using concurrent drug testing, and reviewing with the offender the purposes of information obtained during screening and assessment.

In some contexts (e.g., pretrial and presen- tence settings), offenders are often concerned that screening and assessment results will be used against them; for example to coerce them into a long-term treatment program.

The individual may also want to avoid being labeled as having an addiction problem.

Conversely, an offender may purposely try to skew the results to influence the outcome of trial, sentencing, or placement in custody and/or treatment settings. It is impor- tant for those administering screening and assessment to rec- ognize the factors that may influ- ence the accurate disclosure of information, and to craft their findings accordingly.

Unless potential concerns related to the screening and assessment process are addressed directly, it is unlikely that screening and assessment results will provide an 13 Advice to the Counselor:

Screening and Assessment • It is critical to administer screening and assessment instruments in a way that encourages honesty. Offenders often think the results of these screenings will be used against them and may try to skew the results to influ- ence the outcome of a trial.

• The consequences of honest or dishonest responses should be clarified with the offender.

• Counselors should use available collateral information, such as drug testing results, to verify the accuracy of the information.

Screening and Assessment accurate picture of the offender’s substance abuse problems and treatment needs.

Offenders should be briefed in advance regarding who will have access to screening and assessment information and how the information will be used. Counselors and criminal justice professionals should also clearly indicate their own role in the informa- tion gathering process. It may also help to address myths regarding court-ordered or other mandated treatment and treatment pro- gram requirements, and to describe the bene- fits of participating in treatment. Counselors working in criminal justice settings should also be aware of issues related to confidential- ity and informed consent in the context of screening and assessment (see CSAT 2004 and www.hipaa.samhsa.gov).

Continuity of Information Screening and assessment are not single events but continuous processes that can be repeated by a variety of professionals in a variety of settings (CSAT 1994 a). Efforts should be made to ensure the continuity of the information and to preserve the rights of the client. Ongoing communication and data sharing are important aspects of the screening and assessment process. Substance abuse treatment and criminal justice system staff, at all points in the process, need to pass on information obtained from substance abuse screening and assessment. Key information can be summarized and consolidated using a brief format, but this information should be maintained in a case file—even if a client does not go on to criminal prosecution—so that it can be used in case of subsequent arrest. It is helpful to standardize the format used to doc- ument screening and assessment information so that staff can be trained to more readily access, interpret, and communicate this infor- mation (CSAT 1994 a).

Effective treatment programs require assess- ment and coordination between substance abuse treatment and criminal justice pro- grams and an understanding of the goals ofboth systems. Coordination also leverages the scarce resources for substance abuse treat- ment (CSAT 1994 a). To encourage a team approach to treatment, assessment, referral, and case management, the consensus panel recommends that the two systems develop or strengthen arrangements that support link- ages at the institutional and procedural lev- els. In addition, cross-training can promote the use of screening and assessment results and can reduce duplication of efforts (CSAT 1994 a). Systemwide Information Sharing Frequently, those in the criminal justice sys- tem who conduct initial substance abuse screening and assessment maintain the infor- mation, while others who have contact with the offender later in the course of criminal justice processing have to rescreen or reassess the individual. (See CSAT 2004 and www.hipaa.samhsa.gov for information about confidentiality and certain restrictions regarding sharing of information.) The use of multilevel agreements to share information is one approach that can minimize duplication of screening and assessment activities. One way to achieve this is to convene stakeholder meetings with representatives from all of the involved agencies in the system to develop these agreements. The benefits of multilevel agreements tend to be quite persuasive.

Following are two examples:

• Agency A is spending $15 per drug screen in addition to staff time. If that agency works out an implementation plan with Agency B, both agencies can share the information, avoiding the unnecessary costs of duplicat- ing tests.

• Hospitals that have laboratory test results can add them to a database to confirm or refute self-report information.

At each stage of the criminal justice process there can be individuals or agencies that do not support sharing of substance abuse 14 Chapter 2 screening and assessment information. These groups have legitimate concerns that need to be expressed, and they need to be brought into the decisionmaking process as full stake- holders. Jurisdictions that establish intera- gency agreements can preserve limited staff time and resources and help avoid unexpect-ed resistance to systemwide sharing of screen- ing and assessment information at any stage in the criminal justice process. See the text box below for examples of programs that have developed multilevel agreements for sharing information systemwide. 15 Screening and Assessment Examples of Multilevel Agreements for Systemwide Sharing of Information Developing multilevel agreements is a difficult task and can take years to complete. Large criminal jus- tice systems will clearly benefit from having an intermediary case management or placement system to increase communication and coordination between in-custody programs, community-based providers, and parole offices. Below are several working models of multilevel agreements for systemwide sharing of information.

Lane County, Oregon Lane County uses client consent and a multilevel agreement between agencies to facilitate sharing of information. In this model, the client and agencies must agree up front if someone wants shared access to information. A correctional/mental health official developed a screening and reporting system where every person in jail is screened for drugs, risk, and mental health with a brief instrument. The screening information is available systemwide (i.e., jail, diversion, and community programs), including a tear-off copy for mental health information (National GAINS Center 2000).

High Intensity Drug Trafficking Areas Automated Tracking System The University of Maryland developed a nonproprietary Management Information System (MIS) called HATS, the HIDTA [High Intensity Drug Trafficking Areas] Automated Tracking System, that links sub- stance abuse treatment, mental health, juvenile, and community information. HIDTA is a program with- in the Office of National Drug Control Policy that coordinates drug control efforts in 28 regions around the country. A layered set of informed consent agreements is used to provide different access levels to different stakeholders (e.g., judges, parole, treatment programs). Users gain HATS access by signing an agreement to share any improvements made to the system, to benefit all stakeholders. The MIS is in use from coast to coast as a seamless care screening, assessment, case matching, and monitoring database (Taxman and Sherman 1998). For more information, go to the Washington/Baltimore HIDTA HATS site at www.hidta.org.

Maricopa County, Arizona Maricopa County has a data-link feed between the jail and behavioral health authority to determine whether offenders entering jail have a previous record of mental health services or substance abuse treatment (National GAINS Center 1999c). (See also chapter 8.) The Need To Rescreen and Reassess There are many reasons to rescreen and reassess. Offenders who may fear the conse- quences of self-disclosing substance abuse problems in one setting (e.g., pretrial deten- tion) may be more open to discussing their need for treatment at a later stage (e.g., com- munity supervision or prison).

Offenders’ motivation for treatment may change over time; for example, as they become more familiar with peer mentors, counseling staff, program expectations, and their own self-defeating behaviors from the past. Another example is participants in drug courts who initially appear resistant to treat- ment during status hearings and who are unresponsive to early efforts by the judge and/or treat- ment counselors to instill motiva- tion (e.g., through praise, use of sanctions, and engagement in more intensive treatment), but who later surprise program staff by their progress toward recov- ery over the course of a year or more of program participation.

For these individuals, assessmentmay reflect a gradual process of uncovering reasons to quit their substance use, and iden- tifying strengths that can be built on during treatment. Another key reason for conducting multiple screenings and assessments over time is that previous information obtained may become outdated and may not include recent events that are relevant to treatment, such as relapse episodes, undetected mental disor- ders, or domestic violence. 16 Examples of Multilevel Agreements for Systemwide Sharing of Information (continued) Orange County Probation Department As part of the implementation of Proposition 36, the Orange County (California) Probation Department developed an MIS that links the Drug and Alcohol Division of the County Health Care Agency (HCA) with myriad treatment providers in the county. The law requires that the offender have an assessment and be referred to treatment within 7 days of sentencing. In processing offenders, the Probation Department conducts an initial assessment, while the HCA conducts a clinical assessment to determine the appropriate treatment level. On receiving the case from the court, the Probation Department sends a referral through the system to HCA, who then completes the assessment, selects a provider, and sends a notice through the system to the selected provider. The system then allows the provider to send period- ic progress reports to the Probation Department, including when release of information forms have been signed, assessment levels, drug test results, and progress in treatment (Orange County Probation Department 2002). Advice to the Counselor:

The Need To Rescreen • An offender’s motivation and willingness to enter treat- ment may change over time. Those who fear the conse- quences of self-disclosing substance abuse in a pretrial setting may be more open to discussing their need for treatment while under community supervision or in prison. Others who initially appear resistant to treatment may later surprise program staff by their progress toward recovery.

• Multiple assessments may uncover an offender’s reason to quit substance use and identify strengths that can be built on during treatment. Chapter 2 Timing of Screening and Assessment In some criminal justice settings only a single screening is needed, due to limited treatment options available or to the fact that assess- ment will be provided at a later stage. This screening is typically focused on issues related to eligibility criteria and suitability for treat- ment. In cases in which several treatment options and sufficient time are available, screening is often followed by a more compre- hensive assessment.

Although screening is usually conducted as early as possible after the offender’s entrance into the criminal justice system, assessment may be delayed due to the offender’s sentence length, anticipated date of enrollment in sub- stance abuse treatment services, and other factors. For example, most prison treatment programs provide services for inmates who are serving the last 24 months of their sen- tence, and routinely wait to provide a com- prehensive assessment until the inmate is nearing the enrollment date for treatment ser- vices.

When Is a Formal Diagnosis Necessary?

When identified with a diagnosis that will fol- low them throughout the system or even their lifetime (if entered into the criminal justice system’s computer), people sometimes feel labeled and stigmatized. This is particularly true of diagnoses related to mental disorders.

Because symptoms of mental disorders are often mimicked by recent drug or alcohol use, or withdrawal from these substances, it is particularly important to defer diagnosis until an adequate assessment period is provided under conditions of abstinence. A “people first” description such as “offender who uses drugs” is preferable to the label “drug user.” Moreover, diagnostic classification can some- times preclude offenders from receiving need- ed services. For example, a mental disorder diagnosis can preclude access to substanceabuse services. Likewise, a substance abuse diagnosis can preclude access to mental health services, resulting in no services being rendered. A substance abuse diagnosis can also limit an offender’s access to certain work assignments or vocational training.

To avoid these problems, formal diagnoses should be made based on sound clinical prac- tice. A formal diagnosis may be required when • Reimbursement for services requires it (e.g., Medicaid or Medicare reimbursement is not possible without a DSM-IV-TR code).

• Pharmacological intervention is suggested (e.g., methadone, Antabuse).

• Potential psychiatric concerns emerge (e.g., when the counselor is trying to rule out sub- stance abuse or when symptoms may be drug-induced, organic, or psychiatric).

• The counselor needs to clarify co-occurring disorders that affect treatment decisions.

• The information is for research or evaluation purposes. Drug Testing Drug testing is frequently used as a screening device in community-based and institutional settings. For example, in pretrial settings drug testing is used to identify and monitor drug use and to reduce the number of re- arrests among defendants (Bureau of Justice Assistance 1999). A major objective of pre- trial drug testing is to offer courts alterna- tives to either detention or unsupervised release during the pretrial period. In commu- nity settings drug testing provides a powerful tool for treatment staff, the courts, and com- munity supervision staff to monitor and address relapse episodes and treatment progress. In institutional settings, drug testing is helpful in monitoring abstinence and can serve as an “early warning” device in detect- ing problems among therapeutic residential programs. In all settings, drug testing serves both as a deterrent to use and as a strong incentive for offenders to remain abstinent. 17 Screening and Assessment Because of advancements in drug testing tech- nologies, drug testing can easily be incorpo- rated into the pretrial risk assessment pro- cess. For instance, using hand-held devices, commercial laboratories can conduct analyses of urine, perspiration, and hair to identify the presence of a variety of drugs. Pretrial screening for five drugs can cost anywhere from $5 to $120 (Henry and Clark 1999).

However, protocols for collecting, testing, and disposing of specimens must be carefully observed to preserve the chain of evidence in the pretrial setting. Counselors should ensure that the rights of detainees and offenders are not violated (see chapter 7).

Areas To Address in Screening and Assessment This section describes the key areas that the consensus panel felt were important for effec- tive screening and assessment.

Substance Abuse History Key areas addressed during substance abuse screening and assessment are reviewed in sev- eral published TIPs, including numbers 7, Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System (CSAT 1994 d); 11, Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases (CSAT 1994 e); 31, Screening and Assessing Adolescents for Substance Use Disorders (CSAT 1999 c); and 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005 c).

Major topics covered during screening and assessment include observable signs and symptoms of alcohol or drug use, signs of acute drug or alcohol intoxication and with- drawal effects, drug tolerance effects, nega- tive consequences associated with substance abuse, the self-reported history of substance abuse, age and pattern of first substance abuse, recent patterns of use, drug(s) ofchoice, and motivation for using substances.

A full examination is made of the prior involvement in treatment, both in criminal justice and non–criminal-justice settings.

Family history of substance abuse is also important, including current patterns of abuse by family members who have contact with the offender. Screening instruments The effectiveness of substance abuse assess- ment and screening instruments may vary according to the criminal justice setting and the goals of gathering information in that set- ting. For example, in one study (Peters et al.

2000), eight different substance abuse screen- ing instruments were examined for use among male prisoners. Each of the instruments was found to have adequate test–retest reliability (the extent to which the scores are the same on two administrations of the instrument with the same people), although the validity of the instruments varied, as described later in this section. The screening instruments examined in the study included the following:

• Alcohol Dependence Scale (ADS) • Addiction Severity Index (ASI)–Alcohol Use subscale (ASI-Alcohol) • ASI–Drug Use subscale (ASI-Drug) • Drug Abuse Screening Test (DAST-20) • Michigan Alcoholism Screening Test (MAST short version) • Substance Abuse Subtle Screening Inventory-2 (SASSI-2) • Simple Screening Instrument for Substance Abuse (SSI-SA) • TCU Drug Screen (TCUDS) (Knight et al.

2002) However, these instruments varied consider- ably in sensitivity, specificity, and positive predictive value with different subpopulations (see appendix B for definitions of terms). For example, the SASSI-2 had significantly lower positive predictive value for African Ameri- cans than for Caucasians and Hispanics/ Latinos (Peters et al. 2000). Figure 2-3 lists 18 Chapter 2 recommendations for brief screening instru- ments based on this research (refer also to appendix C for the administration time and uses of specific instruments).

Findings indicated that either the TCUDS or a combination of the ADS and ASI-Drug screen should be used in situations in which it is important to reduce inappropriate referrals to substance abuse treatment. These instru- ments may be particularly useful for treat- ment programs that have limited “slots” available and significant consequences for mismatching offenders to the program (e.g.,therapeutic communities or other residential programs). The SSI-SA is recommended for use in situations in which it is desirable to identify the largest number of offenders who need treatment (Peters et al. 2000). Some cor- rectional systems have begun to use the SSI- SA for initial screening at the time of prison admission, with conducting additional assess- ment later to verify the need for treatment and to determine the specific level of services needed.

In conducting screening and assessment with female offenders, counselors may want to 19 Figure 2-3 Recommended Substance Abuse Screening Instruments Instrument Purpose Description Alcohol Dependence Scale (ADS)A 25-item instrument developed to screen for alcohol dependence symptoms; performs ade- quately in community and institutional settingsThe ADS (Skinner and Horn 1984) can be coupled with the ASI-Drug Use section to provide an effective screen for alcohol and drug use problems among offenders. For more information on the ADS, contact the Center for Addiction and Mental Health (formerly the Addiction Research Foundation) at (800) 661-1111. The ASI is reprinted in TIP 7, Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System (CSAT 1994 e).

Simple Screening Instrument for Substance Abuse (SSI-SA)A 16-item screening instrument that examines symptoms of both alco- hol and drug dependenceAn expert panel developed the SSI-SA as a tool for out- reach workers. The SSI-SA, which can be administered without training, includes items related to alcohol and drug use, preoccupation and loss of control, adverse conse- quences of use, problem recognition, and tolerance and withdrawal effects. The SSI-SA is fully described in TIP 11, Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases (CSAT 1994 f) and is reproduced along with instructions in TIP 42, Substance Abuse Treatment for Persons With Co- Occurring Disorders (CSAT 2005 c).

TCU Drug Screen (TCUDS)A 15-item substance abuse diagnostic screenThe TCU Drug Screen is completed by the offender and serves to quickly identify individuals who report heavy drug use or dependency (based on the DSM-IV-TR and the National Institute of Mental Health Diagnostic Interview Schedule) and who therefore might be eligible for treat- ment. For more information regarding the TCUDS and other related instruments go to www.ibr.tcu.edu. Source: Peters et al. 2000. Screening and Assessment consider use of the Alcohol Use Disorders Identification Test (AUDIT) and the Tolerance, Worried, Eye Openers, Amnesia, Kut Down test (TWEAK), both of which were developed for women and are more sensitive than the CAGE. The AUDIT and TWEAK also provide equivalent sensitivity in African Americans and Caucasians. For screening of alcohol problems among female offenders, counselors may also want to consider use of the Rapid Alcohol Problems Screen (RAPS), which has been shown to be more sensitive than other measures with African-American, Hispanic, and Caucasian women (Cherpitel 1997). See appendix C for information on how to obtain these instruments.

Assessment instruments A wide variety of substance abuse assessment instruments is available for use in the crimi- nal justice system. The most commonly used assessment instrument is the ASI (McLellan et al. 1980, 1992), which is used for screening, assessment, and treatment planning. The ASI was supported by the National Institute on Drug Abuse and is reproduced in TIP 7, Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System (CSAT 1994 e), and TIP 38, Integrating Substance Abuse Treatment and Vocational Services (CSAT 2000 c). The instrument provides a structured interview format to examine seven areas of functioning that are commonly affected by substance abuse, including drug/alcohol use, family/social relationships, employment/sup- port status, and mental health status. Many agencies, including those in criminal justice settings, have adapted modified versions of the ASI for use as a substance abuse screen- ing instrument. Two separate sections of the ASI that examine drug and alcohol use are frequently used as screening instruments.

A positive feature of the ASI is that it has been validated for use in criminal justice pop- ulations (McLellan et al. 1985, 1992; Peters et al. 2000). For example, the ASI is highly cor- related with objective indicators of addictionseverity. The ASI is also one of the few instru- ments that measure several different func- tional aspects of psychosocial functioning related to substance abuse and provide a con- cise estimate of the history of substance abuse as well as recent use. The instrument pro- vides severity ratings in each functional area assessed, which are useful both clinically and for research purposes. In using the ASI for assessment, significant training is needed to administer and score the instrument. The interview version of the ASI requires 45–75 minutes to administer, although the alcohol and drug use sections require considerably less time. A self-report version of the ASI was developed that has been shown to be a reli- able and accurate alternative to the coun- selor-administered instrument (Butler et al.

1998, 2001). Detoxification Needs Screening should address current evidence of intoxication, dependence, overdose, and with- drawal. This is particularly relevant in com- munity corrections and jail settings, in which there may be significant periods of substance abuse that precede contact with the criminal justice system. Criminal justice and treatment staff should be trained to detect signs and symptoms of substance abuse and to refer clients to medical staff to assist in cases of acute intoxication. Once an individual is referred for detoxification, medical staff should perform a comprehensive assessment to determine the level of prior and recent use, and the level of substance abuse or depen- dence.

Safe withdrawal from substances such as stimulants, cocaine, hallucinogens, and inhalants can be achieved with psychological support, symptomatic treatment, and period- ic reassessments by healthcare providers.

Frequent clinical assessments, along with appropriate treatment adjustments, are also important since the intensity of withdrawal cannot always be predicted accurately (Federal Bureau of Prisons 2000). Some sub- stances, such as alcohol, sedative-hypnotics, 20 Chapter 2 and anxiolytics, can produce dangerous with- drawal syndromes once physiological depen- dence has developed. Offenders who have severe and life-threatening symptoms of intoxication or withdrawal should be placed immediately under medical supervision. The Federal Bureau of Prisons (2000) recom- mends that “inmates presenting with alcohol intoxication should be presumed to have alcohol dependence until proven otherwise” (p. 8).

Not all substances of abuse produce clinically significant withdrawal syndromes, but absti- nence generally results in some psychological changes. Offenders should thus be reassessed often. Substance abuse may mask co-occur- ring mental disorders, such as depression, or symptoms of mental illness may disappear when the offender is not using. In some cases, withdrawal may cause symptoms of mental disorders that can be identified and treated.

For more information on the signs and symp- toms of intoxication and withdrawal and the treatment of individuals undergoing detoxifi- cation, see the forthcoming TIP Detoxification and Substance Abuse Treatment (CSAT in development a). The Federal Bureau of Prisons Clinical Practice Guidelines: Detoxification of Chemically Dependent Inmates, December, 2000 can be accessed online at www.nicic.org/pubs/ 2000/016554.pdf. Physical Health Conditions Besides the potential need for detoxification services, screen- ing should also address signifi- cant medical conditions that may affect the offender’s involvement in treatment, such as physical disabilities, tubercu- losis, hepatitis, HIV/AIDS, and other debilitating diseases. Readiness for Treatment In addition to examining the severity of sub- stance abuse problems, it is helpful to know whether a client is receptive to treatment and is committed to recovery goals. Readiness for treatment provides an important indicator regarding where the substance abuse treat- ment should begin.

Readiness for treatment is not always clearly defined or apparent at the onset of treatment.

Most clients do not volunteer for treatment and experience significant ambivalence about the process and level of commitment required. For years, treatment professionals and paraprofessionals believed that a person needed to “hit bottom” 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 are not completely ready. For example, motivational interviewing (MI) techniques (discussed in detail in TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment [CSAT 1999 b]) can be used to help clients resolve their ambivalence toward treatment and toward making changes in their lives. MI pro- vides an empathic, supportive, and directive counseling style that attempts to persuade 21 Advice to the Counselor:

Screening for Detoxification • Screening forms should note evidence of intoxication, dependence, overdose, and withdrawal. This is particu- larly important in community corrections and jail set- tings, in which there may be significant periods of sub- stance abuse that precede contact with the criminal jus- tice system.

• Besides the potential need for detoxification services, screening should address conditions that may affect the offender’s involvement in treatment, such as physical dis- abilities.

• It is helpful to note whether a client is receptive to treat- ment and may be committed to recovery (readiness to change). Screening and Assessment and guide the client toward change rather than to create motivation through confronta- tion of the client’s substance abuse problems and labeling the client as an “addict.” Many individuals who successfully recovered from substance abuse problems were coerced into treatment, either by family, employers, or the criminal justice system. Coerced treat- ment by the criminal justice system has been shown to be at least as effective as non- coerced treatment, when time in treatment is held constant (CSAT 1994 a; De Leon 1988; Hubbard et al. 1988). Coercion can come from multiple sources. Many offenders reported that pressures from “psychological, financial, social, familial, and medical domains” had more influence in their decision to enter treatment than did the legal system (Marlowe et al. 1996, p. 81). However, their decision to stay in treatment is more often based on motivational readiness (Knight et al.

2000) and external leverage. Thus, for clients with low internal motivation, coercive inter- ventions may help to increase their readiness for treatment. Excluding people as “unready” or “unmotivated” would exclude the vast majority of clients and would mean that treat- ment and recovery would never begin for many (CSAT 1994 a). For example, Alcoholics Anonymous counsels people who abuse alco- hol to “bring the body, and the mind will fol- low,” believing that motivational readiness will grow as the program takes hold.

An individual’s readiness for change is one of the most important factors that substance abuse counselors and clinicians should exam- ine during the screening and assessment pro- cess, and has been found to be predictive of treatment retention and other outcomes.

Studies have shown that initial motivation for treatment influences enrollment in post- release treatment services (DeLeon et al.

2000; Simpson and Joe 1993). Several treat- ment interventions (e.g., MI, motivational enhancement therapy) (Miller and Rollnick 2002) have been developed to explore and enhance readiness for treatment. Many sub- stance abuse programs in the criminal justicesystem include a “pre-treatment,” or “readi- ness” phase designed to address the needs of offenders not yet committed to recovery goals and ongoing involvement in treatment. This initial phase of treatment addresses offend- ers’ goals, expectations, and motivation for change. This intervention helps identify offenders who are ready for more intensive treatment services that require full participa- tion in activities designed to encourage changes in attitudes and behaviors.

Assessing readiness includes obtaining infor- mation about clients’ awareness of a sub- stance problem, their ability to acknowledge their need for help, their willingness to accept help, their perception of how others feel about their need for help, and whether they have taken steps to change on their own (Wanberg and Milkman 1998). Generally, clients can be considered “ready” for treat- ment if they want to abstain from substance abuse, see treatment as a means to become drug- or alcohol-free, and recognize the diffi- culty in abstaining from substance abuse without professional assistance (CSAT 1994 a). Figure 2-4 describes several brief instruments that can be used to assess readi- ness for treatment. For more detailed infor- mation on this topic, see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999 b). See also chapter 3 for a discussion of the stages of change model. Co-Occurring Disorders A substantial percentage of those under crim- inal justice supervision have one or more co- occurring mental disorders in addition to their substance use disorder. There were an estimated 283,800 incarcerated individuals in 1998 who had a major mental disorder, including 16 percent of State prison inmates, 7 percent of Federal prison inmates, and 16 percent of jail inmates (Ditton 1999). Of all of these individuals, 49–65 percent were under the influence of drugs or alcohol at the time of their offense, and 24–38 percent had a his- tory of alcohol dependence. Because individu- als often require therapeutic intervention for 22 Chapter 2 co-occurring disorders, accurate screening and assessment are of particular importance.

Much of the literature related to co-occurring disorders in the criminal justice system has focused on the most severe mental disorders (e.g., schizophrenia, bipolar disorder, and major depression) (Broner et al. 2002).

However, less severe disorders (e.g., anxiety, phobia disorders, and posttraumatic stress disorder [PTSD], along with less severe depression, attention deficit disorders, and various types of personality disorders) are also common among offenders with substance use and mental disorders, and can affect treatment outcomes (Broner et al. 2002; Haywood et al. 2000; Henderson 1998; Peters and Hills 1997, 1999; Teplin et al. 1996).An important first step in treating offenders with co-occurring disorders is to develop a systematic approach to screen and assess for these disorders. Relatively few jurisdictions systematically screen for mental health prob- lems or co-occurring disorders upon arrest, prior to or following the arraignment process, or upon entrance into the jails. Despite the high prevalence of co-occurring disorders, these disorders are not always detected from the individual’s arrest charge or mental status during booking. Unless the screening process is systematic, the target population may not be identified. As a result, many individuals are not diverted into specialized programs or provided effective discharge planning— strategies that are likely to reduce recidivism (Broner et al. 2001 a). 23 Figure 2-4 Instruments for Evaluating Readiness for Treatment Instrument Description The University of Rhode Island Change Assessment Scale (URICA) URICA was developed to assess stage of change. The instrument is known to be valid with different populations in a variety of settings. El-Bassel and colleagues have deter- mined that URICA is useful, reliable, and valid among incarcerated women who use drugs (el-Bassel et al. 1998). The URICA and other similar instruments are reprinted in TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999 b). The TCU Treatment Motivation Scales The TCU Treatment Motivation Scales can be used to track the stages of change in treatment motivation. For further information, go to www.ibr.tcu.edu. The Circumstances, Motivation, Readiness, and Suitability Scales (CMRS) The CMRS scales were designed to predict retention based on dynamic client factors related to seeking and remaining in treatment (DeLeon et al. 1994). The Circumstances scale is defined as the external pressure to engage and remain in treat- ment. The Motivation scale is defined as the internal pressure to change; the Readiness scale is defined as the perceived need for treatment; and the Suitability scale is defined as the individual’s perception of the treatment modality or setting as appropriate for himself. A prison version has been developed. A revised version of the CMRS, the CMR, is also available. The CMR is copyrighted and can be obtained by contacting the National Development and Research Institute, Inc., 71 W. 23rd Street, 8th Floor, New York, New York 10010, or [email protected]. Stages of Change, Readiness, and Treatment Eagerness Scale (SOCRATES) SOCRATES includes items specifically focused on alcohol abuse and can be used as a starting point for discussion. A Spanish translation is available. The SOCRATES and other similar instruments are reprinted in TIP 35, E nhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999 b). Screening and Assessment Screening and assessment for co-occurring disorders should occur soon after entry into involvement in the criminal justice system.

Many individuals who are screened or assessed in court, community corrections, or jail settings may be under the influence of alcohol or drugs and may need to be detoxi- fied before determining whether they have co- occurring disorders. Acute symptoms of alco- hol or drug use and residual effects of detoxi- fication can mimic a wide variety of mental disorders, including anxiety, bipolar disor- der, depression, and schizophrenia. Most prison inmates screened for co-occurring dis- orders will have been detoxified by the time of admission to treatment, although chronic residual side effects of drug use may cloud the initial symptom picture. It is therefore impor- tant to identify patterns of recent substance abuse and to observe mental health symptoms over time to see if they resolve as the individ- ual detoxifies. It is often useful to defer diag- nosis (or to provide a provisional diagnosis, if needed) until the interactive effects of co- occurring disorders can be determined.No single instrument can adequately screen for all mental and substance use disorders, particularly given the constraints of length, cost, and required training—but a combina- tion of instruments can be used (Peters and Hills 1999). The choice of substance abuse screening instruments should be based on the purpose of the screening, ethnic or racial characteristics, language spoken, and gender (Broner et al. 2002). Figure 2-5 provides a list and description of instruments used to screen and assess for mental disorders.

Broner and colleagues recommend the Mini- International Neuropsychiatric Interview for mental disorder screening in court-based diversion programs (without the Antisocial Personality Disorder and Substance and Alcohol Abuse modules and with a substance use rule-out question added to reduce false- positives). Several sources recommend the TCUDS, SSI, or ADS/ASI combination for substance abuse screening among offenders with mental health problems (Broner et al.

2001 a; Peters and Bartoi 1997). For assess- ment of psychiatric disorders, Broner and 24 Steps for Assessing the Interactive Effects of Co-Occurring Disorders 1. Assess the significance of the substance use disorder. Obtain a chronological history describing the onset of mental disorder and substance abuse symptoms.

•Determine whether mental disorder symptoms occur only in the context of substance abuse.

•Determine whether ongoing abstinence leads to rapid and full resolution of mental disorder symptoms.

2. Determine the duration of the current period of abstinence.

•If there has not been a 4–6 week period of abstinence, repeat assessment and diagnosis after such a period, depending on clinical judgment about the particular drug abuse history and the offender’s physical status.

3. Reassess mental disorder symptoms at the end of 4–6 weeks of abstinence or at any time such symptoms appear or change.

4. If mental disorder symptoms are fully resolved, consider referral for traditional substance abuse treat- ment; if not, consider referral for mental health or specialized co-occurring disorders services.

5. Provide ongoing reevaluation of the offender’s mental disorder symptoms and progress in treatment. Chapter 2 25 Figure 2-5 Instruments for Screening and Assessing Mental Disorders Instrument Description Beck Depression Inventory II (BDI-II) (Beck et al. 1996) • A 21-item self-report of symptoms that screens for symptoms of depression.

• Requires no significant training to administer.

• Found to be the most effective instrument in detecting depression among individu- als who abuse alcohol (Weiss and Mirin 1989).

• Should not be used as a sole indicator of depression but in conjunction with other instruments (Weiss and Mirin 1989; Willenbring 1986). Brief Symptom Inventory (BSI) (Derogatis 1975 a) • A short form of the Symptom Checklist 90 - Revised (SCL-90-R).

• Comprising 53 items, including three global indices of psychopathology (General Severity Index, Positive Symptom Total, Positive Symptom Distress Index) and nine primary psychiatric symptom dimensions.

• Quick to administer and requires no significant training to administer.

• Only a 6th grade reading level is required.

• May be most useful as a general indicator of psychopathology (Boulet and Boss 1991). General Behavior Inventory (GBI) (Depue and Klein 1988) • A 73-item self-report instrument that examines mood disorders.

• Requires no significant training to administer.

• Differentiates between unipolar and bipolar depression. Hamilton Depression Scale (HAM-D) (Hamilton 1960) • A 17-item scale completed by an interviewer based on self-report information.

• Examines several key elements of depression, including sleep disturbance, somati- zation, anxiety-depression, and apathy.

• Requires training to administer. Mental Health Screening Form-III (MHSF-III) (Carroll and McGinley 2001) • Eighteen simple questions designed to screen for present or past symptoms of most of the main mental disorders.

• A “rough” screening device and asks only one question for each disorder for which it attempts to screen.

• Reproduced in TIP 42, Substance Abuse Treatment for Persons With Co- Occurring Disorders (CSAT 2005 c). Millon Clinical Multiaxial Inventory (MCMI-III) (Millon 1983; Millon et al. 1994) • A self-report measure with several subscales.

• Useful in assessing Axis II (personality) disorders that may affect involvement in treatment.

• Includes the Drug Abuse Scale (DAS), an instrument designed to measure person- ality characteristics often associated with drug abuse (Calsyn and Saxon 1989). Screening and Assessment colleagues recommend the Structured Clinical Interview for DSM-IV (SCID) (Broner et al.

2001 a). Refer to appendix C for these and other examples of instruments that are rec- ommended for use with specific populations.

For more information on screening for co- occurring disorders see chapter 4 of TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005 c). History of Trauma Rates of trauma in men and women entering the criminal justice system are higher than are rates found in community samples. For 26 Figure 2-5 (continued) Instruments for Screening and Assessing Mental Disorders Instrument Description Minnesota Multiphasic Personality Inventory (MMPI-2) (Butcher et al. 2001) • A self-report measure with 567 items, 10 main clinical scales, and 10 supplementary scales.

• A restandardized version of the MMPI.

• Frequently used in correctional settings for classification and assignment to housing or inmate programs, and to predict an inmate’s response to placement in a correc- tional setting.

• Useful in identifying characteristics of antisocial personality disorder.

• Designed to identify psychopathology and not to identify substance use disorders. Personality Assessment Inventory (PAI) (Morey 1991) • A self-report measure with 344 items and 22 scales.

• Eleven clinical scales include separate measures of alcohol problems and drug problems.

• Five treatment scales are also provided in the PAI. Referral Decision Scale (RDS) (Teplin and Swartz 1989) • A 14-item measure of mental disorder symptoms developed to identify mental health problems.

• Developed and validated in a criminal justice setting.

• Found to be useful in detecting the presence of major mental illness among jail inmates.

• Requires no training to administer.

• Self-administered.

• Examines only a few mental disorders (depression, bipolar disorder, schizophrenia). Symptom Checklist 90 - Revised (SCL-90-R) (Derogatis 1975 b) • A 90-item, multidimensional self-report inventory designed to assess recently experi- enced physical and psychological distress.

• Requires no training to administer.

• Self-administered.

• Short amount of time to administer.

• Frequently used in criminal justice settings.

• Covers a wide range of symptom dimensions that include somatization, obsessive- compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Chapter 2 example, Teplin et al. (1996) found that 34 percent of female jail inmates had PTSD.

According to the DSM-IV-TR, trauma is defined by two characteristics:

1. A person experiences, witnesses, or is threatened by physical harm.

2. The person’s response to the event includes “intense fear, helplessness or horror” (APA 2000 a, p. 463).

This definition highlights that trauma is not simply an event of a particular type but includes a subjective dimension in that the per- son’s response to the event is powerfully nega- tive. For example, one person may survive a car accident and not react with “fear, helpless- ness, or horror,” while another person does experience such feelings.

Among female State prisoners, 40–80 percent report a history of emotional, physical, or sexual abuse (Bloom et al. 1994; Snell 1994).

Female prison inmates are three times more likely to report a history of any abuse and six times more likely to report a history of sexual abuse in comparison to male inmates. A histo- ry of physical or sexual abuse has been linked to many types of mental disorders, including PTSD, depression and suicidal behavior, and borderline personality disorder and other personality disorders (Spielvogel and Floyd 1997).Despite high rates of physical and sexual abuse among offend- ers, screening and assessment in the criminal justice system has not historically addressed these issues, nor have treatment ser- vices been provided in jail, prison, or community settings.

There are many compelling rea- sons to address abuse and trau- ma issues during screening and assessment in the criminal justice system. For many offenders, the guilt, shame, and low self-esteem related to their trauma history may lead to social isolation and may reduce participation in treatment activi- ties. For example, given the close relationship between past physical or sexual abuse and substance abuse, treatment that does not address one of the “root” contributors to sub- stance abuse may be perceived as unimpor- tant or irrelevant and may not provide suffi- cient incentives for the offender to change his or her attitudes and behavior. The offender’s resulting lack of engagement in program ser- vices may be misinterpreted as resistance to treatment or lack of motivation rather than to psychological issues related to abuse and trauma. Forced abstinence during jail or prison may also deprive offenders of their primary means of coping with negative emo- tions related to past abuse and trauma (i.e., use of drugs and alcohol). When this coping mechanism is no longer available, many offenders are left vulnerable and may begin to exhibit symptoms of depression and other mental disorders that can interfere with treat- ment. If unaddressed, past trauma can also trigger substance abuse relapse (during or after treatment), through emotional, physical, or situational cues associated with prior abuse experiences.

Only trained counselors should inquire about abuse and trauma issues. The counselor should be prepared for how to respond to self-disclosed experiences related to physical and sexual abuse and how to provide referral for services. In most substance abuse settings, 27 Advice to the Counselor:

Screening for Co-Occurring Disorders • Screening and assessment for co-occurring disorders should occur on entry into the criminal justice system, given the high prevalence of co-occurring disorders in this population.

• Individuals in community corrections or jail settings may need to be detoxified before screening for co-occurring disorders. The acute symptoms of alcohol or drug use and the residual effects of detoxification can mimic a wide variety of mental disorders, including anxiety, bipo- lar disorder, depression, and schizophrenia.

Screening and Assessment the goal of screening or an intake interview is not to compile detailed and comprehensive information regarding past trauma, but to identify that the offender has a history of trauma for purposes of treatment planning, triage, and referral for more intensive ser- vices. As a result, counselors should be famil- iar with and have ready access to resources (e.g., counselors with mental health training, liaisons from women’s shelters and treatment programs) to refer persons who wish to dis- cuss their histories of trauma in more detail.Although clinicians are sometimes concerned about addressing material that is potentially uncomfortable or even overwhelming for either the client or themselves, these adverse consequences are rarely experienced when these issues are raised by well-trained staff.

In fact, offenders are typically relieved to talk frankly about their abuse and trauma experience, albeit in an appropriately limited fashion. Indepth discussion of the specific events surrounding traumatic experiences is typically conducted in followup individual or 28 Screening and Assessment of Abuse and Trauma History Structured interview assessments • Trauma Assessment & Treatment Resource Book New York State Office of Mental Health’s Trauma Initiative Design Center 44 Holland Ave Albany, NY 12229 Fax requests: (518) 473-2684 • The Integrated Biopsychosocial Assessment that includes trauma history questions in an assessment form appropriate for a mental health or substance abuse setting. Available from:

Colleen Clark, Ph.D.

Louis de la Parte Florida Mental Health Institute 13301 Bruce B. Downs Blvd./ MHC 1345 Tampa, FL 33612-3899 Requests by e-mail: Cclark@ fmhi.usf.edu Self-report instruments • The Traumatic Antecedent Questionnaire (TAQ) (van der Kolk 1992). A widely used measure of lifetime experiences of trauma in 10 domains, i.e., physical, sexual, witnessing trauma, etc.

• The Dissociative Experiences Scale (DES) (Bernstein and Putnam 1986). A self-report measure examining several domains of dissociative phenomena, often sequelae of trauma, i.e., amnesia, identity alterations, spontaneous trance states, etc.

• The Clinician Administered PTSD Scale (CAPS) (Blake et al. 1998). A clinician-administered scale that provides an accurate diagnosis of PTSD.

• The Trauma Symptom Inventory (TSI) (Briere 1995). A 100-item self-report instrument that evaluates symptoms in adults that may have arisen from childhood or adult traumatic experiences. Includes 10 clin- ical scales and 3 validity scales. An alternate version (TSI-A) includes no references to sexual issues. The companion Trauma Symptom Checklist 40 (Briere 1995; Briere and Runtz 1989) is a 40-item instrument that contains 6 sub-scales. Items are rated on a 4-point scale covering frequency over the past 2 months.

• Posttraumatic Disorder Scale (PTDS) (Foa et al. 1993). Measures trauma history and specific symptoms associated with posttraumatic stress disorder. Chapter 2 group treatment sessions that specifically address this topic area. Treatment for trauma issues progresses in stages, with early treat- ment goals focused on issues of ensuring safe- ty in relationships, the place of residence, and in the workplace. Later work explores issues of recovery and reconciliation, if appropriate. This later work is frequently conducted by therapists with advanced degrees and in most cases is not appropriately addressed by paraprofessional staff.

Most commonly, assessment of trauma has been conducted through a clinical interview.

In these settings, it is preferable to use stan- dardized questions that avoid the use of terms such as “abuse,” “trauma,” or “perpetrator” and that instead focus on description of spe- cific events or experiences.

Sample interview questions could include:

• Were you ever hit or punished in ways that left bruises, burns, or cuts? Were you ever threatened with knives or guns? Were you ever made to go without eating? Did you ever witness anyone else getting hurt? Did you ever have to be taken from your parents’ care?

• As a child, did you have any sexual experi- ences? With whom and for how long did this go on? Were you ever threatened about it?

Were any photos taken? Did any of these experiences lead to medical or other prob- lems? Do you have any recur- rent memories of these events now?

• Are you safe in your current relationship? Has your safety ever been threatened in any of your adult relationships? Have you been punched, shoved, or hit? Did you ever seek any medical help as a result? Have you talked to people about these experiences? (Spielvogel and Floyd 1997).

For more information on this topic see also TIP 25, Substance Abuse Treatment and DomesticViolence (CSAT 1997 b), TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues (CSAT 2000 d), and the forthcoming TIP Substance Abuse and Trauma (CSAT in development f). Psychopathy and Risk for Violence and Recidivism A number of criminogenic “risk factors” are often assessed in justice settings to determine eligibility for admission to substance abuse treatment programs and community release (e.g., parole), and for placement in institu- tional housing or in different levels of super- vision (Borum 1996; Douglas and Webster 1999; Otto 2000). This information is particu- larly helpful to identify offenders likely to be disruptive in treatment programs, to be re- arrested, or to commit violent crimes after release from institutions. Risk factors can be categorized as static or dynamic. Static risk factors are those that cannot change, such as gender and race, or are relatively enduring traits such as the diagnosis of a mental disor- der, criminal history, family history, and the characteristics of the offender’s victims.

Dynamic risk factors are those likely to change over time and that change according to the client’s environment, social situation, or experiences, such as drug use or homeless- ness. Following is a discussion of the risk fac- 29 Advice to the Counselor:

Screening for Trauma • Trained counselors are best equipped to inquire about abuse and trauma issues. Offenders who have experi- enced abuse or trauma and who are undergoing forced abstinence while in jail or prison may be deprived of their primary means of coping with the negative emo- tions related to past trauma. These offenders may begin to exhibit signs of depression or other mental disorders that can interfere with treatment.

• Counselors should be familiar with and have ready access to resources to refer persons who wish to discuss their histories of trauma in more detail. Screening and Assessment tors for psychopathy and for violence and recidivism.

Psychopathy One stable risk factor often found among offenders with substance use disorders is psy- chopathy and the closely related antisocial personality disorder defined in the DSM-IV classification system. Personality disorders are persistent and pervasive patterns of mal- adaptive behavior that are usually exhibited early in life. Historically, many terms have been used to describe personality disorders that involve criminogenic characteristics.

Four closely linked terms are “sociopath” (and the trait of sociopathy), “antisocial per- sonality” (and antisocial traits), “dissocial personality” (dissocial behavioral traits), and “psychopathic personality disorder” (psy- chopathy or psychopathic traits). Whereas the first three formulations of criminogenic personality types focus on social deficits and mild emotional and cognitive problems result- ing in impulsivity and poor school achieve- ment, psychopathy focuses on primary and severe deficits in attachment and interperson- al bonding, lack of empathy for others’ expe- riences, lack of remorse, and shallow emo- tional functioning. These relatively stable traits are thought to have a biological basis.

As previously indicated, psychopathy is relat- ed to the DSM-IV antisocial personality disor- der but represents a more extreme version of that disorder. Some would argue that psy- chopathy represents a distinct diagnostic group. From 40 to 60 percent of male prisoninmates meet the criteria for antisocial per- sonality disorder, whereas only 10 to 20 per- cent of male prison inmates meet the criteria for psychopathy (Hare et al. 1991).

Psychopathy is an important predictor of treatment dropout, level of involvement in violence, and criminal justice recidivism (Hart et al. 1994; Hemphill et al. 1998; Ogloff et al. 1990; Rice et al. 1992). Offenders iden- tified as having a high degree of psychopathy may require specialized, more structured treatment approaches, although there is not a large body of evidence describing effective therapeutic interventions that have been applied to this population. Assessment for psychopathy is often used in criminal justice settings to rule out individuals for treatment involvement, particularly if there are not suf- ficiently structured treatment programs avail- able.

Few short screening instruments exist for psy- chopathy because of the complexity of dimen- sions that need to be examined. The most widely used instrument to identify psychopa- thy is the Hare Psychopathy Checklist- Revised (PCL-R) (Hare 1998 b; Hare et al.

1991; Hart et al. 1994). The PCL-R is consid- ered the “gold standard” for measuring psy- chopathy. It requires a significant amount of time to review archival information and to conduct an interview. A shorter screening version of this instrument—the PCL-SV—has also been developed for use with this popula- tion and validated in substance abuse treat- ment settings (Hart et al. 1995). Another shorter (60-item) measure, the Self-Report Psychopathy (SRP) instrument, has been developed for use in criminal justice settings by the author of the PCL-R.

Several other short self-report screening instruments for psy- chopathy have been developed but have yet to be fully validated with criminal justice popula- tions. These include the Psychopathic Personality 30 Advice to the Counselor:

Screening for Psychopathy • Psychopathy is an important predictor of treatment dropout, level of involvement in violence, and criminal justice recidivism. Offenders identified as having a high degree of psychopathy may require specialized, more structured treatment approaches, although there is not a large body of evidence describing effective therapeutic interventions for this population. Chapter 2 Inventory (Lilienfeld and Andrews 1996), the Psychopathy Q-Sort (Reise and Oliver 1994; Reise and Wink 1995), and the Levenson Self- Report Psychopathy Scale (Brinkley et al.

2001; Levenson et al. 1995). A number of other screening and assessment instruments examine personality features related, but not identical, to psychopathy (Zimmerman 2000), as described in Figure 2-6 on the next page.

Violence and recidivism Although psychopathy may be the single most important risk factor for criminal recidivism, other risk factors are important to assess among offenders with substance abuse prob- lems. Even offenders determined to have low levels of psychopathy may still be at high risk for violence or recidivism due to other risk factors. Other major risk factors for violence and criminal recidivism include • Antisocial attitudes • Criminal peers • Prior history of crime and violence, and early age at time of first offense/violent act • Active symptoms of severe mental illness • Impulsivity • Environmental stress • Treatment nonadherence • Personality disorders (generally) A number of environmental stressors can lead to renewed substance use and risk for recidi- vism when offenders are released from cus- tody or when their daily structure and level of supervision is reduced (Peters 1993; Wanberg and Milkman 1998). During these transitions, many offenders face employment and financial problems, and few have family or social supports. Meanwhile, there are immediate demands to organize daily activi- ties, develop and maintain constructive rela- tionships, manage personal or household finances and problems, and participate in community supervision. Many offenders involved with drugs have never learned the requisite skills to accomplish these tasks, andsome rapidly return to substance abuse in the absence of opportunities to learn and rehearse those skills.

Many offenders have long histories of psy- chosocial problems that have contributed to their substance abuse and criminal involve- ment. These include interpersonal difficulties with family members, difficulties in sustaining long-term relationships, emotional and psy- chological difficulties, difficulties in managing anger and stress, educational and vocational skills deficits, and employment problems (Belenko and Peugh 1998; Peters 1993).

Offenders do not typically plan or seek out addictive lifestyles or relapse. Rather, it is their lack of planning, personal objectives, and self-monitoring that leads to substance abuse or dependence or relapse. The lack of basic coping skills to manage life and social pressures further contributes to the risk for relapse and recidivism.

Reunification with family members is often accompanied by stress related to the family’s distrust and anger over offenders’ past drug use, unresolved conflicts with the partner or spouse, shifting parental roles, and added financial obligations, as well as drug use in the family or neighborhood. Elements of com- munity supervision can also increase an offender’s stress during re-entry to the com- munity. These include drug testing, use of house arrest, and other surveillance or reporting activities, as well as the offender’s recognition of the significant level of effort and adherence required by community super- vision programs. The community’s ongoing leverage to maintain the offender’s involve- ment in treatment following release from cus- tody or other secure settings can be a further stressor (U.S. Department of Justice 1991).

Figure 2-6 (next page) provides descriptions of three general assessment instruments relat- ed to the risk for violence and recidivism. 31 Screening and Assessment 32 Chapter 2 Figure 2-6 Instruments Examining Psychopathy and Risk for Violence and Recidivism Instruments Description Psychopathy assessment instruments Psychopathy Checklist – Revised (PCL-R) •A 20-item assessment measure that requires use of a semi-structured interview and review of archival records.

•Requires 90–120 minutes for the interview section and 60 minutes for the collateral records review.

•Measures the extent to which individuals exhibit psychopathic features on a 40-point scale, with a cutoff score of approximately 30 indicating psychopathy.

•Has considerable validation for use with offenders and is highly predic- tive of violence and criminal recidivism. Psychopathy Checklist – Screening Version (PCL-SV) •A 12-item measure examining the same construct of psychopathy as the PCL-R.

•Requires 45 minutes for the interview section and 30 minutes for the col- lateral records review.

•Scored on a 24-point scale with a cutoff of approximately 18 indicating psychopathy. Other instru- ments related to psychopathy Carlton Psychological Survey •Used as an intake screening in correctional settings.

•Contains scale scores for five categories: antisocial tendencies, chemical abuse, self-depreciation, thought disturbance, and validity.

•Especially useful for those with low education and literacy as it requires only a 4th-grade reading level. Jesness Inventory • Examines moral development throughout the life span. Paulus Deception Scales • Gauges the extent of deception provided through offenders’ self-report. Millon Clinical Multi-Axial Inventory-III (MCMI-III) • Provides an assessment of personality disorders and psychopathy.

• Correctional version of the MCMI-III provides early identification of substance abuse and mental health problems.

• The 175-question test takes 25 minutes to complete.

• Spanish versions available (Millon et al. 2002). Minnesota Multiphasic Personality Inventory (MMPI-2) • A self-report objective assessment measure with 567 items, 10 main clini- cal scales, and 10 supplementary scales (Hathaway and McKinley 1989).

• The Psychopathic Deviate Scale on the MMPI identifies individuals with psychopathic and antisocial features.

• Frequently used in criminal justice settings (particularly in prisons) for classification and assignment to housing or offender programs and to predict an offender’s response to placement in prison setting.

• MMPI subtypes described by Megargee et al. (1979) are often used to identify offenders who require more intensive supervision and struc- tured program activities. Selection and Implementation of Instruments Using well-accepted and standardized instru- ments can bring uniformity, quality control, and structure to the process. Some instru-ments may be more appropriate than others for particular purposes (CSAT 1994 a), depending on the information needed for treatment decisions. For example, some instruments focus on drug dependence and not abuse, some identify those for whom spe- cific treatment options are appropriate, and 33 Figure 2-6 (continued) Instruments Examining Psychopathy and Risk for Violence and Recidivism Instruments Description Other instru- ments related to psychopathy Personality Assessment Instrument (PAI) • Self-report instrument for assessing traits associated with psychopathy.

• Includes 344 items and requires 50–60 minutes to administer.

• Contains scales for Negative Impression Management, Malingering, and Defensiveness (Morey and Lanier 1998).

• The Antisocial Features (ANT) scale is the most highly correlated with psychopathy and focuses on antisocial behaviors, egocentricity, and stimulation-seeking. General assessment instruments related to the risk for vio- lence and recidivism Level of Service Inventory (LSI) - Revised •A 54-point scale used to predict the chances of criminal recidivism or supervision failure among offenders.

•Useful for identifying those in need of more intensive levels of treatment, placement in halfway houses, and level of supervision and security clas- sification (Andrews and Bonta 1995).

•Used by jurisdictions to support an increase or decrease in the level of community supervision.

•Includes assessment of drug use and is sometimes used in tandem with substance abuse treatment decisions. Historical, Clinical, Risk Management (HCR-20) •Provides a comprehensive risk assessment based on historical, clinical, and risk management assessments.

•Composed of static and dynamic factors with information derived from clinical interview, standardized assessment (e.g., the PCL-R or PCL- SV), and collateral sources.

• Includes three sections—10 historical items, 5 clinical items, and 5 risk management items—with a final risk rating of low, medium, or high (Webster et al. 1997, 2000). The Violence Risk Appraisal Guide (VRAG) (Harris et al. 1993) •An assessment tool for predicting violent recidivism.

•Is an actuarial measure based on 12 objective variables that are linked to recidivism.

•Requires interview and archival review, and incorporates results of diag- nostic testing, IQ testing, the PCL-R, criminal history, and indicators of adult adjustment. Screening and Assessment some are validated for use with criminal jus- tice populations.

The appropriateness of particular instru- ments depends on the type of client being referred to a specific criminal justice program and the goals related to program admission.

For instance, drug education programs are generally provided to a wide number of offenders, and a substance abuse screen that tends to be overly inclusive for this interven- tion might be preferred to a more exclusive screen. On the other hand, because of the limited access to treatment for offenders with co-occurring substance use and mental disor- ders, screening for mental disorders as well as for drug use problems may need to be conser- vative to avoid referring someone who does not need services. Therefore, flexibility in developing screening and assessment approaches is needed, depending on specific program parameters (e.g., type of staff, client goals and needs).

This section describes the various factors that the consensus panel thinks are important in the selection of screening and assessment instruments, including length, cost, window of detection, interview versus self-administered instruments, staff training required, literacy, language, and computerization.

What Guidelines Are Available Regarding the Effectiveness of Instruments?

Screening and assessment instruments vary considerably in their ability to detect sub- stance use disorders and in the coverage of related areas such as mental health and other health issues, family and social functioning, and employment. The consensus panel believes that several guidelines should be con- sidered when selecting substance abuse instruments for a particular criminal justice setting, in addition to the time and cost of administration. These guidelines, also known as “psychometric properties,” are often described in research reports examining a particular instrument or in manuals thataccompany the instruments. Five major sta- tistical guidelines are used to gauge an instru- ment’s accuracy for use with client popula- tions:

• Overall accuracy —the extent to which the instrument classifies respondents correctly.

• Sensitivity —the extent to which the instru- ment accurately identifies those with sub- stance use disorders (true positives).

• Specificity —the extent to which the instru- ment accurately identifies those without substance use disorders (true negatives).

• Positive predictive value —the proportion of offenders identified by the instrument as having substance abuse problems, com- pared to the total number having substance abuse problems.

• Negative predictive value —the proportion of offenders identified by the instrument as not having substance abuse problems, com- pared to the total number not having sub- stance abuse problems.

Psychometric information helps counselors decide the usefulness of a screening instrument in a specific criminal justice setting. Questions counselors should ask include • Are there normative scores for the popula- tion?

• Does the research show the instrument is valid for use with offenders and for rele- vant ethnic/cultural groups represented?

• Is it better to err on the side of false- positive or false-negative results? In other words, a decision must be made about whether to err on the side of sending some- one to treatment who does not need it or not sending someone who does need it. Length Another critical factor that enters into the choice of a substance abuse screening instru- ment is how long it takes to administer.

Although many drug use assessments are well designed and serve as broad sorting tools for treatment and intervention, they tend to take longer to administer than correctional agen- 34 Chapter 2 cies can afford (Knight et al. 2002). Rather, correctional systems usually have a short period of time to determine which of a large number of offenders need treatment. For example, the Program and Services Division of the Texas Department of Criminal Justice coordinates a drug abuse screening and treat- ment referral process for several hundred inmates monthly. The division lacks the staff, time, or financial resources to administer lengthy individual interviews for each new admission. Therefore, simple logic dictates that an instrument should not be used if it takes longer to administer than the staff time available.

Cost The cost of instruments varies according to whether they are publicly or commercially available, whether the instrument is computer- ized, and the unit costs per administration that are assigned by the publisher. There are sever- al screening and assessment instruments avail- able at no cost in the public domain. Other commercially available instruments are avail- able that can often be administered for $1 to $5 per unit. (See appendix C.) Window of Detection Questions phrased to ask about a relatively short window of detection—focusing on current rather than lifetime alcohol and drug prob- lems—are recommended for screening (Cherpitel 1997; Knight et al. 2002) because there is a greater chance of obtaining valid responses. However, shorter detection windows could be too restrictive, and some who need treatment could be overlooked (e.g., offenders who abstained from substances while awaiting trial).

Interview Versus Self- Administered Instruments The method used to administer an assessment instrument has implications for staffing, lan- guage, literacy, and reading level. A face-to-face interview can ensure that the respondent understands the items and answers them, but it is more time consuming and costly. The interview, which may be broken into several sessions, might be more appropriate for those with physical or cognitive disabilities. If cost is a concern, self-administered instruments could be used. Use of small-group interviews is another less costly alternative to individual interviews (Broome et al. 1996 b).

Research suggests that the reliability of the administration method varies by setting and the con- tent evaluated (Broner et al. 2002; Broome et al. 1996 b; Knight et al. 1998).

The method chosen (e.g., interview or self-administered) also affects the amount of training required to adminis- ter the screening. Staff Training Required Training will have a major impact on instru- ment selection. Logically, if resources for intensive training are not available, instru- ments should be selected that do not require interpretation. Although most screening instruments do not require substantial staff training, some, such as the SASSI, may require more training than others. Further, even when little training is required, such as for the CAGE or interview-based instru- ments, the level of training can influence the validity of results. For assessment instru- ments such as the ASI, training may have a significant impact on the interpretation of results, administration of the instrument, and development of basic counseling techniques related to engaging clients, eliciting problems, interviewing strategies, and dealing with resis- tance. 35 Screening and Assessment Correctional staff members who have been trained to administer an instrument can, in turn, train others to use it. Even with qualified staff, extensive training may be difficult to implement. Choosing a brief, easily administered screening instru- ment that requires little staff training can solve these difficulties. In some instances, correctional staff members who have been trained to administer an instrument can, in turn, train others to use it (Knight et al.

2002).

Literacy A brief screening for literacy is recommended if it is suspected that a client may not be able to complete a paper-and-pencil test. The Slosson Oral Reading Test–Revised (www.slosson.com) may be useful if a coun- selor wants to know whether a client can read at a particular grade level. It is important to note, however, that a client’s inability to read or write does not mean he or she cannot take an active part in the assessment. Rather, the counselor can substitute an interview for a paper-and-pencil assessment and a thumbprint for a signature.

Language Optimally, the instrument chosen should be written in the individual’s language of choice, whether English or another language.

However, it should not be assumed that indi- viduals who can speak a particular language can also read that language, or any other. To that end, the client may need to communicate in “street language.” In this case, the coun- selor should mirror and leverage whatever vocabulary the client uses. Professional or clinical jargon should be avoided (CSAT 1994 a).

Translating an instrument on the fly, such as for the Hispanic/Latino population, will greatly reduce the reliability and validity of screening results. Each population has differ- ent usages of language; misunderstandings and inaccuracies can impact engagement in treatment and client motivation for change. Computerization Some instruments allow screening through computerization (e.g., ASI). Computerization can reduce the personnel time needed to con- duct screening and assessment but can also reduce the comprehensiveness of information gathered compared to clinical interviews.

Research indicates that a computerized ver- sion of the ASI provides good reliability and validity for use with substance-involved clients (Butler et al. 1998, 2001). One report (Budman 2002) concluded that the computer- ized ASI is “more reliable, faster to adminis- ter, more accepted by patients, and more cost-effective” in comparison to the interview version of the ASI. While computerization can decrease the effort and time required for scoring, it can be an obstacle for offenders who are unfamiliar with computer technology and introduces added up-front and ongoing costs.

Screening and Assessment Considerations for Specific Populations Within different treatment settings in the criminal justice system, screening and assess- ment instruments and procedures are some- times altered to address the unique needs of specific clinical populations, such as ethnic and cultural minorities, women, and offend- ers with co-occurring disorders. For example, there is a growing recognition that instru- ments vary in their ability to detect substance abuse and other problems among these specif- ic populations and that in some cases new instruments need to be developed. A related concern is that if a screening or assessment instrument is substantially modified for use with specific populations, research is needed to validate the effectiveness of the new instru- ment in that setting. Another concern is that if items are added or deleted, this may affect 36 Chapter 2 the overall scoring of the instrument. The fol- lowing section presents issues to consider when screening and assessing specific popula- tions and suggests strategies for modifications to instruments and procedures.

Racial and Ethnic Minorities When the counselor and the offender are from different racial or ethnic groups, the potential for misunderstanding is consider- able. These differences can affect the staff’s ability to assess client needs and/or to recom- mend culturally competent services for clients from other cultures and can jeopardize the client’s chances for treatment success. The sources of misunderstanding originate in cul- ture, socioeconomic class, and language (Sue and Sue 1999), as well as in race, gender (Broner et al. 2001 a), literacy, and physical or cognitive inability to respond to the instru- ment (CSAT 1994 a).

A general introduction to a screening or assessment could include statements about the effects of substance abuse on society or on the client’s culture, along with information about the purpose of the process. Counselors should ask clients directly about how they view or describe themselves and their preferred usage of terms such as black, African American, person of color, Hispanic, Latino, Chicana, Pacific Islander, gay, homosexual, or lesbian.

Counselors should also be aware of general cultural beliefs and expectations. For exam- ple, screening American-Indian populations can prove difficult because gaining trust is sometimes a challenge. Moreover, some tribal cultures dictate silence about substance abuse issues. As a result, a screening that detects the need for further assessment brings the stigma of losing dignity in the tribe.

American-Indian men and women may also be the victims of other types of abuse that can impede the screening and assessment process.

Further barriers of language, literacy, and comprehension are also present in this popu- lation (Sue and Sue 1999). It may be necessary for a counselor to modify screening and assessment instruments to be sensitive to cultural differences. Individuals interested in modifying instruments should consult the research literature to identify adaptations that have already been developed and validated or new scales that have been adapted for the instruments. For example, several adaptations of the ASI have been developed for use with American Indians (Carise et al. 1998) and with women (CSAT 1997 c). Also, new intake and followup scales have been developed for the ASI (Alterman et al.

1998). Counselors are encouraged to determine whether norms for an instru- ment make sense with the population they are testing. If the recognized crite- rion score results in too many individuals being excluded from treatment, perhaps the counselor should consider lowering it.

(See also the forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment [CSAT in development b].) Women Counselors also need to be aware of special issues in screening and assessing female offenders. Women respond differently to the screening process than men (Kassebaum 1999), and a longer, more flexible format is often useful, particularly to explore unantici- pated areas that may arise. Females are more likely than males to have a co-occurring men- tal disorder and trauma-related problems. In addition, they are more likely to be affected by poverty, abuse histories, unstable social supports, and medical problems (el-Bassel et al. 1996; Fullilove et al. 1993; Haywood et al. 37 Screening and Assessment Women respond differently to the screening process than men, and a longer, more flexible format is often useful. 2000; Henderson 1998; Jacobson and Herald 1990; Jordan et al. 1996; Richie and Johnsen 1996; Teplin et al. 1996). In addition, many have lost custody of their children as a result of incarceration. Important counseling and treatment approaches for women are described in CSAT’s Technical Assistance Publication (TAP) 23, Substance Abuse Treatment for Women Offenders: Guide to Promising Practices (Kassebaum 1999), and the forthcoming TIP Substance Abuse Treatment: Addressing the Specific Needs of Women (CSAT in development g). Additional guidelines for screening and assessment of trauma history among female offenders are discussed earlier in this chapter.

Most substance abuse screening and assess- ment instruments were developed and tested in male populations. Those working with female offenders should carefully review screening and assessment instruments to examine whether they have included content that is relevant to female offenders, such as information related to custody of children and parenting, history of physical and sexual abuse, and symptoms of trauma. Test instru- ments should be examined to determine if they were developed and normed using female populations, and if not, whether there are other instruments that may be more suitablefor this population. One example of an instru- ment that has been tested with both male and female populations is the TCUDS II, which has been found to have good reliability for both genders (Knight 2001). Other screening instruments such as TWEAK have been developed specifically for women. Offenders With Co-Occurring Mental Disorders As noted previously, specialized screening and assessment approaches are needed for offenders with co-occurring disorders.

Integrated screening and assessment approaches should be used to determine the scope, symptoms, and consequences (e.g., level of cognitive and intellectual functioning) of mental and substance use disorders and to examine the relationship between these disor- ders and criminal behavior. Because of the high rates of co-occurring disorders among offenders in criminal justice settings, identifi- cation of a single disorder (i.e., either mental health or substance use) should immediately trigger screening for the other type of disor- der. Somewhat longer periods of screening and assessment may be needed for offenders with cognitive deficits (e.g., limited attention span) related to their mental disorders.

Counselors may need to allow breaks during interview sessions, move at a slower pace during the interview, and obtain collateral information to verify key infor- mation related to mental disor- der symptoms, treatment and medication use, and interactive effects of co-occurring disorders.

Depending on the criminal jus- tice setting, screening may include a brief interview, use of self-report instruments, and review of archival records. A number of short self-report instruments are also available to examine the presence of mental disorder symptoms (Peters and 38 Advice to the Counselor:

Screening Specific Populations • It may be necessary for a counselor to modify screening and assessment instruments to be sensitive to cultural and other differences.

• Women respond differently to the screening process than men, and a longer, more flexible form is often use- ful to explore unanticipated areas that may arise.

• Many adaptations have already been developed and vali- dated. For instance, new versions of the ASI have been developed for use among American Indians and with women.

• Counselors interested in modifying instruments should consult the research literature to identify new adapta- tions or scales for existing instruments. Chapter 2 Bartoi 1997). A mental status examination is also provided during many screenings for co- occurring disorders. In addition to examining key symptoms, mental health treatment histo- ry, and family history of mental disorder, it is helpful to assess the interactive effects of both disorders to determine whether there is an independent mental disorder, or if mental dis- order symptoms are present only when the offender uses drugs or alcohol.

Screening for suicidal thoughts and behavior should occur on an ongoing basis for all offenders with co-occurring disorders in the criminal justice system. This screening is par- ticularly important for offenders with severe depression or schizophrenia and individuals who are experiencing stimulant withdrawal.

Suicide screening should be conducted at the time of transfer to new institutions, or at dif- ferent stages in the justice system (e.g., arrest, pretrial diversion, probation). All sui- cidal behavior should be taken seriously and assessed promptly to identify the types of ser- vices needed. For more information see TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005 c). Integrated Screening and Assessment— Sample Approaches Programs often integrate a variety of screening and assessment instruments to place clients in the most appropriate treatment program.

Several sample models of integrated screening and assessment implementations are described below.

Colorado Department of Corrections (CDOC) Colorado has a unique screening and assess- ment approach applied to offenders in both prison and community settings. All inmates transferred to CDOC for supervision receive a comprehensive screening and assessment for substance abuse problems, including theAlcohol and Substance Use Screening and the Level of Service Inventory–Revised (LSI-R).

Based on the instruments, an extensive treat- ment matching approach places offenders in correctional settings where intensity varies from no treatment to therapeutic communi- ties. The treatment matching approach defines key criteria for admission to each level of correctional treatment services based on the history of involvement in correctional treatment, individual motivation, social sup- port, living arrangements (if in noninstitu- tional settings), level of mental disorder and substance abuse symptoms, substance depen- dence symptoms, and other factors (O’Keefe 2000). Florida Department of Corrections (FDOC) Florida has developed an integrated screening and assessment system for all inmates enter- ing its reception centers. The system uses the SSI-SA coupled with a records review (e.g., referrals from drug courts, history of DUI or drug offenses, FDOC treatment history) and a self-report gathered from interviews during the reception process. Responses from the various sources are weighted and then used to determine the offender’s needed intensity of treatment and placement. Those inmates placed in services are administered a further assessment on transfer to a permanent insti- tution, including the ASI and other psycho- social information. Key screening and assess- ment information is computerized and avail- able to treatment, classification, and proba- tion and parole staff (U.S. Department of Justice 1991).

Jacksonville, Florida, Adult Drug Court Programs This jurisdiction takes an integrated approach to screening and assessment that blends information from screening instru- ments, interviews, and archived records. For example, in the Jacksonville Adult Drug Court program, offenders are first inter- 39 Screening and Assessment viewed and offered treatment by their attor- neys and the public defender. After that, sev- eral steps are followed:

1. Treatment Accountability for Safer Communities (TASC) screens every offend- er in the program (either in jail or in the TASC office) for the likelihood of sub- stance abuse or dependency, using the agency’s screening form, coupled with a commercially available screen.

2. For offenders with substance use disor- ders, the need for treatment is evaluated using section 1 of the American Society of Addiction Medicine (ASAM) Patient Placement Criteria , Second Edition, Revised (PPC-2R) (ASAM 2001).

3. For offenders who need treatment, place- ment criteria are assessed with the other sections of the ASAM PPC-2R, which include prior treatment history; biomedi- cal, emotional, and behavioral conditions and complications; treatment acceptance/ resistance; relapse and continued use potential, and recovery environment.

4. For offenders placed in treatment, a DSM- IV diagnosis is provided.

All screening and assessment information, the offender’s treatment progress, and program evaluation and monitoring data are stored in an MIS that is available to drug court staff, including the drug court judge who can access key information such as recent drug test results during drug court status hearings. The MIS was developed by the drug court staff, court technology staff, and the City of Jacksonville. A juvenile MIS is being devel- oped (Cooper 2002). Orange County, California, Drug Court Program Orange County targets nonviolent offenders charged with possession or being under the influence of illicit drugs, first determining the offender’s eligibility and suitability for the Drug Court Program. To determine eligibility for the Drug Court Program, the districtattorney’s office flags offenders charged with possession or being under the influence.

Then, probation staff reviews prior arrest history and interviews the offender about substance abuse history and willingness and ability to comply with program requirements.

Finally, clinical staff from the program’s treatment providers complete a screening interview.

Eligible candidates are given a predetermined period of time in which to either plead guilty or opt into the treatment program. When candidates opt for treatment, suitability is then determined. This entails a full assess- ment, including a complete review of criminal history, the circumstances surrounding the charged offense, the results of any prior interactions with the criminal justice system, and a risk/needs assessment (with the National Institute of Corrections’ version of the LSI) to assess treatment needs and risk of reoffense. Finally, clinical staff conducts an ASI and a full psychosocial history to deter- mine the offender’s motivation for treatment, desire for change, emotional stability, and ability to comply with program requirements.

The program runs for 18 months, with reassessments every 6 months to re-evaluate risk/needs scores (again using the LSI). The new scores are then used by the Drug Court Team (e.g., clinical staff, judge) to adjust supervision and treatment strategies. Conclusions and Recommendations The consensus panel believes that the follow- ing are important points and recommenda- tions about screening and assessment for criminal justice populations:

• An effective screening and assessment approach will encourage appropriate refer- ral of offenders to different levels of treat- ment and will reduce the likelihood that offenders are released to the community without treatment (see chapter 3 for related discussion). 40 Chapter 2 41 • Appropriate assessment for substance abuse treatment in criminal justice settings exam- ines the substance abuse history, psychopa- thy and related risk factors, history of men- tal health problems, and other psychosocial areas that are affected by substance abuse.

• Intensive treatment should clearly be reserved for offenders who have at least moderate substance abuse problems and at least moderate risk for criminal recidivism.

Intensive treatment for low-risk offenders will have only a minor impact on reincar- ceration rates. However, there is still con- siderable work to be done to determine the most effective procedures for treatment matching with offenders.

• Failure to identify incarcerated offenders who need postrelease treatment reduces the impact of positive change that occurred during correctional treatment.

• Improved instruments and procedures for substance abuse screening and assessment will assist in matching offenders to appro- priate postrelease treatment services.

• Matching has not been consistently demon- strated to be effective, and only limited alternative approaches are available.

• Because reports of offenders’ drug prob- lems are incomplete or contain contradicto- ry information, other collateral sources of information need to be obtained (e.g., drug test results, correctional records) that can be combined with self-report information to make referral decisions. For example, in many correctional facilities, drug tests are used to flag the need for treatment—even when an offender denies recent substance abuse. Similarly, criminal records may indi- cate substance abuse problems, based on a history of drug-related or DUI/DWI arrests, or presentence investigation results.

• While most staff may conduct screenings, staff with appropriate training should pro- vide assessments and related diagnoses and treatment plan recommendations.

• Screening and assessment instruments vary considerably in their ability to detect sub-stance use disorders and to provide infor- mation regarding other areas related to substance abuse. A range of substance abuse screening and assessment instruments have been validated for use with offenders, and some are available at relatively little expense.

• The psychometric properties of screening and assessment instru- ments should be carefully reviewed, and choice of instruments based on demonstrated reliability and validity within substance abuse populations, and optimally, the utili- ty of instruments in criminal justice settings.

• A tiered screening and assessment approach could be developed in set- tings in which sev- eral types of treat- ment services are available. The ini- tial screening includes a broad filter to detect those who have substance abuse problems, while the more intensive assessment reviews specific treatment needs and risk levels so that the offender can be assigned to an appropriate level of treatment.

• Screening and assessment information should be obtained at each major point of transition within the criminal justice system (e.g., booking to jail, placement on proba- tion). In some cases, relevant information can be obtained from previous stages in the system, for example through transfer of records from probation to institutional set- tings. Screening and Assessment A range of substance abuse screening and assessment instru- ments have been validated for use with offenders, and some are available at relatively little expense. • Offenders initially assessed with symptoms of co-occurring disorders should be evaluat- ed over an extended period of time to exam- ine whether these symptoms resolve in the absence of substance abuse. This reassess- ment should be conducted by staff members who understand patterns of symptom inter- action among co-occurring disorders.

• Screening and assessment for a prior histo- ry of physical and sexual abuse should be conducted routinely, particularly in settings that include large numbers of female offenders. Staff training is needed to devel- op effective interviewing approaches relatedto the prior history of abuse, counseling approaches in dealing with abuse and trau- ma issues, and in making referral to mental health services.

• Memoranda of understanding and other formal agreements can be developed across different agencies working within the crimi- nal justice system to promote sharing of screening and assessment information. Key information related to treatment progress, outcomes, diagnoses, and ancillary services needs should be communicated across dif- ferent points in the criminal justice system. Chapter 2 42 43 In This Chapter… Treatment Levels and Components Potential Barriers to Triage and Placement Creating a Triage and Placement System Compiling Information To Guide Triage and Placement Decisions Conclusions and Recommendations Overview Identifying offenders in need of substance abuse treatment is only the first step in providing help to these individuals. Because no single treat- ment has been shown to be effective for all offenders, effective matching to individual needs such as vocational or employment skills, family counseling, and mental health services improves the likelihood that the client will successfully complete treatment. Matching to specific treat- ment interventions also is cost-effective and improves the quality of ser- vices within existing programs. For example, offenders appropriately matched to either a high-structure, behaviorally oriented program or a low-structure counseling program consistently have significantly less severe problems and lower rates of substance abuse than those not appropriately matched to treatment programs. Finally, with only a lim- ited number of available intensive treatment slots (e.g., residential ser- vices) in many criminal justice settings, offenders placed in these pro- grams who do not need or desire intensive treatment may be disruptive or drop out of treatment prematurely, preventing others from benefiting from them.

This chapter provides detailed information on how to best use the infor- mation obtained through screening and assessment in order to match the offender to appropriate treatment services. It begins by discussing three major treatment categories and outlines barriers to placement. A detailed discussion of triage and placement follows.

Treatment Levels and Components The consensus panel believes that treatment matching in the criminal justice system is most effective when there is a continuum of services— ranging from low to high intensity. This section provides a brief descrip- tion of treatment levels that may be available in criminal justice set- tings. The continuum of treatment levels includes three major treatment categories: pretreatment services, outpatient treatment, and inpatient treatment (including residential care). Several types of program services 3 Triage and Placement in Treatment Services often are available within each treatment level. As the text box above indicates, research suggests that all major treatment levels are effective. Nonetheless, the consen- sus panel believes that clients should be matched not only on the intensity of services they need, but also on the particular compo- nents that are responsive to their individual needs.

Pretreatment Services Pretreatment services, which are not part of primary treatment, include primary preven- tion, early intervention, and detoxification.

Primary prevention and early intervention are not typically used in criminal justice settings.

• Primary prevention. These are services for people who have not used substances. Mostprimary prevention programs are in schools or the community.

• Early intervention. This includes psychoed- ucational programs for those who have used substances and are considered to be at high risk for substance-related problems or have a history of substance abuse. Other inter- ventions include screening and assessment to identify substance abuse problems. Brief interventions also are appropriate for offenders who use substances but who do not meet the diagnosis of having a substance use disorder. For example, ongoing evalua- tion can help determine if referral to a more intensive level of care is needed. In some instances, early intervention can be used as short-term treatment for individu- als with low-severity substance abuse prob- lems. 44 Chapter 3 Effectiveness of Treatment Levels—Results From the DATOS Study Results from the federally funded Drug Abuse Treatment Outcome Studies (DATOS) (Hubbard et al. 1997; Simpson et al. 2002) indicate that all major treatment levels (including long-term residential, short-term inpatient, outpatient, and outpatient methadone) are effective in reducing substance abuse and criminal activity. For example, reductions in weekly cocaine use from pretreatment to 1 year posttreatment followup ranged from 46 percent among short-term residential clients to 20 percent among outpatient methadone clients. Reductions in criminal activity from pretreatment to 1 year posttreatment followup ranged from 25 percent among long-term residential clients to 8 percent among outpatient clients.

Key findings and implications from the DATOS studies include the following:

• All substance abuse treatment modalities are effective in reducing substance abuse and criminal activity.

• Residential treatment programs of at least 3 months’ duration are particularly cost-effective for use with criminal justice clients.

• Client readiness for and commitment to change and engagement and retention in treatment are important predictors of treatment outcomes. These factors, when routinely assessed by criminal justice programs, may be useful in targeting offenders who need more intensive services (e.g., intensive case management).

• Measures of client engagement and treatment progress are good predictors of dropout from treatment.

When routinely assessed, these predictors can help identify clients who require specialized interventions (e.g., peer mentors, motivational enhancement therapies, individual counseling) to sustain their involve- ment in treatment.

• Involvement in posttreatment peer support activities is helpful in preventing relapse. Clients are more likely to engage in ongoing peer support groups if they begin these activities during treatment.

• Among clients with prior treatment experience, outcomes are more dependent on the quality of relation- ships with treatment counselors than are outcomes for first-time clients (Franey and Ashton 2002). •Detoxification. Medically supervised detoxi- fication services are required for offenders whose alcohol or drug abuse has caused severe and life-threatening symptoms (e.g., acute intoxication, blackouts). Although detoxification typically is conducted prior to the onset of substance abuse treatment, it is important to provide a thorough assess- ment during detoxification and to provide orientation to the recovery and treatment process. For more information, see chapter 2 of this TIP and the forthcoming TIP Detoxification and Substance Abuse Treatment (Center for Substance Abuse Treatment [CSAT] in development a). Outpatient Treatment Also referred to as ambulatory care, outpatient treatment provides a broad range of services without overnight accommodation and includes nonintensive and intensive outpatient treat- ment, methadone treatment, and day treatment or partial hospitalization. Some of these ser- vices can be provided following inpatient or residential treatment, or as followup care after involvement in a residential program.

• Nonintensive outpatient treatment . This is substance abuse treatment that includes professional assessment and treatment involving less than 9 hours per week in reg- ularly scheduled sessions. Nonintensive out- patient treatment often addresses related psychiatric, emotional, and social issues, and offers a forum to explore issues such as the relationship between violence and men- tal disorders. Nonintensive outpatient treat- ment also can accommodate clients with job or family responsibilities, as treatment ser- vices may be offered on weekends or evenings.

• Intensive outpatient treatment. This is sub- stance abuse treatment with professional assessment and treatment from 9 to 20 hours per week in a structured program.

These programs can be held on evenings or weekends. (For more information see the forthcoming TIPs Substance Abuse:

Clinical Issues in Intensive OutpatientTreatment [CSAT in development d] and Substance Abuse: Administrative Issues in Intensive Outpatient Treatment [CSAT in development c].) • Methadone treatment. This is a medically supervised outpatient treatment that pro- vides counseling while maintaining the client on the drug methadone. This regimen is used primarily for heroin or other opioid addiction and provides a legitimate, closely monitored substitute for illicit drugs. The client must be able to document at least a 2- year history of addiction to qualify for a methadone treatment program. It is rarely used with those who are incarcerated. (For more information see TIP 43, Medication- Assisted Treatment for Opioid Addiction in Opioid Treatment Programs [CSAT 2005 a]).

• Day treatment or partial hospitalization.

This is substance abuse treatment with pro- fessional assessment and treatment of more than 20 hours per week in a structured pro- gram. This is the most intensive of the out- patient treatment options and can be used for treating clients who demonstrate the greatest degree of dysfunction but who do not require inpatient or residential treat- ment. Evening and weekend programming often is included.

Inpatient Treatment and Residential Care Inpatient treatment options include intensive medical, psychiatric, and psychosocial treat- ment provided on a 24-hour basis. The contin- uum of residential care includes psychosocial care at the most intensive end and group living with no professional supervision at the least intensive end. It is unlikely that the full range of services will be available in any one commu- nity.

• Intensive residential treatment. This long- term treatment can be directed by a sub- stance abuse treatment professional or could be medically directed. Intensive resi- dential treatment is appropriate for people 45 Triage and Placement in Treatment Services with multiple problems, especially those with co-occurring mental and substance use disorders (COD). Psychosocial rehabilita- tion is always a goal of treatment. The duration of treatment in this setting varies considerably, from 3 months to as long as 2 years.

• Therapeutic community (TC). The tradi- tional TC is a long-term (15 to 24 months) rehabilitative model that is often staffed by recovering professionals, treatment and mental health professionals, and vocational and educational counselors. Therapeutic help from the resi- dential community paves the way for residents to recover from their sub- stance abuse prob- lems and to develop the vocational, edu- cational, and social skills they need to become productive members of society.

Most TC residents have been involved with the criminal justice system. The theory and practice of the TC have been detailed in the liter- ature (De Leon 2000), and the effectiveness of these programs has been documented both in prisons and in community-based settings (Melnick et al. 2001). A 2-day train- ing course offered by the Mid-America Addiction Technology Transfer Center in Kansas City, Missouri, is available. This course consists of lectures, small groups, and instructional materials on the TC model and how it works. For more informa- tion go to www.mattc.org/index.html.

• Psychosocial residential care. This long- term (6 to 24 months) psychosocial care model has elements similar to the therapeu- tic community model in that it relies heavily on peer pressure as well as formal treat-ment to shape behavior. It is appropriate for people with substance abuse problems and concomitant disorders that do not require acute medical or psychiatric inter- vention. People compliant with psychiatric and other prescription medications are appropriate for this level of care. The focus of care is on psychosocial rehabilitation.

• Medically monitored intensive inpatient treatment. This level of care involves around-the-clock medical monitoring, assessment, and treatment in an inpatient setting, usually by a nurse or nurse practi- tioner. It is used for clients who have acute and severe substance use disorders and who may also have a coexisting medical or psy- chiatric disorder. Such treatment generally involves a short to intermediate length of stay (7 to 45 days) and may include non- medical or social model programs with vari- able lengths of stay.

• Medically managed intensive inpatient treatment. This level of care involves around-the-clock, medically directed evalu- ation and treatment in an acute-care inpa- tient setting, usually by a medical doctor.

This level of care is appropriate for the treatment of medical and psychiatric prob- lems that may require biomedical treatment (such as life support) or secure services (such as locked units). Such treatment gen- erally involves a short to intermediate length of stay (7 to 45 days).

• Short-term nonhospital intensive residential treatment. This treatment is generally 21 to 45 days in length and is designed to teach the client how to live a substance-free life and to provide motivation for the mainte- nance of such a lifestyle. Follow-up care on an outpatient basis and continued partici- pation in peer support groups is recom- mended to maintain the recovery process begun in the residential setting.

• Halfway house. Residents are expected to follow house rules and share house respon- sibilities in a residential setting under staff supervision. Residents generally find their 46 Accurate screening and assessment are necessary for effective placement. Chapter 3 own way to outside activities (e.g., work, court, counseling, vocational training, and schooling). The house sometimes offers treatment services. Length of stay is limited or unlimited depending on the attainment of specific progress goals.

• Group home. This refers to a residential, transitional living situation without any spe- cific treatment plan and minimal staff supervision. It is sometimes known as a three-quarter-way house. Residents may work and receive education, training, or treatment in the community. House resi- dents generally decide on admission of new residents. House responsibilities are shared, and the house is governed and run by its residents. The length of stay is generally unlimited as long as abstinence from substances is maintained; the Oxford House model includes complete resident self-governance and self-sufficiency. The key to success in all such models is that the living situation is substance free, which sup- ports abstinence among residents. Potential Barriers to Triage and Placement Inadequate Screening and Assessment Accurate screening and assessment are neces- sary for effective placement. However, resources, adequate time to conduct compre- hensive assessments, and trained staff are not always available in criminal justice settings. As a result, substance abuse treatment in criminal justice settings often is based on sparse and inadequate information (Knight et al. 2002).

Competing Demands in Institutional Settings A challenge for substance abuse treatment programs in institutional settings is the com- peting demands on offenders’ time. For exam- ple, a prison’s need for labor to fulfill its con-tracts and maintain itself can compete with an offender’s needs for treatment. Or, inmates could be assigned to institutional education programs. In addition, there are also compet- ing demands for treatment. Treatment service options often are limited and waiting lists exist for most services in community-based programs. The community-based system of care across the country largely is funded to provide services to a nonoffender population.

In some cases, prioritization of community treatment services for offenders has placed a strain on the limited number of available treatment slots. Information Flow Issues regarding the transfer of information across different settings in the criminal justice system present a major barrier to effective placement in offender treatment services. For example, this might include a need for a cen- tralized database that can be accessed by vari- ous providers as offenders move through the system.

Creating a Triage and Placement System The consensus panel believes that to ensure appropriate treatment for offenders who abuse substances, the offender’s needs and available resources must be balanced.

Coordination of treatment matching within the criminal justice system can reduce the long-term costs of incarceration and other criminal justice functions only if adequate personnel and funding are available for case management. Ongoing planning and coordina- tion among criminal justice staff, substance abuse treatment staff, and policymakers and other stakeholders is important to establish an effective treatment matching system.

Based on the experiences of consensus panel members, the optimal approach would be to assemble a team consisting of correctional/ supervision and clinical staff to develop a triage and placement system and to assume 47 Triage and Placement in Treatment Services responsibility for compiling and processing treatment matching information. Once the triage and placement system has been devel- oped, the team can review cases referred to treatment, transfers, and placement in high intensity or specialized treatment programs (e.g., co-occurring disorders services).

This coordinated approach also can ensure that ongoing troubleshooting occurs to adjust eligibility criteria, to check admission and transfer procedures, and to monitor reentry to the community. Although triage and place- ment teams do not necessarily meet on a daily basis, they are regularly involved in reviewing offenders’ placement status and decisions to place or transfer offenders to different pro- gram settings. Scoring criteria for assigning offenders to different levels of treatment often are developed by clinical staff with significant involvement and review by criminal justice staff (e.g., classification officers). Use of scor- ing criteria and development of a triage and placement database are useful for document standardization and treatment provision across different groups of offenders.

Following are key triage and placement activi- ties that the consensus panel believes can be jointly undertaken by a team of correctional and clinical staff:

• Developing a treatment placement database of treatment resources available in the com- munity or correctional facility • Defining key characteristics of existing treatment programs and the types of offenders and associated levels of treatment needs with whom the programs are most successful • Documenting the referral process with appropriate timeframes and communication requirements for each system • Outlining the information to be shared between agencies and developing proce- dures for transfer of key information with- out breaching confidentiality (for moreinformation on confidentiality, go to www.hipaa.samhsa.gov and see CSAT 2004) • Describing offender treatment and supervi- sion/management responsibilities for each organization to avoid duplication of efforts, interagency conflict, and lapses in monitor- ing offenders • Evaluating the effectiveness of treatment matching practices and placement criteria on an ongoing basis • Determining offenders’ eligibility for and access to health, mental health, and social services in the community Triage and Placement Strategies Triage and placement strategies for offender treatment programs depend on the range and type of services available, specific eligibility requirements attached to various programs, and the resources available to manage this process. In some criminal justice settings (e.g., jails) only limited types of services are available, such as 12-Step groups or a more intensive treatment program. In these set- tings, elaborate triage and referral systems are unnecessary, and placement decisions are often based on a brief substance abuse screening and a brief risk screening (e.g., for violence, acute mental health symptoms) to determine eligibility for the program. This often is accomplished by a single staff mem- ber and through a combination of self-admin- istered tests, brief interview, and records review.

In settings that feature a range of treatment services, triage and placement are usually lengthier, often involving multiple staff and compilation of multiple sources of informa- tion. These settings often use a scoring system or “algorithm” to determine which offenders should receive priority for available treat- ment slots. The consensus panel recommends that in general, the sophistication of a treat- ment matching system should reflect the 48 Chapter 3 • Range of different levels of treatment intensi- ty available • Scope of information needed to determine eli- gibility for admission to the various levels of treatment • Consequences for “mismatching” offenders to the different levels of treatment Under most conditions, triage and placement decisions are guided by the need to reserve program slots for offenders with more severe substance abuse problems and who present at least moderate risk for criminal recidivism (see Figure 3-1, next page). Research indi- cates that treatment programs targeting offenders with moderate to high risk for recidivism produce the greatest posttreatment reductions in recidivism and are more cost- effective (Andrews et al. 1990; Bonta 1997; Gendreau 1996). However, research does not support placement of moderate- to high-risk offenders in minimally intensive treatment services (e.g., educational groups, 12-Step groups) unless additional, more intensive ser- vices are also provided. In summary, offend- ers with more severe addiction problems and more significant risks for criminal recidivism do not experience positive treatment out- comes unless they are placed in highly struc- tured and intensive treatment programs.

Conversely, assigning low-severity offenders to these high-intensity programs often is inef- ficient and counterproductive for people who use drugs casually, who are then exposed to the corrosive effects of more seasoned offenders with pronounced criminal attitudes, beliefs, and lifestyles. Compiling Information To Guide Triage and Placement Decisions Screening and assessment are discussed com- prehensively in chapter 2. This section outlines how to use information derived from screening and assessment to make triage and placement decisions.

As described in Figure 3-1, placement and triage strategies in criminal justice settings often use a tiered approach. In the first stage of this process (screening and assessment), attempts are made to identify major mental health problems or psychopathy that would interfere with involvement in substance abuse treatment. If one of these problems is identi- fied, the offender can be directly routed to a specialized treatment or management unit/ program. This tiered approach enables crimi- nal justice staff to quickly identify offenders who are not good candidates for substance abuse treatment and prevents unnecessary substance abuse screening and assessment for offenders who would perform poorly in exist- ing substance abuse programs.

If a range of offender treatment options is available, placement in services usually is determined by the following factors:

• Risk for criminal recidivism 49 Triage and Placement in Treatment Services Advice to the Counselor:

Triage and Placement • Measurements of client readiness for change, commit- ment to change, and engagement in treatment are important predictors of treatment outcomes.

• In settings with limited services available, elaborate triage systems are unnecessary and placement often can be determined with a brief interview of the offender, some self-administered tests, and a records review.

• Accurate screening and assessment are necessary for effective triage and placement in the face of competing demands for resources. • Level of offender needs for substance abuse, mental health and other psychosocial or med- ical services, and employment • Offender motivation and readiness for treat- ment • Other offender characteristics including cog- nitive and intellectual abilities, abilities to read and write, and related abilities to com-municate in individual and group settings and to withstand stress in highly intensive therapeutic communities Research indicates that treatment programs that place individuals in services according to these areas are likely to enhance outcomes for offenders (Andrews et al. 1990; Gendreau 1996). The following sections discuss each of 50 Figure 3-1 Placement and Triage Strategies Source : Zimmerman 2000. Chapter 3 these areas in relation to triage and place- ment services, identify information sources necessary for placement, and list instruments that can be used to compile the information.

For more information on the instruments list- ed, see chapter 2 and appendix C.

Risk for Criminal Recidivism Assessment of the risk for future criminal and/or violent behavior is of vital importance in the process of assigning offenders to treat- ment programs within the criminal justice system. Offender characteristics and environ- mental factors used to estimate the likelihood of future criminal behavior are termed “risk factors.” (See chapter 2 for information on identifying risk factors.) Once criminal risk factors are identified, research indicates that structured and inten- sive cognitive–behavioral approaches can address offenders’ “criminogenic needs” related to their dynamic risk factors (those that are likely to change over time) (Andrews and Bonta 1998; Wanberg and Milkman 1998). Andrews and Bonta (1998) have identi- fied several promising targets for treatment intervention based on dynamic risk factors:

• Developing and improving life management, problemsolving, and self-control skills • Developing associations or relationships and bonding with prosocial and anticriminal peers and with prosocial and anticriminal role models • Enhancing closer family feelings and com- munication • Improving positive family structures to pro- mote monitoring • Managing and changing antisocial thoughts, attitudes, and feelings In general, offenders who are at high risk for criminal recidivism require more structured and intensive treatment interventions such as intensive outpatient treatment, day treat- ment, residential treatment, or TCs, while low-risk offenders are better suited for low-intensity interventions such as outpatient treatment, drug education, and peer support or 12-Step programs (see Figure 3-1) (Falkin et al. 1999). Information needed for triage and placement • Criminal history, including age at first arrest, number and type of prior arrests, history of violence and aggressive behavior, history of incarceration, probation and/or parole revocations • Age, education, marital status, employment history • Characteristics of psychopathy, including entitlement, impulsivity, superficial inter- personal relationships, lack of empathy, sensation seeking, poorly controlled anger • Nature of offender’s family and social net- work (prosocial versus procriminal) • Other personality disorders, including paranoia Instruments used to compile this information Use of some of these instruments is described in chapter 2.

• Psychopathy Checklist—Revised (PCL-R) and the Psychopathy Checklist–Screening Version (PCL-SV) •Psychopathic Personality Inventory (PPI) •Level of Services Inventory—Revised (LSI-R) •Millon Clinical Multiaxial Inventory—III (MCMI-III), Correctional Form •Personality Assessment Instrument (PAI) •Novaco Anger Inventory •Jesness Inventory •Paulus Deception Scale •Inventory of Sensation Seeking 51 Triage and Placement in Treatment Services Level of Substance Abuse Problems Offenders with current alcohol or drug dependence and a history of chronic sub- stance use generally require more structured and intensive levels of treatment (Knight et al. 1999 b; Simpson et al. 1999 a). There is some evidence that highly structured treat- ment approaches that use a cognitive–behav- ioral orientation are more effective for offenders with pronounced substance abuse problems, in comparison to less structured client-centered approaches that use nondirec- tive, supportive counseling strategies (Thornton et al. 1998). Offenders who have less serious substance abuse problems are likely to benefit from a variety of treatment options across a range of modalities and levels of intensity (Knight et al. 1999 b; Simpson et al. 1999 b). Information needed for triage and placement • Substance dependence symptoms • Substance abuse-related arrests (e.g., driving under the influence [DUI]/driving while intoxicated [DWI], drug possession and sales) • History of substance abuse (frequency, quan- tity, type of substances, route of administra- tion) • Drug test results or other pre- or postsen- tence information related to substance abuse • History of involvement in substance abuse treatment services Instruments used to compile this information Use of these instruments is described in chapter 2.

• Addiction Severity Index (ASI) • Simple Screening Instrument for Substance Abuse (SSI-SA)•Texas Christian University Drug Screen (TCUDS) •Alcohol Dependency Scale (ADS) Level of Mental Health Problems Offenders with co-occurring mental disorders have participated successfully in many sub- stance abuse treatment programs in criminal justice settings, although they generally have more pronounced difficulties in employment, family relationships, and physical health (Peters et al. 1992) and sometimes have cogni- tive deficits related to their mental disorders.

Although offenders with co-occurring sub- stance use and mental disorders present unique challenges, their ability to participate in treatment programs varies according to their functioning level in several key areas, including the ability to sustain attention and to participate in individual and group inter- actions, their vulnerability to emotional con- flict, and the presence of acute symptoms (e.g., paranoia, delusions). As a result, triage should include a mental health assessment to examine the potential effects of mental health problems on their participation in available treatment programs. Even moderate to high levels of mental disorders can be accommo- dated in many criminal justice treatment pro- grams, particularly those with mental health and other health services staff available, and that feature specialized treatment services for people with co-occurring disorders (Edens et al. 1997).

Information needed for triage and placement • Acute mental disorder symptoms that can influence the offender’s ability to partici- pate in individual or group treatment set- tings • Suicidal or other violent behaviors • Cognitive and interpersonal or social impairment caused by current mental disor- der symptoms, specifically related to atten- 52 Chapter 3 tion and concentration, problemsolving skills, interpersonal skills, and frustration tolerance • Effects of stress and other environmental influences on mental disorder symptoms and related behavioral problems • Likelihood of recurrence of mental disorder symptoms and behavioral problems given environmental conditions in available treat- ment programs • Accommodations available in existing treat- ment programs to address mental disorder symptoms and behavioral problems Instruments used to compile this information Use of these instruments is described in chap- ter 2.

• Minnesota Multiphasic Personality Inventory (MMPI) • Millon Clinical Multiaxial Inventory—III (MCMI-III) • Symptom Checklist 90-Revised (SCL90-R) • Brief Symptom Inventory (BSI) Offender Motivation and Readiness for Change The offender’s motivation and readiness for treatment is another key factor in triage for placement in substance abuse treatment.

Motivation and readiness for change are important predictors of treatment compli- ance, dropout, and outcome, and this infor- mation is vital (Ries and Ellingson 1990).

Treatment is likely to be ineffective until indi- viduals accept the need for treatment of their substance abuse as well as other related problems.

An offender’s motivation to participate in treatment is influenced by justice system sanctions and incentives, including court orders to complete treatment, probation revo- cation, more intensive mandatory treatment,“good time” credit for involvement in correc- tional treatment, and incarceration in jail or prison. Offenders also may be motivated by negative consequences outside the justice sys- tem, including threats to stable housing, employment, family, and marriage (Ziedonis and Fisher 1994).

However, the consensus panel cautions that assessments of motivation and readiness for change that occur outside clinical settings can misidentify signifi- cant numbers of offenders who could benefit from involvement in sub- stance abuse treat- ment. Many offend- ers who initially appear unmotivated can quickly become engaged in treat- ment through peers who are committed to recovery and who are actively involved in treatment.

Involvement in group counseling and contact with program partici- pants and staff can stimulate motivation for change in the previ- ously unmotivated offender.

Motivation for treatment changes over time, and offenders often cycle through several pre- dictable stages of change during the treatment and recovery process. The stages of change model has been developed to describe recov- ery from various types of addictive disorders (Prochaska et al. 1992), and includes the fol- lowing stages:

• Precontemplation (unawareness of substance abuse problems) • Contemplation (awareness of substance abuse problems) 53 Triage and Placement in Treatment Services The offender’s motivation and readiness for treatment is a key factor in triage for placement in substance abuse treatment. • Preparation (decision point) • Action (active behavior change) • Maintenance (ongoing preventive behaviors) Offenders who are in the precontemplation stage of change have little awareness of sub- stance abuse (or other) problems and have few intentions of changing their behavior.

Awareness of problems increases in later stages, as the individual begins to consider the goal of abstinence. However, due to the chronic relapsing nature of substance use disorders, movement through stages of change is not a linear process, and offenders often return to earlier stages of change before achieving sustained absti- nence.

Assessments of offenders’ motiva- tion for treatment and their current stage of change are useful in matching to different types of treatment and to developing treat- ment plans. For example, matching offenders to treat- ment services that are appropriate to the current stage of change is likely to enhance treatment compliance and outcomes. Conversely, for offenders who are in the early stages of change, placement in treatment that is too advanced and that does not address ambivalence regarding behavior change may lead to unsuccessful termination from treatment. For individuals in the later stages of change, placement in services that focus primarily on early recovery issues also may lead to unsuccessful termination fromtreatment. Several considerations are provid- ed in chapter 5 regarding matching treatment services to the offender’s stage of recovery.

For more information, see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999 b). Information needed for triage and placement • Perceived severity of drug and alcohol problems • Interest in making changes in drug and alcohol use • Steps that have been taken by the offender toward abstinence from alcohol or drugs • Perceived importance of receiving sub- stance abuse treatment Instruments used to compile this information • Circumstances, Motivation, Readiness, and Suitability Scale (CMRS) (De Leon and Jainchill 1986; DeLeon et al. 1994) • Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) • University of Rhode Island Change Assessment Scale (URICA) (DiClemente and Hughes 1990) Examples of Triage and Placement Approaches The consensus panel thought that the following three examples demonstrated effective use of triage and placement strategies.

Florida Department of Corrections The Florida Department of Corrections has operationalized a multilevel triage process to refer inmates to substance abuse treatment programs. This process involves the following steps: 54 Matching offenders to treatment services that are appropriate to the current stage of change is likely to enhance treatment compliance and outcomes. Chapter 3 • Review by classification staff to examine sentence structure, prior arrests, and cor- rectional history.

• Brief screening for substance abuse prob- lems and dependence symptoms using a modified version of the SSI-SA.

• Personal interview.

• Determination of the need for treatment based on the substance abuse screening, the history of drug or alcohol offenses, prior history in correctional treatment, recom- mendations by drug courts or other sen- tencing courts, and staff or self-reported referral for treatment.

• Assignment of a “priority score” for sub- stance abuse treatment, based on the sub- stance abuse screening score, the number of prior substance abuse offenses, number of prior correctional treatment episodes, posi- tive drug test results, and counselor inter- view results.

• Routine identification of inmates prioritized for substance abuse treatment through “flags” initiated within the computerized database.

Several of the components contributing to the priority score are weighted, including recom- mendations for treatment from drug courts or other sentencing courts, DUI manslaughter convictions, and unsuccessful termination from community corrections residential treat- ment programs. The inmate priority score is entered on a computerized database. Inmates with high priority scores are then transferred to facilities with substance abuse treatment programs, where an additional substance abuse screening and interview is conducted.

Priority placement in intensive treatment ser- vices is provided for inmates with at least 12 to 18 months remaining on their sentence. Megargee and Case Management Classification Systems Correctional systems have long used a variety of typologies to match clients to treatment and supervision approaches in institutional and community settings. These typologies usually are based on a combination of crimi- nal history variables and psychosocial char- acteristics. One example of a multidimension- al treatment matching system is the Megargee System, which is based on an extensive analy- sis of Minnesota Multiphasic Personality Inventory (MMPI) responses given by a large sample of Federal prison inmates. Ten dis- tinctive profile types have been identified, each with varying treatment implications that range from recommended placement in the least restrictive setting to placement in spe- cialized mental health facilities (Vigdal and Stadler 1996).

The Case Management Classification (CMC) system was developed by the Wisconsin Department of Corrections. Based on an offender’s responses to a 45-minute semistructured interview, four categories are used to determine treatment assignment with- in the correctional system:

1. Selective intervention for offenders who have led relatively stable, prosocial lives.

The current offense resulted from an isolat- ed stressful event and represents a tempo- rary lapse.

2. Environmental structure for offenders lack- ing social and vocational skills who are typi- cally led by others into criminal activity.

3. Casework control for offenders with very unstable lives who are actively involved with drugs or alcohol and have a number of prior arrests.

4. Limited setting for offenders with long-term criminal involvement and who are comfort- able with their criminal lifestyle and strive for success through criminal activity. 55 Triage and Placement in Treatment Services ASAM Patient Placement Criteria One approach that has been developed to assist in triage and placement decisions for substance abuse treatment services is the revised version of the American Society of Addiction Medicine (ASAM) Patient Placement Criteria (PPC-2R) for the Treatment of Substance-Related Disorders , Second Edition, Revised (ASAM 2001). These criteria provide guidance for substance abuse counselors and other treatment staff in deter- mining the best “match” between client char- acteristics and several levels of treatment ser- vices. An interview format of the ASAM PPC- 2R is under development for use in clinical settings. Within the ASAM approach, treat- ment matching is facilitated for several differ- ent levels of treatment, including the follow- ing:

• Level 0.5—Early intervention • Level 1—Outpatient treatment • Level 2—Intensive outpatient treatment/par- tial hospitalization • Level 3—Residential/inpatient treatment • Level 4—Medically managed intensive inpa- tient treatment Client characteristics are described across six dimensions for each level of treatment. Within each of these dimensions, the client characteris- tics described are intended to reflect a good “match” between client needs and the treat- ment setting. Dimensions of client characteris- tics in the ASAM-PPC-2R system are 1. Alcohol intoxication and/or withdrawal potential 2. Biomedical conditions and complications 3. Emotional, behavioral, or cognitive condi- tions and complications 4. Readiness to change 5. Relapse, continued use, or continued prob- lem potential 6. Recovery environmentThe ASAM approach, or similar dimensional matching strategies, may be useful for sub- stance abuse treatment staff within criminal justice settings. Although the ASAM criteria have not yet been formally adapted for offender populations, the PPC-2R could prove helpful in providing a structured vehi- cle for determining which offenders would benefit from different levels of treatment intensity, structure, and supervision. One additional dimension that could be useful to incorporate in criminal justice adaptations of the ASAM PPC-2R is the risk for criminal recidivism. Levels of treatment services speci- fied within the ASAM criteria would also need to be tailored to specific types of criminal jus- tice settings (e.g., drug courts, restitution or day treatment centers, in-jail and in-prison settings), with additional client–offender dimensional criteria developed for each of these new settings. Although this adaptation process would require some attention, there is likely to be significant overlap between client–offender dimensional criteria for these new settings (e.g., drug courts), and existing ASAM criteria for various settings (e.g., intensive outpatient treatment, therapeutic communities). Conclusions and Recommendations The consensus panel recommends that several key points be considered when developing a triage and placement system for substance abuse treatment in the criminal justice system:

• An effective triage and placement system should be developed to ensure adequate training and availability of staff to conduct assessments.

• In general, offenders who have significant risk for substance abuse and criminal recidivism should be prioritized for initial placement in substance abuse treatment services, rather than in other institutional programs (e.g., educational or vocational/employment services). These offenders should be referred to intensive 56 Chapter 3 treatment programs (e.g., day treatment, intensive outpatient, residential services).

• Mental disorder symptoms and impairment should be carefully considered in determin- ing placement in substance abuse treatment services. The functional ability of inmates should be the central concern in triage and placement decisions, rather than mental disorder diagnoses.

• A centralized substance abuse treatment database should be created to organize results from screening and assessment, to help coordinate the triage and placement process, and to track offender progress in treatment.• In addition to key information regarding substance abuse problems, risk for criminal recidivism, and mental health problems, triage and placement decisions also should consider the offender’s motivation and readiness for treatment, the length of sen- tence/incarceration, prior history in treat- ment, violence potential, and other related security and management issues.

• A centralized database that provides timely information on offenders as well as the availability of services should be developed to improve triage and placement. 57 Triage and Placement in Treatment Services 59 4 Substance Abuse Treatment Planning In This Chapter… Assessing the Severity of Substance Use Disorders Assessing the Severity of Co-Occurring Disorders Criminality and Psychopathy Client Motivation and Readiness for Change Implementing an Effective Treatment Planning Process Conclusions and Recommendations The good treatment plan is a comprehensive set of tools and strategies that address the client’s identifiable strengths as well as her or his prob- lems and deficits. It presents an approach for sequencing resources and activities, and identifies benchmarks of progress to guide evaluation. —Center for Substance Abuse Treatment (CSAT) 1994 d, p. 21 Overview While screening and assessment identify the offender’s need for sub- stance abuse and other treatment services, and triage and placement services match the offender to the proper treatment, the treatment plan is where the information gathered is used to put treatment into practice.

A treatment plan is a map specifying where clients are in recovery from substance use and criminality, where they need to be, and how they can best use available resources (personal, program-based, or criminal jus- tice) to get there. At a minimum, the treatment plan serves as a basis of shared understanding between the client and treatment providers.

Clients learn what is expected of them in program commitments and attendance.

There are many approaches to treatment planning, but they possess some basic commonalities; this chapter discusses each in further detail.

The severity of substance abuse-related problems must be determined, since this is the basis for appropriate placement in a treatment pro- gram. In addition, the presence of co-occurring mental disorders must be assessed because these may limit the type of treatment approach and identify the need for psychiatric care. Also important is assessing fac- tors such as procriminal attitudes and psychopathy that may suggest persistent criminality unrelated to substance abuse. The degree to which the individual is motivated to change behavior and lifestyle is another critical factor that has a bearing on whether motivational enhancement interventions, sanctions, or more self-directed treatments are appropriate. Finally, offender-clients should be involved in develop- ing their treatment plan so that they can be referred to appropriate ser- vices in the community. Assessing the Severity of Substance Use Disorders Treatment planning within the criminal jus- tice system requires a comprehensive assess- ment of an offender’s substance abuse history and patterns of use, including drug(s) of abuse, chronological patterns of use, specific reasons for use, consequences of use, and family history of drug and alcohol abuse.

Often treatment involvement within the crimi- nal justice system is based primarily on a con- viction or plea to a drug-related offense.

Although the number and type of substance- related charges is sometimes a fairly good indicator of substance abuse and related problems, the offense category alone is not a foolproof indicator of treatment need or of appropriateness of referral to a specific pro- gram. The presence of intoxicants in blood or urine at the time of arrest is a better, albeit imperfect, indicator.

Using multiple indicators for assessing the severity of a substance use disorder is impor- tant because individuals with few substance- related problems typically do not respond favorably to intensive treatment and fail to identify with the process of recovery. Close association with more severely affected offenders can result in the less-severe offend- er becoming socialized into a criminal and drug-oriented lifestyle through contagion of attitudes and introduction to a criminal social network. Minimally, an assessment of severity should focus on determining the impact of use on the individual’s community adjustment.

Usually this also entails taking a drug history that inquires about the frequency, dosage, and types of drugs used. A drug history may also inquire about the times at which, or set- tings in which, an offender uses.

Assessment of the severity of a substance use disorder may lead to an actual diagnosis of a substance use or dependence disorder.

However, most offender treatment programs consider routine use of illicit drugs without a diagnosable disorder to be a legitimate focusfor treatment, since any use is illegal and may result in arrest or violations of community supervision guidelines. Also, most settings lack the qualified staff and time required to make formal diagnoses, and clients are some- times in the setting for too short a time to delay treatment while awaiting formal diagno- sis of a substance use disorder. In these set- tings, clinical impressions are more feasible than are formal diagnoses, and common sense, assisted where possible by standard- ized assessment instruments, should prevail in deciding whether and how to provide treat- ment services. Fortunately, several standard- ized instruments with good psychometric properties are available in the public domain, or at low cost, for the purpose of screening and assessment of substance use severity (see chapter 2). Assessing the Severity of Co-Occurring Disorders Another important area to assess in develop- ing a treatment plan is the presence and impact of psychological and emotional prob- lems, particularly those that are not the direct result of substance abuse. Offenders with severe substance use disorders have rela- tively high rates of affective disorders, anxi- ety disorders, and personality disorders.

These disorders can contribute to the devel- opment of substance use problems, or the emotional disorders may develop as a conse- quence of the physiological effects of long- standing drug use and the stressful or trau- matic life events that are often experienced as part of a lifestyle in which drug use plays a central role. Some individuals have mental health problems prior to intake; others devel- op them during adjudication, incarceration, or community supervision. Commonly encountered disorders include anxiety, depression, and posttraumatic stress disorder (PTSD) (Teplin et al. 1996). Developing pro- grams to assist those with co-occurring mental and substance use disorders requires inte- grating treatments and modifying commonly 60 Chapter 4 used interventions to take into account possi- ble cognitive disabilities and increased need for support among these individuals. In addi- tion, system-level barriers in funding, staffing, and training must be overcome (Drake et al. 2001). (See also TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders [CSAT 2005 c].) Although the treatment of co-occurring severe mental disorders and substance use disorders sometimes is provided in specialized, more intensive programs, less severe mental disor- ders that do not cause major functional impairment can be treated and managed effectively within mainstream programs.

Moreover, not addressing these underlying problems can increase the likelihood of relapse. It is important to note, however, that the early stages of recovery often are marked by increases in depression and anxiety, due, in part, to residual effects of substance with- drawal and also to the individual’s recogni- tion of consequences related to his substance abuse, including incarceration or other restrictions to his liberty. Likewise, substance abuse may mask an underlying mental disor- der that may not become apparent until the offender is no longer using drugs or alcohol.

Thus, assessments should be repeated regu- larly during the treatment process. Posttraumatic Stress Disorder and Depression Problematic early life experiences, physical and sexual abuse, witnessing violence among family and friends, and other traumatic life events often emerge as key issues in substance abuse treatment. Whether identified initially or after a period of treatment, it is important that these issues be reflected in the treatment plan, matched with interventions likely to be effective, and tracked with regard to progress. For example, while most clients will find that negative mood will decrease over the first few months of abstinence and treatment, an individual’s depression, nightmares, and other trauma-related symptoms might persist after several months. If symptoms do not require transfer to a mental health services program, this individual should be referred to mental health professionals for further assessment and treatment. The referral could result in recommendations for antidepres- sants and/or antianxiety medications and/or involvement in cognitive–behavioral therapy related to trauma and substance abuse issues.

These interventions may be instrumental in preventing substance abuse relapse and allowing the client to continue making progress within her substance abuse treat- ment program. Serious Mental Disorders Although they occur less frequently than PTSD and mild anxiety or depression, serious mental disorders (including schizophrenia, delusional disorder, bipolar disorder, and major depression) can adversely affect the ability of treatment programs to man- age an offender’s behavior. Behav- ioral disorders that involve self-harm (e.g., cutting or burning oneself, suici- dal threats or attempts), and impul- sive and uncontrollable aggression are particularly problematic to manage in a treatment setting. These more severe 61 Substance Abuse Treatment Planning Advice to the Counselor:

Mental Health Issues • After a few months of abstinence, most clients will show a decrease in negative mood related to their substance use. However, abstinence may reveal the presence of other, more serious mental disorders (such as posttrau- matic stress disorder, depression, schizophrenia, intermit- tent explosive disorder, or borderline personality disor- der) that will require collaboration with a mental health professional. Some individuals will achieve a level of adjustment that will allow them to continue in main- stream substance abuse treatment, but others will require more intensive intervention for their co-occur- ring disorders. behaviors require involvement of mental health professionals for diagnostic workup and treatment interventions.

In the case of serious mental disorders and threatening behavioral disorders, an assertive, psychiatrically based treatment approach is needed during the most intensive phases of the disorder. After the more severe symptoms have abated (usually through medi- cation and behavioral management on a spe- cialized unit or in a hospital), collaboration between mental health and substance abuse professionals is needed to determine the best approach to manage and treat the individual.

Some individuals will achieve a level of adjustment that will allow mainstreaming within substance abuse programs, with medi- cation monitoring in collaboration with medi- cal staff. Other individuals will require more intensively integrated care and intervention for their co-occurring disorders.

Intermittent Explosive Disorder Treatment planning for individuals who pre- sent with an intermittent threatening behav- ioral disorder is complex. If these behaviors are fairly frequent, it will be impractical to manage the individual in a mainstream pro- gram. If these behaviors occur infrequently, the individual may be manageable in the mainstream setting, but only with additional assessment as to the causal antecedents (immediate situation and circumstances) of the outbursts or self-harm behaviors and an analysis of the incentives and perpetuating factors that fuel the behavior. With this assessment in hand, the treatment plan can be used to alert and guide the individual and staff regarding triggers for the unwanted behaviors and ways to defuse their appear- ance, or ways to limit the threat they present to the client and others.

The treatment plan in such cases will often involve the client’s committing to a behavior contract that requires reporting strong temp- tations or urges to the staff, specifies self-con-trol strategies, and clarifies the consequences of the behavior, which may include sanctions for misconduct, intensification of treatment, or removal from the mainstream program with referral to a specialized behavioral unit.

In many cases psychiatric consultations and medication management can be helpful. Borderline Personality Disorder Individuals diagnosed with borderline per- sonality disorder (BPD) sometimes engage in severely disruptive behaviors. Individuals with this disorder typically experience many specific negative emotions (vulnerability, hos- tility, sadness, anxiety, etc.) or a nonspecific but intense sense of distress or “feeling bad.” This is combined with an inability to monitor and control emotions, alternating chaotic or contradictory ways of relating to self and oth- ers, and self-harm or dramatically self- destructive behaviors.

Dialectical Behavior Therapy (DBT) (Linehan 1993) has been developed specifically for treatment of BPD. This treatment requires specialized training, and manualized inter- ventions are available to guide group treat- ment sessions. DBT approaches can be suc- cessfully integrated with substance abuse treatment in much the same way that the treatment of severe mental disorders is coor- dinated with mainstream substance abuse treatment. Clients participating in DBT do so on a voluntary basis, and agree to attend skills training sessions and to work on reduc- ing suicidal or self-injurious behavior and other behaviors that interfere with treatment.

Core DBT interventions involve careful exam- ination of clients’ problems and emotional difficulties, as well as a recognition that these problems make sense within the context of current life situations. Problemsolving skills are used throughout DBT, as are contingency management, cognitive–behavioral treatment approaches, supervised “exposure” to past trauma events, and use of psychotropic medi- cation. 62 Chapter 4 The DBT approach typically consists of at least 1 year of treatment, comprising weekly individual psychotherapy and group therapy sessions. Individual sessions explore problem- atic behaviors and chains of events leading up to the behaviors, while therapy sessions focus on interpersonal effectiveness skills, tolerance of distress, emotional regulation, and self- awareness or “mindfulness” skills. The pre- treatment phase of DBT is dedicated to assessment, orientation, and developing com- mitment to the treatment process.

Three subsequent stages of treatment empha- size self-examination and development of skills. Stage 1 of DBT involves examination of suicidal and other problem behaviors that interfere with treatment and the client’s qual- ity of life, and development of related skills to address these issues. Stage 2 of DBT address- es problems related to PTSD, and Stage 3 is focused on developing self-esteem and addressing individual treatment goals.

Criminality and Psychopathy In developing treatment plans for substance- involved offenders, it is important to assess whether criminal attitudes and behaviors pre- dated drug and alcohol abuse and whether criminogenic personality features will impede involvement in treatment. This assessment is useful in constructing a balance between risk containment and rehabilitative activities pre- scribed for the offender, and, along with sub- stance use disorder severity and presence ofpsychopathology, is one of the most important predictors of treatment outcome. Although substance abuse treatment has become increasingly integral to the criminal justice system, it should not be assumed that crimes committed by drug-involved offenders are solely the result of drug-acquiring behavior or are attributable to intoxication and impaired brain functioning. The majority of drug-involved offenders show a dramatically reduced pattern of criminal activity while they are abstinent and involved in treatment, as compared with periods of active substance abuse (De Leon et al. 1982; Deschenes et al.

1991). Nonetheless, some offenders persist in committing a high frequency of property and violent crimes, even in the absence of sub- stance abuse. Sources of Criminality Many offenders begin their criminal careers before the onset of substance use, with drugs and alcohol being more symptomatic of a broader pattern of delinquency, act- ing-out, and social deviance. Three sources of criminal behavior that are closely associated with drug use can be identified: procriminal values, pro- criminal associates, and psychopathy. Procriminal values Procriminal values in adults are most often the result of the combination of early involvement with delinquent peers, the experience of parental neglect or abuse, the absence of prosocial resources and strengths (such as literacy, employability, and social skills), and exposure to an overly permissive or procriminal environment, such as an unsafe school or crime-ridden neighborhood.

Examples of procriminal values include intol- erance for personal distress and unwillingness to accept responsibility for behaviors that adversely affect others. Procriminal values and attitudes, coupled with a longstanding pattern of antisocial and criminal behaviors, are the key elements of psychopathy. 63 Substance Abuse Treatment Planning Advice to the Counselor:

Borderline Personality Disorder • Severely disruptive clients may have borderline personali- ty disorder. Dialectical Behavior Therapy has been devel- oped specifically for treatment of this disorder and can be successfully integrated with substance abuse treat- ment programs. Procriminal associates Procriminal associates can develop from life in proximity to high-frequency crime areas, but more often the choice of criminal associ- ates is the logical result of “criminal thinking” and procriminal values. Procriminal associa- tions are also formed during incarceration or involvement in criminal justice programming.

Often these are not balanced by prosocial friendships because of the person’s inability to overcome the stigma of having a criminal record or attract and maintain relationships with individuals who are socially less “marginal.” Procriminal values and thinking, as well as criminal associates, are rooted in normal cog- nitive, emotional, and social processes, such as the need for belonging and approval, the need to feel that one has gotten a “fair deal” in life, and the need to feel a sense of self-effi- cacy and security. Because the origin and perpetuation of these factors are based pri- marily in normal psychosocial aspects of the person—that is, they are based on thoughts, emotions, and ways of relating that are within normal limits—they are fairly susceptible to being modified using the psychosocial meth- ods common to the major substance abuse treatment modalities. Individuals whose crim- inality results primarily from these two fac- tors can learn new ways of thinking and valu- ing, as well as new ways of feeling and how to manage their feelings, especially in the con- text of developing new prosocial and pro- recovery relationships. Treatment approaches that address criminal thinking are discussed in chapter 5.

Psychopathy Psychopathy is distinguished from both pro- criminal values and procriminal associates in that it is most often conceptualized as a per- sonality trait with primarily biological under- pinnings. When this trait becomes extreme it can be described as a personality disorder.

Personality disorders are distinctive, long- standing, pervasive patterns of behavior,which usually begin early in life. Personality disorders tend to affect almost every aspect of a person, such as thinking, feeling, perceiv- ing, and relating to others, with worsening cycles of self-defeating and maladaptive behavior. Most theorists and researchers view psychopathy as the result of interactions between biological differences—primarily located in the brain (Anderson et al. 1999; Laakso et al. 2001)—and the most early and basic experiences that shape the personality, such as the experience of bonding, attach- ment, and concern for others (Hare 1996).

Psychopathy is expressed in ways of thinking (impulsive, irresponsible, and grandiose) and feeling (without empathy and shallow) that typically result in behaviors that seriously infringe on the rights of others.

In contrast to the BPD, the most notable characteristic of individuals with severe psy- chopathy (other than persistent criminality and exploitation of others) is the lack of nor- mal attachment to and value for other people.

Although they can be glib and charming, peo- ple with psychopathy have a shallow and fleeting ability to experience, express, and understand social emotions such as embar- rassment, self-consciousness, shame, guilt, pity, and remorse. This affective-interperson- al deficit often is expressed in the form of cold and callous use of other people without regard for their feelings or well-being. This lack of empathy is usually the basis for a lack of remorse for criminal behavior and is sup- ported by the belief that society and the vic- tim are at fault, rather than the perpetrator, or that the damage done by one’s crimes is of little consequence (Hare 1998 a).

The Psychopathy Checklist–Screening Version (PCL–SV) can provide an important screening mechanism for identifying those offenders who may require a more extensive evaluation. The PCL-SV and other instru- ments for examining psychopathy are dis- cussed in more detail in chapter 2. All other things being equal, individuals who are low in psychopathy can be expected to respond favorably to substance abuse treatment in the 64 Chapter 4 criminal justice system and to significantly reduce their criminal behavior as the result of this treatment. Individuals who are in the moderate range of psychopathy will benefit from treatment but will require more inten- sive monitoring, an emphasis on consequences and potential sanctions versus personal aspi- rations and goals, and vigilance for deception and manipulation of treatment and criminal justice supervisors.

Individuals high in psychopathy require the most intensive in-prison and community supervision and monitoring. Intensive treat- ments that engage the client in deep emotional processing, that require “working through” life experiences to develop insight, or that stress the development of social skills for their own sake should be avoided for this group. Treatments should be limited to prac- tical relapse prevention activities, including relapse to illegal or seriously self-defeating forms of manipulation and exploitation of others, with increased monitoring for drug use. All self-reported aspects of community adjustment must be carefully corroborated by first-hand observation or reported by an independent third party, including, for exam- ple, attendance at required programming, status of living conditions, type and hours of work, criminal background of close associ- ates, and use of leisure time.

Offenders with severe psychopathy tend to do poorly in treatments of all types, when com- pared to those without severe psychopathy.

Of great importance is the sur- prising and paradoxical finding (now replicated) that offenders with severe psychopathy who are given intensive treatment re-offend more frequently and more seriously than offenders with psychopathy who go untreated (Hobson et al. 2000; Reiss et al. 1999, 2000). In other words, treatment may be contraindicated for offenders with severe psychopathy. Client Motivation and Readiness for Change The successful implementation of a treatment plan depends, to a great extent, on the client’s motivation and readiness for change.

Motivation level has been found to be an important predictor of treatment compliance, dropout, and outcome, and is useful in mak- ing referrals to treatment services and in determining prognosis (Ries and Ellingson 1990). Motivation is sometimes thought of as an emotional commitment to voluntary engagement in treatment. However, this view is overly simplistic, since motivation can be influenced by many factors including the threat of sanctions or the promise of rewards for treatment engagement (such as reduced jail time, access to needed services, or trans- fer to a desired correctional facility where the treatment will take place). Motivation and readiness for treatment are expected to change over time, and individuals often cycle through several predictable “stages of change” during the treatment and recovery process. Due to the chronic relapsing nature of substance abuse problems, offenders fre- quently return to previous stages of change before achieving recovery goals and sustained periods of abstinence. (See chapter 3 for a discussion of the stages.) A number of attempts have been made to link the readiness to change approach to a substance abuse-specific model that involves 65 Substance Abuse Treatment Planning Advice to the Counselor:

Psychopathy • Individuals high in psychopathy require the most inten- sive in-prison and community supervision and monitor- ing. Treatment should be limited to practical relapse pre- vention activities, including relapse to illegal or seriously self-defeating forms of manipulation and exploitation of others, with increased monitoring for drug use.

• All self-reported aspects of community adjustment must be carefully corroborated by first-hand observation or an independent third party. “phases” of recovery. Each phase of recovery is typified by a characteristic level of motiva- tion, often reflected in engagement with treat- ment and with specific recovery-related activ- ities. These models have considerable value for both treatment planning and research as ways of describing and communicating about where a client is in regard to readiness (McHugo et al. 1995).

Assessment of treatment readiness and stage of change is useful in treatment planning and in matching the offender to different types of treatment. For example, matching offenders to treatment that is appropriate to their cur- rent stage of change is likely to enhance treat- ment compliance and outcomes. For individu- als in the early stages of change, placement in treatment that is too advanced and that does not address ambivalence regarding behavior change may lead to early termination from the program. For offenders who are in later stages of change, placement in services that focus primarily on early recovery issues may also lead to premature termination from treatment. Staff involved in treatment plan- ning should be careful to assess the offender’s stage of change and readiness for substance abuse treatment and to consider this informa- tion when developing treatment plan goals.

Ongoing review of readiness for treatment can be provided through use of self-report instru- ments, focused discussion with the client, observation of the client within a treatment program, and review of collateral reportsfrom treatment staff, criminal justice staff, and family members. Several techniques for screening and assessment of readiness for change are discussed in chapter 3.

Motivation for change is so often an issue for criminal justice clients that perhaps most treatment plans should contain a section addressing motivation and readiness for change. Surprisingly, individuals who verbal- ize the greatest desire for treatment may not have more than a vague sense of their own motivation to escape the negative conse- quences they are currently experiencing, such as incarceration, debt, or ill health. However, staying focused on the positive consequences and rewards of recovery is an essential aspect of the recovery process. From the first point of intake to the final community supervision session, promoting and utilizing motivation should be an upfront aspect of criminal jus- tice management of substance abuse treat- ment. Motivational interviewing methods, providing feedback to clients on key aspects of assessment findings and progress toward treatment plan goals and intimate involve- ment of the client in the construction and revision of the treatment plan are important ways of enhancing client engagement in treat- ment. (For more information, see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment [CSAT 1999 b].) Focus on Personal Strengths The strengths-based approach to treatment planning in juvenile justice and adult criminal justice settings has been received with enthusiasm in many quarters.

This contrasts with the tradi- tional deficit-based approach to treatment planning for adults involved in the criminal justice system. Strengths can be recog- nized and used in treatment planning without neglecting deficits or decreasing the neces- sary emphasis on accountability and responsibility. Offenders 66 Chapter 4 Advice to the Counselor:

Motivation for Change • Treatment plans should contain a section addressing motivation for change. Clients may have only a vague sense of their own motivation for treatment. However, staying focused on the positive consequences of recovery is an essential aspect of the recovery process.

• From the first point of intake to the final community supervision session, promoting and utilizing motivation should be an upfront aspect of substance abuse treatment. tend to exaggerate or minimize their strengths. Assisting clients in identifying and getting an accurate estimate of their personal strengths should emphasize, but not be limit- ed to, those that are relevant to recovery.

Strengths assessment often begins by deter- mining what interests or inspires the client or by identifying those things in which the client has a sense of pride. Therapeutic community settings often identify specific roles within the treatment environment that clients can take on as their strengths and work to develop them further. Other modes of intervention perhaps need to create roles or activities for clients that use their strengths or identify opportunities outside of the program itself.

Women’s programs often emphasize the strengths that enabled survival during peri- ods of abuse or neglect. Identifying and work- ing with strengths in the treatment planning process allows the client to be less defensive about the identified deficits and problem areas in the same plan. It is important, how- ever, that the perception of the strengths as legitimate and of value be shared among the members of the planning team and with the client.

Implementing an Effective Treatment Planning Process Offender Involvement in the Development of the Treatment Plan The consensus panel believes that it is essen- tial for clients to be involved in setting case management goals that are in their own best interests. Success of the treatment plan can be greatly aided by the client’s involvement in the development of specific objectives and interventions. An example of this process is the Client’s Recovery Plan (CRP), in use at the Walden House program in San Francisco (see Figure 4-1, next page). The client docu-ments his perception of his circumstances, needs, and tendencies, and these are incorpo- rated into the program treatment plan. The CRP opens the dialog between the client and the staff on a more equal footing. Coordination of Treatment Planning and Sharing of Treatment Information Treatment planning activities in criminal jus- tice settings should include the full range of professionals involved in supervising, moni- toring, and providing therapeutic services. In noncustody settings, it is useful to have pro- bation or parole officers involved in this pro- cess, in addition to staff from halfway houses, employment/vocational services, and family members. In custody settings, treatment plan- ning could involve case management or tran- sition staff who may be responsible for coor- dinating prerelease plans and making arrangements for treatment appointments fol- lowing release from custody. The consensus panel recommends that treatment plans be updated at different transition points in the criminal justice system (e.g., following release from custody, transfer to less intensive super- vision status, or departure from a halfway house setting), as the offender’s motivation, response to environmental stressors, and level of involvement in treatment may significantly change. Signed releases of confidential infor- mation and interagency memorandums of agreement can help to ensure that treatment plans and other key information are trans- ferred to appropriate staff during these tran- sition points.

Relapse prevention plans often are used with- in community-based treatment programs in the criminal justice system to develop a coor- dinated approach to supervision, treatment, and judicial supervision that recognizes the importance of substance abuse relapse.

Relapse prevention plans often describe high- risk situations for the offender which increase the likelihood of relapse, relapse “triggers” or cues (e.g., interpersonal conflict, negative or 67 Substance Abuse Treatment Planning 68 Chapter 4 Figure 4-1 Client’s Recovery Plan (CRP) Name ________________________________________ Date ____________________ WH # ______________________ Note to client This form is provided to you, as a Walden House client, in order to obtainy yo ou ur r input into your treatment plan.

Your counselors will be evaluating you and your treatment needs based on the Psycho-Social History and Assessment that you provided them. This form is your opportunity to do your own self-evaluations on the same cat- egories.

Instructions Please describe your own preferences or ideas of what you feel you need in the following categories (if the category does not apply, please put “N/A”).

Drug and Alcohol _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ Childhood/Family _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ Relationship/Marital/Sexual _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ Friendship/Recreation and Leisure/Religious/Spiritual _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ Parenting/Child Protective Services (CPS) _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ Criminal Justice _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ Education _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ Employment _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ positive emotions, drug paraphernalia, old drinking or drug associates), skills to be developed to address problems related to relapse, and specific strategies to deal with relapse urges, “triggers,” and high-risk situa- tions. Relapse prevention plans are used in a number of drug courts, and help develop con- sensus among court, supervision, and treat- ment staff about an offender’s current “risk” level for relapse and in organizing responses to critical incidents and problem behaviors.

Linkages With Community Treatment For criminal justice clients who will not remain long in a jail setting, linkages to the appropriate community services are an essen- tial part the treatment plan. The shorter the jail detention, the more important these links become, especially if a client needs a range of services, including educational, vocational, legal, medical, and mental health. For these links to work most effectively, the treatment plan must include all relevant informationabout the client that may be needed by the community providers involved. This will allow all the different parties to agree on their own responsibilities to the client as well as the conditions for reporting back to the case manager as needed for the client’s welfare. In some cases an interagency audit, however informal, can be useful to identify gaps in the treatment plan and barriers to the client’s progress, as well as the strengths present in the client’s situation.

Successful links with community agencies require careful planning and considerable resources to develop. Treatment planning and case management as a whole will be easier for treatment professionals if these relationships already exist and can be called upon quickly.

Case managers can cultivate these relation- ships by being involved whenever possible in activities of the agencies they work with, such as by attending committee or planning meet- ings, in helping staff members of these organi- zations to develop offender programs and policies, and by contributing to resource materials and manuals. (See TIP 30, 69 Substance Abuse Treatment Planning Housing _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ Mental Health _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ Overall, is there anything else you feel you need that is not covered in the above areas that is related to your sub- stance abuse recovery?

_ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ In your opinion, how much treatment time do you feel you need? Be specific.

_ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ Your signature: _______________________________________________________________________________ Thank you. Your input is appreciated and will be taken into consideration in the development of your treatment plan. You are to bring this completed form with you to your clinical assessment meeting. Continuity of Offender Treatment for Substance Use Disorders From Institution to Community [CSAT 1998 b].) Conclusions and Recommendations The consensus panel recommends that several key points be considered when developing a substance abuse treatment plan for clients in the criminal justice system:

• Sufficient resources are needed for compre- hensive assessment and treatment planning, including adequate staffing, clerical sup- port, and access to computers and manage- ment information systems.

• When sharing information is not feasible (e.g., routinely providing detailed informa- tion to a drug court judge regarding offend- er disclosures in treatment), consultation, training, and written agreements are need- ed to define the types of information that will be shared, with whom, and under what circumstances.

• Procedures should be developed to control the flow of relevant information to the vari- ous staff involved in an offender’s treat- ment and supervision. These procedures are required to protect the privacy and confidentiality rights of offenders. (For more information on confidentiality, consult www.hipaa.samhsa.gov and see CSAT 2004.) • The offender should be involved in all major aspects of the treatment planning process.• Procedures should be adopted for in-prison treatment programs regarding information sharing and flow of treatment records from one institution to another. Such procedures should control access to treatment providers and provide protection against rerelease of information related to self-dis- closures of previous unreported criminal behavior or the intent to commit future crimes and psychiatric and medical histo- ries, except when required by law. (For more information on confidentiality, consult www.hipaa.samhsa.gov and see CSAT 2004.) • Treatment plans should assess the severity of the substance use disorder as well as any COD in order to place the offender in an appropriate treatment setting.

• Treatment plans should address motivation and readiness for change.

• Treatment plans should incorporate a strengths-based approach.

• Offenders possessing some degree of psy- chopathy may respond less well to tradi- tional substance abuse treatment but bene- fit from intensive in-prison and community supervision that emphasizes consequences and sanctions for relapses.

• Correctional therapeutic community (TC) programs should consider use of instru- ments to measure client progress in treat- ment, as defined by the TC’s goals for social and psychological change. 70 Chapter 4 71 5 Major Treatment Issues and Approaches Overview While many similarities exist between substance abuse treatment for those in the criminal justice system and for those in the general popu- lation, people in the criminal justice system have added stressors, including but not limited to their precarious legal situation. Criminal justice clients also tend to have characteristics that affect treatment.

These include criminal thinking and criminal values along with the more typical resistance and denial issues found in other substance abuse treatment populations.

Many offenders also have a long history of psychosocial problems that have contributed to their substance abuse: interpersonal difficulties with family members, difficulties in sustaining long-term relationships, emotional and psychological problems and disorders, difficulty man- aging anger and stress, lack of education and vocational skills, and problems finding and maintaining gainful employment (Belenko and Peugh 1998; Peters 1993). These chronic problems often are associat- ed with reduced self-esteem, anxiety, depression, and enhanced expec- tations about the initial use of substances. Unsuccessful attempts at abstinence also tend to reinforce a negative self-image and increase the likelihood that offenders will use substances when faced with con- flict or stress.

This chapter addresses strategies for modifying substance abuse treat- ment services for criminal justice clients. Some of these strategies are underlying program components, such as incentives for program par- ticipation and emphasis on personal accountability; others are more directly related to clinical issues, such as intervening with criminal thinking and teaching basic problemsolving skills.

While the suggestions offered here are applicable to many criminal justice clients, it is important to note that treatment approaches must take into account the unique situation of the offender and his stage in the recovery process. Treatment plans and assessments should be con- tinually revised to reflect changes in the client’s situation, such as In This Chapter… Clinical Strategies Program Components and Strategies Conclusions and Recommendations recent relapses, continued sobriety, and improvements in mental and psychological functioning. For more on issues affecting spe- cific subpopulations within the criminal jus- tice system, see chapter 6.

Clinical Strategies Substance abuse counselors working with criminal justice clients are likely to face a host of challenges. Offenders may require help meeting basic life needs, such as finding housing, applying for a job, or cooking a meal. Moreover, counselors generally will ha