Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System [Front Matter] [Title Page] Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Treatment Improvement Protocol (TIP) Series 7 James A. Inciardi, Ph.D. Consensus Panel Chair U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Rockwall II, 5600 Fishers Lane Rockville, MD 20857 [Disclaimer] This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume, except quoted passages from copyrighted sources, is in the public domain and may be reproduced or copied without permission from the Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated. This publication was written under contract number ADM 270-91-0007 from the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration (SAMHSA). Anna Marsh, Ph.D., and Sandra Clunies, M.S., served as the CSAT Government project officers. Michelle Paul, M.A., Randi Henderson, and Deborah Shuman served as contractor writers. The opinions expressed herein are the views of the consensus panel members and do not reflect the official position of SAMHSA or any other part of the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of SAMHSA or DHHS is intended or should be inferred. The guidelines proffered in this document should not be considered as substitutes for individualized patient care and treatment decisions. DHHS Publication No. (SMA) 94B2076. Printed 1994. What Is a TIP? CSAT Treatment Improvement Protocols (TIPs) are prepared by the Quality Assurance and Evaluation Branch to facilitate the transfer of state-of-the-art protocols and guidelines for the treatment of alcohol and other drug (AOD) abuse from acknowledged clinical, research, and administrative experts to the Nation's AOD abuse treatment resources. The dissemination of a TIP is the last step in a process that begins with the recommendation of an AOD abuse problem area for consideration by a panel of experts. These include clinicians, researchers, and program managers, as well as professionals in such related fields as social services or criminal justice. [Front Matter] Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Once a topic has been selected, CSAT creates a Federal resource panel, with members from pertinent Federal agencies and national organizations, to review the state of the art in treatment and program management in the area selected. Recommendations from this Federal panel are then transmitted to the members of a second group, which consists of non-Federal experts who are intimately familiar with the topic. This group, known as a non-Federal consensus panel, meets in Washington for 5 days, makes recommendations, defines protocols, and arrives at agreement on protocols. Its members represent AOD abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A chair for the panel is charged with responsibility for ensuring that the resulting protocol reflects true group consensus. The next step is a review of the proposed guidelines and protocol by a third group whose members serve as expert field reviewers. Once their recommendations and responses have been reviewed, the Chair approves the document for publication. The result is a TIP reflecting the actual state of the art of AOD abuse treatment in public and private programs recognized for their provision of high quality and innovative AOD abuse treatment. This TIP provides practical information regarding the screening and assessment of AOD abuse among adults in the criminal justice system. It contains discussions of screening and assessment and treatment planning. The TIP also examines assessment issues related to primary health care, sexually transmitted diseases, mental health, safety, and relapse. Legal and ethical issues, such as the Federal regulations on confidentiality, are reviewed. This TIP, titled Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System, represents another step by CSAT toward its goal of bringing national leadership to bear in the effort to improve AOD abuse treatment. Consensus Panel Chair: James A. Inciardi, Ph.D. Professor and Director Center for Drug and Alcohol Studies University of Delaware Newark, Delaware Facilitators: Marcia D. Andersen, Ph.D., R.N., F.A.A.N., C.S. President Personalized Nursing Corporation Plymouth, Michigan Duane C. McBride, Ph.D. Professor and Chair Behavioral Sciences Department Institute of Alcoholism and Drug Dependency Andrews University Berrien Springs, Michigan Harvey A. Siegal, Ph.D. Director Substance Abuse Intervention Programs Consensus Panel Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Wright State University Dayton, Ohio William R. Williford, M.P.H., Ph.D. Deputy Director New York Office of Alcoholism and Substance Abuse Services Albany, New York Workgroup Members: Richard Asarian, Ph.D. Clinical Director Ielase Institute of Forensic Psychology Pittsburgh, Pennsylvania Virginia Blackburn Director Women's Alcohol and Drug Prevention Fort Wayne Women's Bureau Fort Wayne, Indiana LaClaire Green Bouknight, M.D., F.A.C.P. Medical Director Residential Care Division Michigan Department of Social Services Maxey Training School Whitmore Lake, Michigan Margaret K. Brooks, J.D. Consultant Montclair, New Jersey Leah Colette Clendening, R.N., M.P.A. Associate Executive Director Queens Hospital Center Jamaica, New York Preston A. Daniels, M.S. Director Central Assessment Center and Mid-City Programs National Council on Alcoholism and Other Drug Dependencies Des Moines, Iowa Zoila Torres Feldman, R.N., M.S. Executive Director Great Brook Valley Health Center Worcester, Massachusetts Michael L. Green, M.S.W. Chief Probation Officer Workgroup Members: Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Mercer County Probation Department Trenton, New Jersey Howard Isenberg, M.A. Project Director North East Treatment Centers Wilmington, Delaware Pamela F. Rodriguez, M.A. Director of Program Services Treatment Alternatives for Special Clients of Illinois Chicago, Illinois Gerald L. Vigdal, M.S.W., B.C.D. Director Office of Drug Programs Wisconsin Department of Corrections Madison, Wisconsin Foreword The Treatment Improvement Protocol Series (TIPs) fulfills CSAT's mission to improve alcohol and other drug (AOD) abuse and dependency treatment by providing best practices guidance to clinicians, program administrators, and payers. This guidance, in the form of a protocol, results from a careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates employs a consensus process to produce the product. This panel's work is reviewed and critiqued by field reviewers as it evolves. The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. I am grateful to all who have joined with us to contribute to advance our substance abuse treatment field. Susan L. Becker Associate Director for State Programs Center for Substance Abuse Treatment Chapter 1 -- Introduction Alcohol and other drug (AOD) abuse and AOD abuse-related problems are among society's most pervasive medical and social concerns. Reliable, valid, and clinically useful instruments, as well as procedures for wide general use in screening and assessment for AOD-abusing adults, are available as complements to clinicians' experience. A panel of experienced researchers and clinicians who work with AOD-abusing adult offenders was convened in 1993 by the Center for Substance Abuse Treatment (CSAT) to develop guidelines for screening and assessing drug users' problems as the basis for appropriate program referral and treatment. This treatment improvement protocol (TIP) on screening and assessment is an outgrowth of that meeting. It should be viewed as a companion volume to two other TIPs that are available or being developed for use by State AOD abuse agencies and AOD abuse treatment programs in the criminal justice system that are funded with Substance Abuse Prevention and Treatment Block Grant funds. The other two TIPs are: Chapter 1 -- Introduction Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System · Combining Alcohol and Other Drug Abuse Treatment Services with Intermediate Sanctions for Adults in the Criminal Justice System · Planning for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice System The panel on AOD abuse screening and assessment among adults in the criminal justice system was charged with developing guidelines to: · Identify AOD abuse screening and assessment services that need to be provided to offenders with various levels of AOD abuse problems and concurrent needs for correctional supervision · Identify specific screening and assessment tools that appear to be particularly appropriate for offender populations and help to facilitate treatment planning · Assist criminal justice agencies in the use of screening and assessment tools to enhance treatment outcomes. The emphasis of this document is on practical screening, assessment, and treatment planning procedures that can help to improve care and treatment outcomes. Underlying the clinical experience reflected in the consensus panel membership, and in this TIP, is the goal to prepare guidelines, based on best practices, that can be used easily by clinicians and other workers in the field. This TIP summarizes the results of the consensus panel's deliberations. The intention is to provide guidelines, based on best practices, to criminal justice and AOD abuse treatment personnel based on considerations by individuals with broad experience in the field. The TIP does not prescribe any particular screening or assessment tool. Nor is it a manual for learning how to administer instruments. However, it does provide a starting point for increased and improved coordination among providers of AOD abuse services to adults at various points in the criminal justice process. Three basic principles guided the panel's efforts: · Adult offenders should receive effective and appropriate care. Thus, health and social service agency personnel, corrections staff, prosecutors, judiciary, police, and a variety of other personnel who come into regular contact with adult offenders should use appropriate and effective means to identify potential AOD abuse problems among this group. In turn, adult offenders have an obligation to follow screening and assessment procedures with appropriate treatment and interventions that are indicated by the results of the assessment procedures when the interventions are available.1 · Adult offenders have a right to privacy and to the confidential handling of any information they provide. Screening and assessment are not neutral or passive procedures. Used intelligently, they can provide vital information to appropriate professionals, thus contributing to effective care. Used in a careless or unprofessional manner, there is the potential for significant harm to the individuals who need help. In the discussions that follow, the offenders' rights to privacy and confidentiality are emphasized to make clear the need for professional and sensitive handling of information at each step of the screening, assessment, and treatment planning process. · Cultural, ethnic, and gender concerns must be considered in all aspects of the screening and assessment process. It is vital for program staff to keenly understand the impact that culture, ethnicity, and gender of both the adult offender and the staff member can have on everything discussed herein. Multicultural programs are essential in today's society. People involved in screening, assessment, and treatment planning must understand how their own culture, ethnic background, and life experiences affect this process. These concerns are discussed in the TIP. Definitions and Limitations Of Terms Used in This TIP This TIP and the others that address the continuum of AOD abuse among adults in the criminal justice system discuss the interface between two delivery systems -- AOD abuse treatment and criminal justice -- with different generic mandates. In Appendix B, the CSAT Criminal Justice Treatment Planning Chart illustrates interfaces between the two Definitions and Limitations Of Terms Used in This TIP Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System delivery systems where screening, assessment, and treatment planning for AOD abuse can be most effectively provided. It is critical for personnel in both systems to know and understand each other's vocabulary. Attaining this shared knowledge and understanding will lead to improved outcomes for both systems. To facilitate shared understanding, terms that may have different meanings in the two fields are used as defined below by the consensus panel: Abstinence -- the complete abstention from the use of alcoholic beverages and/or other drugs of abuse. Acculturation -- the process of change in which the members of one culture take on the elements of another, after continuous contact with that culture. Addiction -- Drug craving accompanied by physical dependence that motivates continuing use, resulting in a tolerance to a drug's effects and a syndrome of identifiable symptoms when the drug is abruptly withdrawn. Adult offender -- Any person over the age of 17 charged with a criminal offense. AIDS -- Acquired immunodeficiency syndrome, a severe manifestation of infection with the human immunodeficiency virus (HIV). AOD abuse -- the use of alcohol or other drugs at a level that creates problems in one or more areas of functioning and requires intervention. Assessment -- the collection of detailed information concerning the client's AOD abuse, emotional and physical health, social roles, and other relevant areas. Case management -- A problem-solving activity designed to address inadequacies in the service delivery network that become barriers to a client's acquiring needed benefits, support, and care. Classification -- the process by which a jail, prison, probation office, parole, or other criminal justice agency assesses the security risk of an individual offender and the individual's need for social services. Community corrections -- Adjudications that provide alternatives to incarceration such as court diversion programs, house arrest and electronic monitoring, intensive supervision, probation and parole, restitution, community service, and work release. Constitutional law -- the legal rules and principles that define the nature and limits of governmental power and the duties and rights of individuals in relation to the State. Court-mandated treatment -- Definitions and Limitations Of Terms Used in This TIP Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System A court order to participate in treatment as part of a sentence or in lieu of some aspect of the judicial process. Cultural appropriateness -- Demonstrating both sensitivity to cultural differences and similarities and effectiveness in using cultural symbols to communicate a message. Cultural competence -- A set of academic and interpersonal skills that helps individuals to increase their understanding and appreciation of cultural differences and similarities within, among, and between groups. It requires a willingness and ability to draw on community-based values, traditions, and customs, and to work with knowledgeable persons from the community in developing focused interventions, communication, and support. Cultural sensitivity -- An awareness of the nuances of one's own and other cultures. Culture -- the shared values, norms, traditions, customs, art, history, folklore, and institutions of a group of people. Gender issues -- Factors, problems, and concerns that are specific to members of a particular gender. Habilitation -- A person's initial socialization into a productive and responsible way of life (as contrasted with a return to a way of life previously known and perhaps to the term "rehabilitation," which emphasizes the forgotten or rejected). HIV -- Human immunodeficiency virus, the causative agent of AIDS. Three Basic Principles à Adult offenders should have effective and appropriate care. à Adult offenders have a right to privacy and to confidential handling of any and all information they provide. à Cultural, racial, ethnic, and gender concerns must be considered in all aspects of the screening and assessment process. Jail -- Local detention facility for temporary confinement. Multicultural -- Designed for or pertaining to two or more distinct cultures. Parole -- the status of being released from a correctional institution after serving part of a sentence, on the condition of maintaining good behavior and remaining under the supervision of an agency until a final discharge is granted. Presentence investigation -- Definitions and Limitations Of Terms Used in This TIP Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System An investigation into the background and character of a defendant that assists the court in determining the most appropriate disposition. Prison -- A correctional institution maintained by a State or the Federal Government for the confinement of convicted felons. Probation -- A sentence not involving confinement that imposes conditions and retains authority in the sentencing court to modify the conditions of the sentence or to resentence the offender if he or she violates the conditions. Readiness for treatment -- A client's perception and acceptance of his or her need for treatment in order to achieve personal change. Screening -- A gathering and sorting of information used to determine if an individual has a problem with AOD abuse, and if so, whether a detailed clinical assessment is appropriate. Split sentence -- A sentence involving a short period of incarceration followed by probation or some other form of community supervision. Treatment planning -- the process of planning a client's total course of treatment. Treatment progress assessment -- A process that determines the value of the chosen course of treatment, its suitability for the client, and how it should be extended or adjusted if necessary. Urinalysis -- the testing of a urine sample for the presence of drugs. Organization of This Volume The comprehensive screening, assessment, and treatment planning process described in this volume exists in only a few criminal justice systems. In hopes of remedying this situation, CSAT consensus panel members worked to identify and develop the guidelines and related basic requirements for an integrated and practical screening, assessment, and treatment planning system that could be put into practice in a variety of criminal justice settings. Chapter 2 provides an overview of the criminal justice setting and the screening, assessment, and treatment planning that should occur there. Chapter 3 covers treatment screening, needs assessment, and readiness for treatment, including how the AOD-abusing adult offender enters the criminal justice system, who should do the assessment, assessment indicators and sources of information, and issues involving availability and nonavailability of treatment. It also covers clinical assessment and treatment planning, including such areas as assessment and diagnosis, setting treatment goals, and identifying available treatment resources. Specific instruments are reviewed, and some samples are included in the appendices. Chapter 4 discusses assessments for treatment progress, its components, sources of information, related criminal justice issues, issues of integrity, and limitations in reaching treatment goals. Organization of This Volume Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Chapter 5 addresses special issues such as race, ethnicity, gender, sexual orientation, physical disability, infectious disease risk and status, history of abuse, and the incorporation of these relevant data into the treatment plan. Chapter 6 reviews constitutionality, confidentiality, and ethics as these relate to the rights of the AOD-abusing adult offender. There are several appendices at the end of this document. Appendix A is a list of references cited and a brief bibliography. A more comprehensive bibliography regarding screening and assessment appears in Appendix D. Appendix B is the CSAT Criminal Justice Treatment Planning Chart. Appendix C consists of several screening and assessment instruments, and Appendix D is a description of numerous supplementary assessment instruments. Endnote 1 Although most professionals involved with treating adult offenders with AOD problems believe these offenders have the right to treatment, this philosophy has not been upheld by the courts. In O'Connor v. Donaldson (422 U.S. 563), a 1975 case involving mental patients, the U.S. Supreme Court refused to decide on the matter of rights to treatment. Other decisions, while recognizing the right of prisoners to basic medical care, have specifically ruled that there is no constitutional duty imposed on a government entity to rehabilitate prisoners. AOD abuse treatment is not universally considered an aspect of basic medical care by everyone in the medical and legal professions. Chapter 2 -- Criminal Justice and Assessment: An Overview This chapter presents an overview of screening and assessment for alcohol and other drug (AOD) abuse problems. It first defines these processes and clarifies how assessment differs from the classification of offenders as performed by the criminal justice system. This is followed by descriptions of the basic elements of a comprehensive assessment. Next, the chapter details the training and qualifications needed by professionals who perform clinical screening and assessment. A rationale is offered for increased coordination between criminal justice and AOD abuse treatment programs and guidelines for building successful linkages. The chapter concludes by reviewing several special issues involved in the assessment of criminal justice clients and the selection of treatment options for these clients. These issues are explored in greater detail in Chapters 4, 5, and 6. Classification, Screening, and Clinical Assessment Classification The term classification is used by the criminal justice system to refer to the process by which a jail, prison, probation, parole, or other criminal justice program assesses both the security risk represented by the individual offender and, ideally, the individual's need for social services. In its broadest sense, classification is the process in which the educational, vocational, treatment, and custodial needs of the offender are determined. In theory, it is a system by which a correctional agency reckons differential handling and care, and fits the rehabilitation and security programs of the institution to the requirements of the individual (Inciardi, 1993). In practice, many criminal justice programs attempt to assess and meet the human service needs of offend-ers, but this Chapter 2 -- Criminal Justice and Assessment: An Overview Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System assessment is subordinated to the need to maintain security and to protect the community. Clinical Screening A clinical screening is a preliminary gathering and sorting of information used to determine if an individual has a problem with AOD abuse, and if so, whether a detailed clinical assessment is appropriate. The screening may be performed by personnel from the criminal justice system, a treatment program, or a linkage system such as Treatment Alternatives to Street Crime (TASC).1 The limited availability of funds for clinical assessment necessitates this screening process. Screening also filters out individuals who have medical, legal, or psychological problems that must be addressed before they can participate fully in treatment. A screening program should connect individuals with these and related problems to a specialized social service program tailored to meet such primary needs. Assessment for the specialized program will occur at the special program site. Eligibility criteria for AOD abuse treatment programs vary. This is true in part because treatment programs provide services that are appropriate for some patients but not others. Similarly, patients have specific needs that may or may not be met at a specific program. In some cases, a treatment program screens out an individual but refers him or her to another treatment program that can provide the specialized assessment and treatment that the individual needs. The screening process consists of asking a few questions designed to: · Identify the existence of an AOD use problem · Identify individuals with a history of violent offenses or severe medical or psychiatric problems · Identify individuals who have severe mental retardation · Identify individuals who would not for any reason be eligible for release to treatment or accepted by a treatment program. Most importantly, however, the screening process is designed to determine who can benefit from treatment and which general category of treatment (for example, long-term versus short-term; residential versus outpatient; drug-free, etc.) is most appropriate for each client. Clinical Assessment Current practices of clinical assessment evolved from the classification schemes found in correctional systems and prison reception centers. A clinical assessment is the collection of detailed information concerning the client's substance use, emotional and physical health, social roles, and other areas that may reflect the severity of the client's abuse of alcohol or other drugs, as a basis for identifying an appropriate treatment regimen. The clinical assessment is performed by trained treatment professionals. The primary purpose of clinical assessment is to develop a picture of the client's substance abuse pattern and history, social and psychological functioning, and general treatment needs. With the benefit of this detailed portrait, the treatment program can prepare an appropriate clinical response. A second function of assessment is to initiate the process of treatment. The assessment can serve this function only if the interviewer succeeds in actively engaging the client in the assessment process. In a clinical assessment, the individual is confronted with the consequences of his or her substance abuse and challenged to see that the continuance of this behavior represents a personal choice. Together, the client and the clinician determine the behavioral changes that the client wants to make. The recommendations of the assessment are later reviewed with the client, who then decides whether to consent to treatment. Clinical Screening Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Elements of Clinical Assessment The many dimensions of the clinical assessment are grouped here under three broad domains -- socio-behavioral, psychological, and physical. In addition to gathering detailed, multidimensional information, the clinician should prepare a summary statement that integrates and interprets the information. Sociobehavioral Domain An assessment of clinical risk explores the social world and behavioral history of the individual to gather information concerning the individual's history of AOD abuse, involvement in the criminal justice system, social support and social roles, educational and vocational needs, and spirituality. History of AOD Abuse The assessor gathers information about how and when the client's use of AODs began, the frequency and pattern of use, the types of drugs used, the client's previous attempts at self-help, previous formal treatment and its results, and patterns of AOD abuse in the individual's family. Given the health risks associated with tobacco smoking and passive exposure to smoke, and given that treatment options exist for nicotine addiction, the assessment should include questions related to nicotine addiction. Involvement in the Criminal Justice System The assessment interview should document the client's past involvement in the criminal justice system and current legal charges. Clients may be removed from treatment as a result of a disposition concerning pending charges against them. Thus, information on current charges is necessary for treatment planning. Social Support and Social Roles The clinician should ascertain the extent and quality of social support the client receives. Do the client's family members and friends support his or her treatment and recovery, or do they act as codepen-dents who enable the individual's addiction to continue? The assessment of social roles should also explore the individual's care-giving responsibilities, the place the individual occupies in the structure of the immediate and extended family, and the individual's employment status. In the case of female clients, it is especially important to gather information about their responsibility for taking care of dependents. Clinical assessments often fail to gather this information, but it has great bearing on the form of treatment that is appropriate for many female clients. Educational and Vocational Needs Information gathered about the individual's current employment status, level of educational attainment, and marketable skills helps determine the individual's need for education or job training. Spirituality Spirituality here refers to a belief in a Higher Power, a general "sense of belonging in the universe," or a sense of community. There is evidence that spirituality plays a positive role in an individual's recovery from alcohol or other drug abuse. Information on spirituality is not gathered for later use in persuading the client to accept any particular religious belief or doctrine. Rather, this information helps match the individual with appropriate services. In fact, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) requires that the organizations it accredits assess the client's spirituality as a part of the clinical assessment. Elements of Clinical Assessment Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Psychological Domain As noted earlier, the initial clinical screening filters out seriously disturbed individuals in order to refer them to appropriate psychological treatment. A client's serious emotional disorders and disturbances must be treated first, if they are primary, or concurrently, to enable the client to benefit from treatment. The psychological portion of the clinical assessment may likewise identify an individual who should be referred to psychological treatment before receiving treatment for AOD abuse. The clinical assessment also builds a psychological profile of the client that facilitates the provision of treatment. The interview should assess the following: · Levels of anxiety and depression · Personality disorders · Locus of control · Level of psychological development · Organic brain syndromes · Central nervous system function and impairment · History of sexual, emotional, and/or physical abuse · History of violent behavior. Biomedical Domain The biomedical portion of the assessment determines the client's general state of medical and dental health and identifies any chronic or acute medical problems, including nutritional deprivation. The assessment also obtains information on the client's history of infectious and contagious diseases, including HIV and tuberculosis. The rationale for the biomedical assessment is threefold. First, this assessment, like the psychological assessment, provides information to help the treatment program staff design the optimal treatment. Second, this assessment makes it possible for the treatment program to refer clients to appropriate medical services. Third, by performing standard medical assessments, treatment programs can gather data that can be used to raise public awareness of the increasingly limited availability of basic health care services. Summary Statement The assessment should conclude with an integrated summary of critical information and diagnostic impressions concerning the individual and his or her treatment needs. This summary should comment on the individual's general quality of life and level of functioning. It should also set priorities for the treatment of the various problems related to the client's abuse of alcohol or other drugs. Such a summary is required of institutions accredited by the JCAHO. Qualifications for Individuals Conducting Screening and Assessment Any professional staff member of a treatment or criminal justice program can be trained to conduct the initial clinical screening. To perform an indepth clinical assessment, an individual needs training, professional experience working with substance abusers, and an intuitive or learned ability to engage the client's active participation. With appropriate training, ex-offenders and other people recovering from AOD abuse can become very effective clinical interviewers for some segments of the overall clinical assessment process. To conduct the psychological and sociobehavioral portions of the assessment reliably, the interviewer must have sufficient professional training and clinical experience. The interviewer must also be able to communicate the findings of the assessment concisely and accurately to the client and all other relevant parties. Appropriate professionals for this task include psychologists, social workers, certified substance abuse or addiction counselors, and clinical nurse specialists. The individual's understanding of the assessment process is as important as the type of professional credential he or she holds. The biomedical portion of the assessment should be conducted by a licensed medical Psychological Domain Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System professional with training in diagnostic skills, such as a physician, physician's assistant, nurse practitioner, or nurse clinical specialist. Training for all portions of the clinical assessment, including the medical assessment, should build several kinds of skills: 1) the ability to establish rapport; 2) the ability to conduct nonjudgmental, nonthreatening interviews; 3) the ability to succinctly document information throughout the assessment and in the integrated summary; and 4) cultural competence. Specific training should also be given for the use of any specific assessment instrument. To provide consistent information for individual treatment planning as well as program evaluation and systemwide service planning, it is important for programs to use standard assessment instruments. It is also appropriate for programs to develop additional clinical instruments to meet their particular needs. Standard assessments should not be the sole means of assessing a client's needs. Rather, they should be used in combination with the interviewer's structured, clinical, and intuitive assessment of the client. Linkages: Coordinating Treatment and Criminal Justice Programs Coordination between treatment and criminal justice programs makes assessment and treatment programs more effective. Criminal justice decisions regarding treatment can be more appropriately made, and are more acceptable to treatment personnel, when consultation between the two groups has occurred. It is important for treatment and criminal justice staff to understand the goals of both systems. Policies and practices in the criminal justice system are more likely to support the goals of treatment when consultation has occurred, and vice versa. Finally, scarce resources for the treatment of AOD abuse are put to the best possible use when they are used after consultation between the two systems. Criminal justice and treatment systems cannot achieve enhanced coordination simply by reaching a formal agreement to collaborate. To encourage a team approach to treatment assessment, referral, and case management, the two systems need to develop or strengthen arrangements that support linkages at the institutional level and in the management of each client's treatment. In addition, cross-training can maximize the effect of both systems' screening and assessment efforts and minimize the need for duplication of effort. Coordination Between Institutions At the institutional level, the team managing coordination between the two systems should include the director of probation or prison director, judges, prosecutors, representatives of the defense bar where appropriate, and the treatment director. Led by this team, the two systems should collaborate to develop broad statements of working policies that specify the principles and rationales guiding the new collaborative relationships. In particular, those documents should provide details on the following: · The needs and goals of each institution · The means by which these needs and goals will be met, with suggested timeframes · Guidelines for sharing information at the various stages of the assessment and treatment process, · within the framework of consent regulation · Guidelines for providing a continuum of care that makes it possible to match the particular treatment needs of a client with a specified level of treatment, often at transitional points in the correctional process. For example, when the client is transferred from prison to a community correctional program, he or she may be able to enter an outpatient treatment program. Linkages: Coordinating Treatment and Criminal Justice Programs Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Individual Case Management The management team for each client should include a representative of each institution involved (for example, the probation officer and a treatment counselor). Criminal justice personnel must be included in the individual case management team at each stage of the treatment process, beginning with the clinical assessment. The case management team should reach formal agreement on the answers to the following questions: · What are the goals and timeframe for treatment? · What guidelines will govern the kinds of information that will be shared? (For example, will the parole officer expect the treatment program to report if the offender relapses to drug use?) · What process will be followed to reach decisions concerning such questions as whether pretrial release, probation, or parole should be revoked; when treatment should be considered a failure; and how personnel in both systems will respond in the event of specific treatment problems? Improving Coordination With Existing Resources The intent of these recommendations is not to create new bureaucratic systems, but, rather, to use existing agencies and personnel to achieve close coordination among systems. The use of coordinated case management teams is necessary to make efficient use of scarce resources and to increase the effectiveness of case management. Increased coordination does not require new personnel, but only new training of existing personnel in all systems. Special Issues in Assessment Professionals working in systems that link treatment and corrections must be aware of a broad range of special issues in assessment related to clients' gender, culture, ethnicity, sexual orientation, educational level, religious affiliation or spirituality, and other such sociocultural characteristics. Issues related to a number of these characteristics are discussed below. Literacy and Communication Skills The person performing the assessment must be able to tailor the interviewing process to the client's levels of literacy, verbal communication, and listening skills. The person performing the assessment needs to establish sufficient rapport with the client to make sure that the client understands the questions asked and the information being shared. The interviewer should avoid presupposing the client's literacy level based on social class, race, or ethnicity. The interviewer should also be aware that a client's inability to read or write does not make the client unable to take an active part in the assessment. For some clients, it may be necessary to substitute an oral interview for a paper-and-pencil assessment. Language It may be necessary to perform the assessment in the primary language of the individual, which may not be English. Assessors should avoid the assumption that a speaker of any given language can also read that language. The client may not be functionally literate in any language. Another part of the staff member's sensitivity to language should be an awareness that the client may need to communicate in "street language." The assessor should be attentive to the kind of vocabulary that the individual client feels most comfortable using. To the extent possible, concepts should be stated in lay language, even street language, if appropriate, but not professional or clinical jargon. Using appropriate language is an essential part of making a true connection with the individual, so that he or she Individual Case Management Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System becomes engaged in the assessment process. While good assessment may be largely an intuitive process, specific assessment skills can be taught. Training can be provided in nonjudgmental interviewing techniques, rapport building, sensitive probing, and multicultural sensitivity. Cultural Identity and Ethnicity For appropriate assessment, it is critical that culturally and linguistically competent staff are available. The assessor must be aware of the importance of the client's cultural identity and the extent of his or her acculturation into the dominant culture. Some programs attempt to draw on traditional cultural strengths of the individual in specific ways; these may be appropriate for the individual who has a strong identification with his or her culture of origin, but it may be inappropriate for other individuals of the same group. It is necessary to gain some sense of the meaning that the individual's culture holds for him or her personally, rather than relying on presuppositions. The client's culture has many potential implications for the process of the assessment. Some cultures view direct questioning as inappropriate. Therefore, individuals from this type of culture may view the assessment process as highly intrusive. A goal of the assessment process is to understand the client's world from his or her own cultural perspective. The importance of making appropriate inferences from information about an individual's culture makes it imperative that programs involved in assessment exert a strong effort in good faith to hire assessors representative of the populations they serve. When qualified professionals from these cultural groups are not on staff, treatment programs can seek to employ counselors or support staff from these groups, in order to create a diverse multicultural program environment. For effective assessment and placement, it is necessary to recognize that institutional and individual discrimination may exist in the criminal justice system and other institutions, and that bias can negatively affect classification, screening, and assessment. Gender In the last decade, the growth in women's prison populations has been dramatic. According to the Bureau of Justice Statistics, the average daily population of women confined in local jails rose by more than 95 percent, as compared with only a 50 percent increase in the male jail population. The need for sensitivity to gender issues is apparent. Treatment programs should guard against perpetuating institutional sexism -- institutional policies and practices that systematically ignore the special diagnostic, assessment, and treatment needs of women. They should also be aware that female clients may not have received a full exploration of findings that suggest treatment need. For example, many current assessment tools were developed specifically for male clients. These instruments tend to explore factors related to men's traditional roles such as performance in the workplace. (The Addiction Severity Index now includes modified severity indexes for women, as well as sections on living arrangements and relationships that are more sensitive to women's lives than previous versions. Instruments need to be tailored in this way for men and women.) Furthermore, women's abuse of AODs may go unnoticed because women are less likely to have contact with employers or others who would press them into treatment. Fear of the male offender is another impetus for the criminal justice system to refer men to assessment and treatment while neglecting the assessment needs of women, who may be viewed as less threatening to society. Misdiagnosis can occur if the person performing the assessment has preconceptions about the kinds of psychological dysfunction that women are likely to present. For example, physicians or psychologists may misread symptoms of alcoholism as symptoms of depression. Rates of depression for male alcoholics are comparable to the rate for males in the general population, but female alcoholics are significantly more likely to have a diagnosis of depression than Cultural Identity and Ethnicity Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System either women in the general population or male alcoholics. Professionals performing medical assessments must be aware of physical differences in the ways that the abuse of AODs is manifested in men and women. Some research suggests that there may be differences in the way alcohol is processed in men and women. Sexual Orientation and Identity A complete biopsychosocial assessment includes nonjudgmental questions designed to assess the individual's sexual orientation, the individual's understanding of and attitudes toward his or her own sexual orientation, and the family and social supports available to the gay or lesbian client. This information has implications for the etiology of AOD abuse, for related mental health issues, and for the placement of the individual in treatment. Some treatment programs, because of their institutional culture, may not be appropriate for homosexual, bisexual, or lesbian clients. Questions intended to explore the individual's sexual orientation should be framed neutrally. For example, "How do you identify yourself -- as gay, lesbian, bisexual, heterosexual . . . ?" Clients may be at varying stages in exploring and defining their sexual identity. Asking questions in an open-ended way gives clients the opportunity to explore their sexual identity in the course of the assessment and treatment. Poverty and Socioeconomic Status As public funding has declined, treatment programs concerned about their economic survival have often become biased against the poor. A common assumption is that in allotting limited treatment slots, treatment programs should sacrifice the treatment of the poor. The many common negative stereotypes about the poor and their motivations contribute to this bias. Programs that are committed to providing services to the poor must recognize that indigent people may require more intensive services because they have not had access to adequate food, shelter, or medical treatment. Religion and Spirituality The person performing the assessment should be respectful of all religious affiliations and of the nonreligious client. The assessor should be sufficiently familiar with the beliefs and practices of various religious groups in the community to avoid offending the client and to refer the client, when appropriate, to a treatment program that can make use of the client's spirituality or religious belief as a strength. As mentioned earlier, belief in a Higher Power or a sense of "belongingness" within one's family and the universe has a positive association with effective treatment. Working together with corrections, treatment personnel should also serve as advocates for religious freedom in prison as a part of treatment services in prisons. Physical Disability The assessment process should include an assessment of any physical disabilities. The physically handicapped client must be placed in a treatment program that is physically accessible. Some clients will be screened out of placement in a particular treatment program if it is inaccessible; others will not be screened out but will need some accommodation for their special needs. This is an important part of the treatment match; the assessor should take care to gain specific information about what the disabled client can and cannot do for himself or herself, in order to place the client in a workable setting. Assessment for HIV Risk The primary risk factors for HIV infection that should be assessed include the frequency of drug injections, the sharing of drugs and injection equipment, the use of bleach to sterilize needles, the number of sexual partners, patterns of condom use, sex-for-drug exchanges, and a history of sexually transmitted diseases. Given that more than Sexual Orientation and Identity Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System one-fourth of individuals who have been diagnosed with AIDS are drug injectors, all assessments performed should include an evaluation of the client's risk of contracting HIV. For women and people of African-American, Hispanic, and Caribbean origin, drug injection or sexual relations with a drug injector are principal risk factors for HIV transmission. One of the purposes of this evaluation is to develop a plan for reducing the client's HIV risk behavior. Treatment professionals working with criminal justice populations have a particular responsibility for addressing the AIDS epidemic, for several reasons. First, analysis indicates that the criminal justice system comes in contact with the portion of the AOD-abusing population that is most at risk for HIV infection. Second, there is a disproportionately high incidence of HIV seropositivity in prisons. Third, because the prison population is captive, treatment programs have an opportunity to assess HIV risk and encourage preventive measures. It is important to emphasize that risk behaviors, as well as HIV status, should be assessed. However, HIV testing should not be mandatory, for several reasons. First, the decision of an individual to learn his or her HIV status is a private one that requires pretest and post-test counseling. Second, knowledge that an individual is HIV-positive can threaten his or her access to services, personal safety in the prison environment, and access to medical insurance. Third, massive HIV testing clouds the issue because the focus of HIV prevention efforts should be on reducing risk, not identifying individuals' HIV status. Fourth, mandatory testing would override confidentiality regulations and violates some State laws. When symptoms of AIDS are discovered during the course of a medical assessment, HIV testing may well be indicated. Individuals diagnosed with HIV infection or AIDS should be referred to appropriate counseling and medical services. As noted earlier in this chapter, assessment is the first step in the treatment process. Assessment is a good place to begin educating the client about the risks and consequences of HIV infection. It is imperative that clients who engage in high-risk behaviors be referred to programs that emphasize ongoing risk reduction education. Endnote 1 For a discussion of TASC, see Inciardi, J.A., and McBride, D.C. Treatment Alternatives to Street Crime (TASC): History, Experiences, and Issues. Rockville, MD: National Institute on Drug Abuse, 1991. Chapter 3 -- Screening, Assessment, and Readiness for Treatment Screening, clinical assessment, and determining a client's readiness for treatment represent the beginning of the treatment process. The elements of each of these activities are detailed at length in this chapter. Screening The goals of screening criminal justice offenders for alcohol and other drug (AOD) problems are to identify potential candidates for treatment intervention as early as possible in their criminal justice processing and to interrupt their cycles of addiction and crime. The screening process can begin when a police officer responds to a complaint or makes an arrest. At an initial screening, a few quick and simple questions are all that are needed. Basic, simple, and direct questions can yield useful answers. Not asking them will yield no information. Simple questions might include: · Did you ever do anything while drinking or using drugs that you regretted later? · Have you ever gotten into a fight because of your drinking or drug use? Chapter 3 -- Screening, Assessment, and Readiness for Treatment Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System After this initial point of contact, there are several more points where either formal or informal AOD screening can be conducted as AOD users move through the criminal justice system. These points include: in the jail or the lockup, at arraignment, at pretrial investigation, at meetings with prosecutors and public defenders, in interactions with various officers of the court and representatives of the criminal justice system, and at probation violation hearings. These officials can be made aware of their potential impact on AOD abuse treatment, and taught basic screening techniques. Despite the lack of nationwide uniformity in the various agencies and institutions that comprise the criminal justice system, similar techniques can be applied systemwide, and can effectively identify a large number of offenders for further assessment -- which is the point of screening. Why Screen? The use of AODs is pervasive in today's criminal justice population. Study results vary, but most suggest that up to 80 percent of the street crime in this country involves AOD use. Offenders may use AODs and/or steal to feed drug habits, and violence often results from AOD abuse and during drug deals. Nearly half of all traffic fatalities involve the abuse of alcohol. There are high correlations between AOD abuse and certain public health problems. Moreover, AOD screening can be an opportunity to screen for diseases such as tuberculosis (TB), hepatitis, and HIV infection and other sexually transmitted diseases. Thus, as increasing numbers of AOD abusers are screened and treated, the potential exists to reduce associated crimes, deaths, and accidents. Because arrestees are often in a state of psychological crisis, arrest can be an excellent stage for screening. Arrestees are often anxious, depressed, and frightened. The negative consequences of their AOD abuse are often obvious and severe, and hard for the arrestee to deny. At this point, offenders may offer information about their AOD abuse. Once released from the criminal justice system, their concern for the gravity of their situation will usually fade. From the standpoint of public safety, the pretrial phase, when the largest number of potential abusers are in the system and under control, provides the greatest potential for early identification. Without identification and intervention, most AOD-using offenders will rejoin the general population with little or no knowledge of their AOD abuse problem or resources that exist to assist them. General Considerations An initial screening is useful in separating those who are likely to be addicted from those who are not. Screening does not require extensive training. It begins with being aware, and includes listening and noticing behavior and actions. Screening interviews should be done in private. Offenders have a right to privacy and to confidential handling of all information they provide. Most users are likely to abuse several drugs. Sometimes the AOD involvement is obvious. The smell of alcohol may be readily apparent; a suspect's behavior may be bizarre or disoriented; drugs may be evident on the scene. Sometimes the AOD involvement is less obvious. Episodes of domestic violence or fighting among friends may involve AOD abuse that is hidden from sight. However, police officers can learn to look for signs of AOD use and to trust their instincts, intuition, and judgment about the possible role of AODs. They can pass their impressions on to the next criminal justice official handling the case. Ongoing communication and data-sharing are important aspects of the screening process. Screening is not a single event, but a continuous process that can be repeated by a variety of professionals in a variety of settings. A number of basic screening instruments are available, such as the CAGE questionnaire, which has four simple questions to look for potential alcohol involvement. More indepth screening and assessment can be done by using the Michigan Alcoholism Screening Test (MAST) or the Offender Profile Index (OPI). Several of these instruments are included in the appendices to this document. Certain biological measures such as Breathalyzer, blood-alcohol, and Why Screen? Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System urine tests are also important screening tools. Components of Screening Screening is a hierarchical, although flexible, procedure. If it errs, it should err toward the false positive. The idea is to rule out people without problems, and raise the index of suspicion regarding others. A positive screening, at any point in the process, is a trigger for a more formal and thorough AOD use assessment. Those involved in the screening process can include police officers, city and county jail employees, defenders, probation officers, magistrates, prosecutors, hearing officers, and counselors. Screening can be conducted in the lockup, the probation office, the prosecutor's office, the detective's interviewing room, the arraignment or hearing officer's courtroom or chambers, and the jail or prison orientation room. It is the function of criminal justice system officers, at all points of the process, to pass on information they have obtained from the AOD screening procedure. Although screening does not have to involve much paperwork, information should be documented in written form in a case file, even if a client does not go on to criminal prosecution, so that it can be acted upon in cases of subsequent arrest. It helps if a standardized format is used so that it will be understandable to people in justice and treatment who refer to it in the future. If a client acknowledges having an AOD problem and recognizes the extent of the problem, much has been accomplished -- for this represents the end of the screening, a signal to initiate further AOD assessment. If he or she denies AOD involvement, the screener should look for evidence in major life areas, including: · Relationship of the current charge to AOD use · Recent or current AOD use · Past treatment history · Health problems (including the presence of HIV infection, TB, hepatitis B) · Criminal justice system history · History or evidence of mental illness · Results of urine, breath, or blood testing · Problems with family, social integration, employment, housing or financial instability, or homelessness. Training the Screener Screening can be done with a minimum of special training by almost any criminal justice official. Screening education strategies can vary, based on the need and/or point in the system. The orientation to the process can be included in routine training and ongoing staff development. This orientation should be done systemwide, so that everyone from the arresting officer to the judge knows the importance of screening and the screening decision, and what screening decisions mean. Screening should be a fairly "seamless" process. That is, screeners should be fully integrated in the process and not be seen as adjuncts to the overall process. In fact, to a large extent, the degree to which screening is integrated with other processing activities will determine its success in the criminal justice system. Screening is possible at every contact point in the criminal justice system. Screening at an early point in the system does not preclude screening further down the line. Screeners should understand that their own impressions may change, even in the short time in which they have contact with a client. Many abusers use more than one drug, and various effects and withdrawal symptoms may become evident at different times, causing a variety of unanticipated behaviors. Screeners should be trained to expect the unexpected. Offenders' behavior and motivation to admit to AOD abuse also fluctuates; consequently, screening at all points in the system is likely to identify potential candidates for assessment despite their earlier denial of use. Components of Screening Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Screening Instruments Screening instruments are the objective arm of the screening procedure, providing uniformity, quality control, and structure to the process. Some instruments may be more appropriate than others in certain settings. Among the more commonly used instruments are the CAGE questionnaire, the MAST, and the OPI. The CAGE Questionnaire The CAGE questionnaire is a simple but effective test designed to screen for alcohol abuse. It consists of four questions: · Have you ever felt the need to Cut down on your drinking? · Do you feel Annoyed by people complaining about your drinking? · Do you ever feel Guilty about your drinking? · Do you ever drink an Eye-opener in the morning to relieve the shakes? Studies reveal that two "yes" answers to the CAGE questionnaire will correctly identify 75 percent of the alcoholics who respond to it and accurately eliminate 96 percent of nonalcoholics. Modifying the CAGE questionnaire for other drugs involves simply substituting "drug use" for "drinking" in the first three questions, and asking for the fourth question, "Do you use one drug to change the effects of another drug?" or "Do you ever use drugs first thing in the morning to `take the edge off'?" The Michigan Alcoholism Screening Test The MAST is a frequently used test that is more detailed than the CAGE questionnaire. The MAST consists of 25 questions and can be used during longer interviews or in holding and confinement situations. It is a commonly used indicator of alcoholism. The MAST is included in Appendix C. The Offender Profile Index The OPI measures the client's drug use severity as well as his or her "stakes in conformity" within a variety of contexts: family support, education, and school involvement; work, home, and correctional history; psychological and treatment history; drug use severity; and HIV-risk behaviors. It can be administered in about 30 minutes by an experienced probation officer, counselor, or other trained clinician. It includes a straightforward grading guide to help interpret the seriousness of an AOD abuser's problem. A day of training is required to be able to administer it, and a training manual is available. The client's numerical score has a corresponding treatment recommendation. The OPI is reproduced in Appendix C.1 Assessment The goals of assessment are to gather information about the client and to describe how the treatment system can address his or her AOD-abuse problems and the impact these problems have on the client's life. The assessment process is descriptive as well as prescriptive. It identifies the client's individual strengths, weaknesses, and readiness for treatment, and recommends a level of services appropriate to address the client's problems and/or deficits. Typically, an assessment is conducted in a 2- to 3-hour procedure, although this can vary. In most cases, assessment involves a combination of clinical interview, personal history taking, biological testing, and paper-and-pencil testing. Depending on the methods used, the assessment may require more than one session. Screening Instruments Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Assessment has a number of specific goals and purposes: · To determine the extent and severity of the AOD abuse problem. · To determine the client's level of maturation and readiness for treatment. · To ascertain concomitant problems such as mental illness. · To determine the type of intervention that will be necessary to address the problems. · To evaluate the resources the client can muster to help solve the problem. Typical resources include family support, social support, educational and vocational attainment, and personal qualities such as motivation that the client brings to treatment. · To engage the client in the treatment process. Who Does the Assessment? Assessment can be done by an independent assessment group (such as a systemwide central intake unit or an independent Treatment Alternatives to Street Crime program) or by the same professionals who will be providing treatment if it is determined that the type of intervention they provide is appropriate for the particular client. The assessor should be a qualified human services professional with demonstrated competence in AOD programs, such as an addiction counselor, a licensed social worker, or other trained clinician. A cre-dentialed and/or certified alcoholism, substance abuse, r chemical dependency counselor should be available. It is desirable that each individual assessor work in a licensed or certified setting to ensure that there are adequate resources and a multidisciplinary approach, to take advantage of the collective wisdom of the agency. Ongoing training and supervision are critical to ensure the skill level and accountability of the service providers. Components of Assessment The assessment process should include a broad variety of components that will yield an evaluation of the client that is as comprehensive and holistic as possible. The assessment should provide the information required to recommend the most appropriate course of treatment. Areas that should be investigated in the assessment include: · Archival data on the client, including -- but not limited to -- prior arrests and contacts with the criminal justice system, as well as previous assessments and treatment records · Patterns of AOD use (see below) · Impact of AOD abuse on major life areas such as marriage, family, employment record, and self-concept · Risk factors for continued AOD abuse, such as family history of AOD abuse and social problems · Available health and medical findings, including emergency medical needs · Psychological test findings · Educational and vocational background · Suicide, health, or other crisis risk appraisal · Client motivation and readiness for treatment · Client attitudes and behavior during assessment. As this listing of professionally accepted data and criteria suggests, the assessment process must be driven by specific data and criteria. For example, in considering the patterns of AOD use, the assessor should determine the presence or absence of such signs and symptoms as: · Tolerance (High tolerance suggests that a client has a history of heavy drinking or drug use.) · History of physical withdrawal symptoms · Episodes of uncontrolled drug or alcohol use, binges, or overdoses · Use of AODs for "self-medication" of painful and unpleasant emotions Who Does the Assessment? Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System · Attempts to hide use · Physical signs of drug use, such as needle track marks, emaciation, and alcohol odor · Positive drug test results · History of attempts to quit AOD use · Family dysfunctioning relative to AOD abuse · History and onset of drug use · Drug use behavior (e.g., does client use drugs alone? For sex? To go to work?) · Method of administration, including injection, snorting, smoking, or drinking. Assessment Instruments Assessment instruments are standardized tools that are productively used in tandem with the personal history data obtained by the clinician in formulating a clinical impression. Instruments provide another data source for the assessor to use in evaluating the client. Instruments are an integral part of any assessment. Their results should be used in conjunction with good clinical judgment. There is no single litmus test applicable to all situations and all clients. It is recommended that practitioners review available instruments, and then use, combine, and/or adapt them to suit their own assessment and planning needs. The following instruments, while they may have some limitations, can provide useful and valuable information. The Addiction Severity Index The Addiction Severity Index (ASI) is perhaps the most widely used assessment instrument. It can be administered in about 60 minutes by a trained counselor. The premise of the ASI is that addiction must be evaluated within the context of problems that may have contributed to or resulted from AOD use. It collects data to estimate the client's level of discomfort in seven areas: alcohol use, medical condition, drug use, employment, financial support, illegal activity, family and social relations, and psychiatric problems. It incorporates both the client's and the assessor's assessment of his or her needs and priorities. A copy of the ASI is reproduced in Appendix C. The Wisconsin Uniform Substance Abuse Screening Battery This battery combines identification, classification, and treatment assessment instruments with personality profiles and measurements of specific offender needs. It is composed of four instruments: the Alcohol Dependence Scale, the Offender Drug Use History, the Client Management Classification interview, and the Megargee offender typology derived from the Minnesota Multiphasic Personality Inventory (MMPI). The battery provides sound data that can move with the offender through the entire correctional system. It determines not only treatment needs but also the need for specific programs. Two weaknesses of the battery are that the MMPI is an expensive tool and the Alcohol Dependence Scale is copyrighted, requiring a fee for its use. Another alcohol component can be substituted in place of the alcohol component in the instrument. The AIDS Initial Assessment Jail/Prison Supplement This tool was developed by researchers at the Comprehensive Drug Research Center at the University of Miami School of Medicine as part of the National AIDS Demonstration Research Program of the National Institute on Drug Abuse. Primarily focused on assessing HIV risk, it also measures criminal history, legal history, injection drug use, needle use and sharing during incarceration, and sexual activity during incarceration. It is best used in conjunction with other assessment tools. A copy of this instrument appears in Appendix C of this document. Assessment Instruments Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Biological Testing Biological tests can be valuable instruments to determine AOD use, especially when such use is denied by the client. Urinalysis, breathalyzer tests, blood tests, and all other available physical tests should be considered when AOD use is not self-reported. Such tests can be used when a client acknowledges AOD use but may be unclear about exactly what drug or drugs have been used. Therefore, if at all possible, self-reports should be corroborated with biological testing. Given the reemergence of TB in many correctional populations, it is important that testing be done.2 The presence of TB, furthermore, is often an indicator for HIV infection. The cost and timeliness associated with biological testing must be factored into decisions regarding the use of the tests. Presentation of Findings The results of the assessment process should be presented in a valid, reliable, and clinically useful document, one that clearly makes its point, can be replicated, and contains data that will be relevant in treatment. A good assessment avoids simplistic formulations that reduce a client to a number, a score, a check list, or a simplistic label. The presentation of data backing up the assessment should be offered in language that is sufficiently jargon-free to be understood by all relevant personnel, including the client, with only minimal interpretation. Acronyms and abbreviations should be explained when used. In most jurisdictions, the client is entitled to access to his or her record, and the client and his or her attorney should be able to read and understand it. The screening and assessment instruments provide data on each area surveyed. These data, along with the more extensive history from the clinical interview, need to be fused into a narrative document. Any summary assessment needs to relate to its supporting data and show how the data were collected and interpreted. For the purposes of a court, many judges are comfortable with just a summary paragraph of assessment and do not want to be inundated with extra information. But even in a condensed report, there should be at least three definable, well organized sections: · An introduction, explaining how this assessment came to be, who ordered it, and why. · A section on methodology, explaining how the data were collected, what tests were used, and how the results were interpreted. · A straightforward presentation of the data, relating to the various content areas suggested above (see Components of Assessment) without interpretation, followed by a clinical impression and recommendations. This is essentially a strategic management plan. It should include recommendations for additional referrals or assessment, when necessary. The narrative document should include a defensible paragraph or two explaining how and why the assessor has reached his or her conclusions. For example, writing only that "Mr. Jones is an alcohol abuser" is insufficient. A more useful rationale for the conclusions reached might be: We met with Mr. Jones and determined, based on his life circumstances and personal observations, that he is having trouble with alcohol. His third marriage is ending, and he cannot keep a job more than 9 months. He misses work because of his drinking. He came to his interview smelling of alcohol. The test results confirmed the initial impressions. We believe he definitely has an alcohol problem, and appropriate treatment should be provided. A client may refuse to cooperate with the assessment process, refuse to provide information, or provide information that is intentionally or internally inconsistent and contradictory. That might result in a "cannot assess" report. But there may be other, more hidden problems than simple recalcitrance. The client may not know or may be unable to relate the answers to the questions that he or she is being asked. Recognition of this may trigger a need for further assessment to ascertain if mental illness, brain damage, or other organic indicators might explain the clinical picture. Biological Testing Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Assessors should realize that getting to the bottom of this client's problem may be more than their program can handle, that they may be dealing with another condition in addition to an AOD problem, and that a more sophisticated neuropsychiatric workup is needed. Confidentiality and Client Consent The results of the assessment can be useful to a number of different individuals and agencies. However, in many cases, results cannot be presented to anyone -- including the judge or referring criminal justice representative -- without the signed consent of the client, in accordance with Federal confidentiality regulations. Once a client is asked to sign a release, he or she should know the precise reason for the release and understand what is covered in it. The client is also entitled to know what recom-mendations are made in the assessment report. It is important that the judge know if the client does not agree with the determinations and recommendations of the assessment. In most States, clients are entitled to a second opinion, although they usually have to pay for it themselves. Chapter 6, Legal and Ethical Issues, includes a full discussion on confidentiality and client consent. Quality Assurance And Improvement Quality assurance and improvement are important in any treatment system. Quality assurance is defined by the Joint Commission on Accreditation of Healthcare Organizations as the ongoing activities designed to objectively and systematically evaluate the quality of client care and services, pursue opportunities to improve the quality of client care and services, and resolve identified problems. There are two types of quality improvement: internal and external. Both are recommended. External review tends to be a one-time or intermittent evaluation, while internal review should be an ongoing process, with each review providing a foundation for subsequent reviews. In external quality assurance, an outside source, such as an independent contractor or a State licensing agency, conducts the evaluation. It is recommended that external reviews be conducted on a yearly basis to ensure the integrity of the process. Internal review is done by both peer and supervisory personnel and can be a relatively quick and informal process designed to weed out flagrant problems. A more formal internal review is a self-study that should be done routinely as required by State or local regulations and should include an audit and a survey of assessments to see if any patterns are suggested. This survey can be used to set certain goals for the agency; for example, when one instrument shows up repeatedly in assessments, all staff members should be taught to understand the instrument. Readiness for Treatment A client is ready for treatment when he or she perceives and accepts the need for treatment in order to achieve personal change. Readiness for treatment has to do with a client's insight into his or her own condition, a willingness to effect change, and the appreciation that prior attempts at effecting change have not yielded desirable results, at least not consistently. Readiness can be prompted in two ways: by circumstances or extrinsic pressures such as loss (of job, family support, money, etc.) or fear (of incarceration, violence, health risks including overdose, or even suicide). Intrinsic pressures or motivation bring a client closer to readiness. These pressures include guilt, self-hatred, and despair; weariness with the drug-related lifestyle; and a feeling that life can be better. Note that simply acknowledging the need for personal change does not necessarily imply readiness for treatment. Rather, people with AOD problems may seek treatment alternatives, such as self-change; getting help through friends, relationships, religion, and employment; or geographic relocation as a way to stop AOD use. Confidentiality and Client Consent Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Readiness can be measured both by subjective impression and objective quantification. One scale measures readiness for treatment (and other factors) on a 1-to-5 scale, asking for responses to statements like, "I am sure that I would go to jail if I don't come to treatment," "I am worried that my spouse will leave me if I don't come to treatment," and "I feel that my AOD use is a very serious problem in my life" (De Leon and Jainchill, 1986). Increasing someone's readiness for treatment begins with the assessment process, during which the assessor should not just record information, but also feed back impressions to the client. For example, "You say you don't have a drinking problem. Well, how about those five marriages? How about those six jobs in 2 years? How about the fact that you're on probation for your third DUI? Don't you think any of this indicates a drinking problem?" Among clients mandated to treatment from the criminal justice system, it is unusual for a client to be genuinely enthusiastic about entering treatment. Most clients are not ready, do not want to be in treatment, and do not like it. Usually, though, they see treatment as a more attractive alternative than incarceration. This is not necessarily totally negative. Research data have suggested that coerced treatment can be as effective as voluntary treatment, if not more so (Leukefeld and Tims, 1988). In the language used by Alcoholics Anonymous, "Bring the body, and the mind will follow." Indeed, one of the typical traits of the AOD abuser is denial, the inability or unwillingness to recognize the significance of a problem. Only after a client is in treatment can the subject of denial receive the direct and systematic attention it requires. Excluding people from treatment merely because of a lack of readiness, based on denial, would mean that the treatment process would never begin for many. It is essential to link clients who exhibit denial to the most appropriate program that will address the denial problem. Indeed, addressing denial is an integral aspect of treatment. Not all clients, of course, are reluctant to enter treatment. Many men and women view treatment as an alternative to incarceration, job loss, or losing custody of their dependent children. Clients are less likely to drop out of treatment if they understand the treatment process and if they've been prepared for assuming the role of patient. A strong incentive to keep clients in treatment is the knowledge that they will benefit from the treatment, not only for AOD abuse, but also for other problems and issues in their lives. Assessing Readiness Research indicates that readiness for treatment is strongly associated with an individual's perception of needing assistance in the process of personal change, compared to alternative options (De Leon and Jainchill, 1986; Collins and Allison, 1983). These researchers' work with the Circumstance, Motivation, Readiness, and Suitability Scales suggests that retention in treatment may be related to an individual's understanding of treatment options. The task of assessing individuals' readiness for treatment is related to their perceptions of the severity of their AOD abuse problems; their understanding of what treatment options are available, compared to the alternatives; the extent of their ambivalence about a need for personal change; and, in the case of a nonvoluntary participant, what measures can be employed to create a motivational crisis that makes them amenable to treatment. Treating "Unready" Clients AOD-involved offenders may be referred to a program for assessment and/or treatment as a result of a court order or another compulsory effort requiring compliance. Often their motivation for change does not correspond to their desire to comply with these compulsory measures in order to avoid negative consequences. As noted earlier, research has demonstrated that coerced treatment is at least as effective as voluntary treatment, suggesting the importance of connecting even nonmotivated AOD-involved offenders with assessment and treatment resources. Most AOD abusers experience a stage of ambivalence about changing their destructive patterns of behavior (Shaffer, Assessing Readiness Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System 1992). An increased awareness of the impact of destructive behavior on every aspect of an individual's life is required to shift ambivalence toward an acceptance of responsibility for behavior change. Programs that employ the results of a comprehensive assessment to inform the AOD user set the stage for promoting treatment readiness. The resultant shift of perception, coupled with the motivational crisis created by coercion into treatment, leads the way for further efforts toward motivation and eventual retention in the process of treatment and recovery. The previous discussion notes the common reality for AOD abuse treatment -- most recipients of services are not voluntary participants. For years, treatment professionals and paraprofessionals believed that a person needed to "hit bottom" in order to be "ready for change." Today, it is recognized that people can be ready for treatment without "hitting bottom" and that many people can receive benefits from treatment even if they aren't completely ready for treatment. One of the major constructs currently recognized for under-standing the process of addiction and recovery is the Developmental Model of Recovery. According to this model, several tasks are involved in working through the ambivalence associated with the first stage in the process of recovery, which Gorski calls the Transitional Stage (Gorski, 1991). Developing motivating problems, which refers to behaviors resulting in "hitting bottom," and accepting the need for abstinence and help are a few of these tasks. Clinicians can identify an individual's position along the process of recovery by assessing which stage- specific tasks must be resolved. The primary focus of the transitional stage is recognizing the addiction and developing the motivation to become abstinent. Generally a client can be considered "ready" for treatment when he or she wants to be, sees AOD abuse treatment as a way to become drug or alcohol free, and recognizes that he or she cannot do it alone without professional assistance. But readiness is not often so clearcut. In reality, readiness for treatment is a question of degree, not absolutes. Even more important than readiness are linking clients with the appropriate level of service, and using inducements and the leverage of the criminal justice system to maintain them in treatment, with the expectation that their own changing perceptions will soon keep them in treatment of their own volition. Endnotes 1 The OPI and a copy of its training materials are reproduced in: Inciardi, J.A., ed. Drug Treatment and Criminal Justice. Newbury Park, CA: Sage Publications, 1993. 2 CSAT convened a consensus panel to design and recommend two screening instruments, which are now being tested. One is for AOD-abuse staff to screen for possible infectious disease in AOD clients. The other is for public health workers to screen clients for AOD abuse. Chapter 4 -- Treatment Planning And Treatment Progress The treatment plan is the overall management strategy for treating people with alcohol and other drug (AOD) problems. Ideally, the plan incorporates, to some extent, the World Health Organization's five dimensions of health: physical, social, mental, spiritual, and intellectual. The Treatment Plan Treatment planning should develop from the assessment process and embrace the importance of appropriate client-treatment matching. Matching clients to treatment can be difficult in small communities with limited resources, Chapter 4 -- Treatment Planning And Treatment Progress Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System or even in larger communities where funding is an issue. But matching a client with the first empty slot is generally not the best way to meet his or her needs -- or the community's needs. The difficulty of addressing these needs is underscored by the debilitated nature of many AOD clients in the criminal justice system. Many have never had a stable home, are functionally illiterate, and have had few employment experiences. An AOD- abusing client may come from a family with generations of AOD abusers. The treatment plan must address not only the need for rehabilitation, but also for "habilitation." Rehabilitation emphasizes the return to a way of life previously known and forgotten or rejected; habilitation is the client's initial socialization into a productive and responsible way of life. The treatment plan is based on each client's identified needs, problems, and resources. It seeks to match the client with what the assessment process has identified as the best level and modality of intervention. 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 problems and deficits. It presents an approach for sequencing resources and activities, and identifies benchmarks of progress to guide evaluation. Components of the Treatment Plan Two key concepts guide the development of every treatment plan for every client: · The plan should be individualized. · The plan should be participatory. The counselor does not devise the treatment plan for the client. Instead, the counselor and client prepare it together. The counselor's values should not be superimposed on the process. The client should have part ownership of the treatment plan, and she or he should be able to honestly look at the plan as a shared effort to work toward a common goal, not as something imposed from without. Other professionals from the treatment agency may also have input into the plan. Ideally, the final version of the plan will include the collective wisdom of the agency staff and contributions from referring and supervising criminal justice personnel, as well as from the counselor and client. Treatment Planning Goals and Objectives The treatment plan should have clearly stated goals and objectives. Goals should be realistic end points. There should not be too many goals, and goal-setting should be ongoing. An unnecessarily ambitious treatment plan is nearly as likely to fail as an inadequate one. Goals should be specific, measurable, and quantitative. For example, the goal of "having a better life" is inadequate. Rather, a goal should be specific: "Find an apartment to live in," "Get back with my wife," "Stay away from my dealer friends," or "Exercise four times a week." The treatment plan should help the client establish a positive sense of self and self-esteem. Abstinence-based therapeutic goals are customary in most AOD treatment programming today (except in methadone maintenance programs), but the treatment plan should have some flexibility to accommodate some relapses or slips during treatment. It can be therapeutic to set realistic early goals, such as, "Fewer dirty urines a month, for the next 3 months." For some clients, merely getting to an appointment sober is the most realistic goal that can be set. However, goals must conform to limitations imposed by the court, by the parole or probation department, or by any other criminal justice agency with jurisdiction over the client. The client participates in the process of setting goals, but does not dictate them. For example, if the halfway house that the client is living in requires proof that he or she is drug-free, then abstinence must be an immediate goal. However, it is important that criminal justice officials understand the incremental nature of change and the necessity of individualized objectives for the AOD-abusing Components of the Treatment Plan Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System offender. Incorporated into these goals and objectives should be examples for the client regarding the handling of life and relationships without AOD in a variety of arenas, including friends, fun, family, sex, employment, and problem-solving. The client must be shown illustrations of successful living, especially positive examples in his or her own life, if any are identifiable. Therapeutic goals must translate to behavioral indicators. Measures of improvement to be considered include changes in appearance, making different friends, and abstinence from or cutbacks in AOD use. Goals and objectives can also encompass elements that address the client's spiritual and social life. Examples that can be considered include attending Alcoholics Anonymous, Narcotics Anonymous, other self-help groups, or church; having healthy friends; or taking part in activities, hobbies, or volunteer service. Treatment Flexibility The treatment plan must be custom-tailored to the client, as much as resources and time will allow. A good plan is organic, dynamic, evolving, and flexible. Events occur over time that necessitate altering goals and objectives. A good plan is designed to address three types of potential problems: · Attrition · Noncompliance · Inadequate progress. Mechanisms should be built in to handle these problems. For example, noncompliant clients could be required to report back to the supervisory criminal justice authority, experience some kind of sanctions, be reevaluated and referred to more appropriate services, or be terminated from the treatment program. In some cases, flexibility must work the other way. Sometimes the client responds so well that treatment can be accelerated or streamlined. This can lead to reduced supervision from criminal justice agencies. It is important to note here that not all treatment failures or examples of inadequate progress are the responsibility of the client. In some cases, inadequate assessment, poor planning, or inappropriate services may be the primary cause. Therefore, each client failure should provide the program with an opportunity to evaluate itself and its services, in order to identify areas for improvement. Client Accountability Just as clients must be allowed to help design the treatment plan, so must they be responsible to it and accountable to its rules. Clients must know what the results of noncompliance and poor progress are and must understand the penalties for breaking rules that are intended to guide behavior. Clients must understand that treatment programs have certain unbreakable rules (for example, no violence or intimidation), and that penalties for breaking rules can include dismissal from the program, return to court, and incarceration. These penalties should be specifically spelled out, so there is no room for rationalizations later. There should be no doubt in the client's mind regarding the consequences of specific misbehavior. Accountability also includes objective measures and monitoring as a basis for measuring the client's progress and determining the need for reassessment. Treatment Flexibility Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Who Is on the Treatment Team? The answer to this question depends on the jurisdiction and the resources available to the system. Ideally, a treatment team should consist of whatever specialists are necessary to address the client's problems and deficits. These may include a drug and alcohol counselor, a clinical director, a licensed social worker, a case manager, and whatever medically trained personnel are necessary to address acute or chronic illnesses that have been diagnosed at assessment. A registered nurse is a valuable member of a good treatment team. Short of this ideal, at minimum the team needs a case manager and counselor who are certified and experienced in providing AOD treatment. The criminal justice system should be represented on the team. Members of the treatment team need to be culturally and ethnically sensitive, and some of them should be members of the same group as the client being treated. There should be no linguistic barriers. Potential Conflicts Between Treatment and Criminal Justice As noted briefly in Chapter 2 of this TIP, there is the potential for conflict between treatment and criminal justice agencies. This conflict can be anticipated and avoided, to a certain extent, if certain points are made clear from the beginning of the treatment planning process. Criminal justice officials need to understand that the treatment system does not coddle the client and that the goals of treatment are consistent with the aim of getting the client out of the criminal justice system. Treatment providers need to understand the legal obligations of criminal justice personnel -- to ensure public safety and to protect the rights of the offender. It is best to spell out these points in a memorandum of understanding (MOU) between the two agencies. This is a formal agreement between two parties that specifies expectations, roles, communication procedures, decision-making processes, and action steps to be taken in response to clearly delineated unacceptable behavior. The MOU should list specific actions of the client that can result in dismissal from the treatment program or a change in supervisory status. It should spell out expectations, definition of terms, methods of communication, deliverables, roles, grievance procedures, and crisis management. The MOU can also answer the following questions. · How often should details of treatment be communicated to the criminal justice system? · What access to treatment and assessment records should the probation or other criminal justice officer have, and to what level? · How is client confidentiality to be respected? · Which members of the treatment team are to have contact with the criminal justice system? · What sanction mechanisms begin on the criminal justice side in the case of noncompliance and relapses? The client should be also aware of the details of the MOU so that the consequence of relapse or noncompliance does not come as a surprise. And, in a similar vein, criminal justice officials must understand that the treatment process is not a linear function to be interrupted or declared a failure by a single relapse. Rather, it can be viewed as a graph to be plotted over time; success occurs over an overall upward slope, regardless of sporadic, noncritical dips. Another TIP, Planning for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice System, discusses the conflicts between the treatment and criminal justice systems, and how they can be resolved. Assessment of Treatment Progress The process of assessment does not end once a client has been classified, assessed, and assigned to a treatment program. Assessment is part of the ongoing treatment process, an essential tool that can determine: · The value of the course of treatment chosen Who Is on the Treatment Team? Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System · How that course should be adjusted · How realistic are the goals that have been set · What linkages need to be made to obtain services for the client from other agencies · When maximum benefit of the intervention has been achieved · The plan for further intervention. The purpose of assessment during the treatment process is to determine how effective the treatment has been up to the assessment point, what kind of progress the client is making, the appropriateness of the present treatment, and what the next level of treatment should be. Assessment in the course of treatment is a dynamic, longitudinal process, not a single event. It is an objective, quantifiable measure of the progress achieved by the client and the treatment program. Ongoing assessment of treatment progress using standardized criteria is a cost-effective procedure, revealing early in the treatment process such problems as inappropriate referral, misdirected treatment, or unrealistic goals. How This Differs From Other Assessments Progress assessment is a clinical management tool focusing on the client already in treatment. In contrast to an intake assessment, which establishes a baseline for the client, progress assessment measures the client's response to the treatment that has been provided. It also measures change and degree of change, if any. This change may be either positive or negative. It is important that progress assessment be compatible with intake assessment, so that the treatment team will have a consistent continuum to use as a guide in considering a client's progress. Goals set for progress assessments must be realistic, individualized, and determined through a participatory process that includes the client. As part of the assessment process, it should be made clear to the client and the criminal justice system that treatment is not punishment. This can be a very difficult concept for mandated clients to understand, particularly those who see themselves as controlled by the criminal justice system, often with treatment linked to their sentences. It is necessary to emphasize that treatment is not punishment, so that clients do not feel that "doing time" is all that is required of them in treatment. It is unlikely that a client with this attitude will be a participatory member of the process and reach the goals that have been set. Who Does Treatment Progress Assessments? The assessment of treatment progress should be routinely performed by a clinician and the treatment team. It is important that the treatment team be equipped to handle linguistic and cultural diversity, as well as gender issues. If security needs are an issue, a representative of the criminal justice system should inform the treatment team regarding matters of security. Criminal justice requirements must be considered, but they should not dictate the treatment agenda. This is discussed in more detail later in this chapter. How Often Should Assessments Be Conducted? According to some involved in the treatment process, the answer to this question is, "As often as you can afford to." There are no set standards for the frequency of treatment progress assessments, and frequency is often dependent on financial resources and the availability of technical support. Different instruments also specify differing time periods between progress assessments. Different types of interventions -- long-term, short-term, residential, or outpatient -- may be needed at differing intervals. The frequency of treatment progress assessment should be agreed upon by the client and the clinician at the beginning of treatment and adjusted, if necessary, as treatment continues. State licensing requirements often mandate treatment planning reviews at specific intervals. Thus, the treatment program may not have a choice regarding the frequency of How This Differs From Other Assessments Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System assessment. Assessment can be part of the ongoing treatment plan. Specific Assessment Instruments The assessment instrument is a tool used to quantitatively measure progress. There is a need for valid, reliable, and widely recognized tools, and they must be standardized, understandable by both the AOD and the criminal justice systems, and culturally sensitive and appropriate. Whatever tool is used should be repeated to foster consistent measurement and reliability of data. The most objective tools for measuring progress are urine and blood tests for the presence of AODs. These tests can be used beyond their obvious pass/fail connotations as therapeutic tools to measure progress. For example, treatment might be divided into three phases, with a goal of "clean" urine 50 percent of the time in Phase 1, 75 percent of the time in Phase 2, and 100 percent of the time in Phase 3. Another important consideration with respect to urine testing is the context within which it is done. A positive urine test from a client who has just begun treatment in a maximum security institution has considerably different implications than a test from someone who has received extensive treatment and is currently in a community-based residential program. Urine testing should not be employed independently as a measure of progress but, rather, used only in conjunction with other measures of progress. There is disagreement within the treatment community regarding how standardized and objective assessment instruments should be. On the one hand, standardized, quantitative methods of measurement provide clear and easily accessible documentation of progress in treatment. But many treatment personnel resist what they see as the "robotization" of assessment and prefer assessments that are subjective and individualized. There are few assessment instruments designed specifically for measuring progress in AOD abuse treatment programs for a population referred from the criminal justice system. However, a number of existing instruments, such as the Addiction Severity Index, can be adapted for this purpose. Criteria for Measuring Treatment Progress The treatment plan, developed as an important component of the clinical assessment, is reviewed, assessed, updated, and revised throughout the course of treatment. Ideally, the plan is adapted as intermediate goals are met successfully. Then, at the end of a successful process, the treatment plan evolves into a discharge plan. All treatment plans should address specific substantive issues. Among these are: · Employment, vocational, and educational needs · Housing in an environment that is free from AODs · Medical and psychological concerns · Recovery support · Self-esteem development · Relapse prevention · Stress management · Self-help resources · Abstinence or reduced AOD use. Different issues will be addressed at different points of assessment, and individual issues should not be considered in isolation but, rather, in the context of the treatment process. For example, was the client successful in finding housing because of his or her own efforts, or because of the efforts of a counselor? The aim is not for the counselor to overly facilitate the solving of the client's problems. Rather, it is for the clients to make internal changes in the way they view the world and themselves. Internal changes in the way the clients view the world and themselves are desirable. Specific Assessment Instruments Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Sources of Information Obtaining information to assess progress is a pragmatic procedure that is dependent on a number of sources. The most obvious, of course, is the client. What must be emphasized, however, is something that every treatment professional knows: Clients often tell us what they think we want to hear, and unintentionally deceive themselves. What the client says must be considered within this context and verified whenever possible. Verification is discussed in greater detail later in this document. The assessor should try to remain current with events in the client's life: where he or she is living, with whom, etc. This information can be gathered either through interview or through a self-administered form, if the client has sufficient literacy. Beyond this basic biographical information, the assessor should try to get the client to describe what he or she has learned throughout the treatment process. For example, what has the client learned about addiction? It cannot be assumed that clients are learning merely because information has been provided to them. Observation of the client's appearance is another way the assessor can gather information. If clients are unemployed and wearing expensive clothes and jewelry, their denial of drug dealing is suspect. This kind of sensibility and sensitivity can be applied by the clinician to a wide range of clients' behavioral cues. The counselor should also elicit information about the impact of treatment. For example, has the client moved away from a previous circle of drug-using friends? Is the client consciously exercising impulse control when confronted by a situation that a few weeks ago would have triggered a dangerous rage? What does the client think about treatment? Is the client satisfied with his or her progress? What does the client think the next stage of treatment should be? What are his or her complaints? There are sure to be complaints and they should be noted and considered seriously. The assessor can also gather information from family members and others close to the client. Input from these sources can corroborate information about the client's attitudinal and behavioral changes. Contacts with sources in the criminal justice system can provide additional information about the client, as well as verify information received from other sources, such as a social services agency. This exchange of information can be specifically described in a memorandum of understanding between the two agencies, listing how and when the communication can take place. Information shared between agencies should be written whenever possible, but other types of verification can be used. For example, if clients are attending self-help meetings, they should be able to describe the meeting format, their reactions to the meetings, and the issues that were addressed. This kind of verification is often more valid than the results of a standardized test, where there is no assurance that a client is responding truthfully. Potential Conflict Between Systems It is important for the treatment and criminal justice systems to recognize each other's needs, and to understand each other's methods and goals. Sometimes these needs, methods, and goals may differ, but with the same clients passing through both systems, it is imperative that coordination, understanding, and synchronization be achieved if the best interests of the clients, the systems, and society are to be served. Information must be shared between the two systems for mutual benefit. A treatment counselor needs to know if the client has had new encounters with the law or has been noncompliant with conditions of probation and parole, since these are indicators of serious behavior problems. If a probation officer learns that a client is compliant with treatment and is progressing well, he can adjust the level of supervision and better allocate the resources of an overtaxed agency. Sources of Information Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System The two professionals can also work together to avoid duplication of effort in handling such things as Social Security and Medicaid eligibility. There can be areas of tension between the treatment counselor and the criminal justice official. A counselor may be satisfied that a client is making good progress toward specific treatment goals. The criminal justice officer might respond, "Sure, treatment may be going well, but what about these other behavior problems? This guy is still testing the conditions of release and is hanging out with his undesirable associates." There are inherent conflicts as well between the treatment community's need to factor cost into its decisions and the mandate of the criminal justice system to protect public safety and security. Cost considerations may lead to the least restrictive program that can be appropriate. A judge or other criminal justice official may not be willing to accept this recommendation. "We do our best to inform the criminal justice system of our assessment," said a Chicago-area counselor in the Treatment Alternatives for Special Clients program. "And when we recommend residential treatment, it's usually favorably received. But when we recommend outpatient treatment, the judge tells you where he thinks that client should go." Somehow these conflicts must be resolved and the tensions used constructively. Ultimately, an offender's fate is in the hands of the criminal justice system, and AOD abuse is only one of a number of factors that must be considered in determining placement. Treatment personnel must consider the whole client in their dealings with the criminal justice system, or they will lack credibility with criminal justice personnel. Likewise, criminal justice staff can learn to understand that treatment involves many shades of gray. For example, just because a client is not in a residential program does not mean that she or he is not in an intensive treatment regimen. Residential treatment should not be viewed by the criminal justice system as punishment due to its restrictive nature. Meetings should be set up between criminal justice representatives and AOD abuse treatment repre-sentatives to consider such issues as supervision, community protection, and treatment content and progress. It is important that judges understand that they should not sentence offenders to specific treatment plans. Rather, they should order clinical assessment at an early stage, and then mandate treatment based on the outcome of the assessment and under the supervision of the treatment provider and/or the probation department. Attrition and Noncompliance Issues The problems of attrition and noncompliance should be anticipated early in treatment. If they are noted sufficiently early in the treatment process, it may be possible to avert them. Regarding issues of noncompliance, a proactive attitude is needed from the treatment counselor. The criminal justice representative should be alerted when noncompliance occurs, long before a client is actually expelled from a program, if it appears that a situation leading to this outcome is developing. The client needs to know that there are certain nonnegotiable rules in treatment, and that breaking one of these rules can result in expulsion from the program. Some programs are more rigid than others. The criminal justice representative, as well as the client, needs to be informed about the specifics of these rules, so that if expulsion becomes necessary, the course of action will be understood. For example, if a client physically assaults a counselor, and assaulting counselors is specified in the rules as a cause for expulsion, an expulsion should be a surprise to no one. Obviously, any infraction such as this should be documented in writing and immediately communi-cated to the supervising criminal justice authority. It is also helpful if the treatment counselor and criminal justice representative discuss certain general trends in advance. Such particulars as retention rates, the most likely dropout points, and relapse rates in various stages of treatment, can be used to alert case managers in other systems to potential problem periods and when they are be likely to occur. Attrition and Noncompliance Issues Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Limitations in Reaching Treatment Goals Every clinician knows that the limits to reaching treatment goals can span a wide variety of circumstances, both predictable and unforeseen. The treatment may no longer be effective. The client may have other serious life problems that preclude successful treatment. The counselor may leave the program, and the client may feel he or she does not have the energy to start again with someone new. Another limitation in reaching goals derives from the complex problems of the clients being seen today in the criminal justice system. Compared to problems seen in clients 10 or 15 years ago, the problems of today's generation of clients are far more complex and multilayered. In many cases, the issues are not simply poverty or AOD abuse, but problems stemming from generations of poverty and generations of AOD abuse. This population is more debilitated than previous generations. Clients may be illiterate and often lack a sense of family, structure, or purpose. They may not have any concept of the value of employment. They may need help in developing qualities that provide the underpinnings needed to be productive members of society. The treatment program can be an important part of the habilitative process. Chapter 5 -- Special Assessment Issues This chapter contains tips and guidelines regarding several areas of the assessment of clients in the criminal justice system. The first part of the chapter discusses basic considerations regarding the client and the assessor that underlie the assessment process. These include: · Determining who should do the assessment · Laying the foundation for assessment · Addressing the client's basic needs · Consideration of the client's literacy · Reviewing the assessor-client relationship. The second part of the chapter discusses the skills and knowledge needed to effectively conduct the parts of the assessment on cultural, educational, ethnic, racial, and gender issues. The topics discussed include: · The assessor's skills regarding ethnic and cultural diversity · The assessor's approach to gender issues · The assessor's ability to deal with issues of spirituality, religious belief and practice, and creativity. The final part of the chapter discusses processes and approaches used to obtain assessment data on various aspects of the client's health and mental health status. These include: · General health status · Physical and sexual abuse · Risk for HIV and other sexually transmitted diseases · Mental health status · Safety concerns · Relapse potential. The overarching aim of the chapter is to help increase the skills of practitioners who assess clients in the criminal justice system. An additional aim of the chapter is to help assessors develop skills in establishing a bond with clients that will facilitate successful treatment. Chapter 5 -- Special Assessment Issues Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Basic Considerations Underlying Assessment Who Should Do the Assessment? The assessor should not be part of the correctional system. Having assessment done by someone in the criminal justice system can reduce the likelihood that the client will thoroughly trust the assessor and the assessment process, and increase the potential for a conflict of interest in the assessor. If the assessor is employed by the correctional system, achieving his or her primary responsibility -- protecting society from the incarcerated -- may interfere with acting in the best interests of the client. An assessor must be able to act in the best interests of the client. Moreover, the assessor should be able to provide followup services to the client following incarceration or other disposition regarding continuing treatment services. The individual performing the assessment should be an advocate for the client. Ideally, long-term followup should be done by someone with whom the client has been able to establish a meaningful bond, or by an agency with which the client has established a relationship. The ability to conduct accurate assessments and use appropriate tools derives from training and the continual updating of knowledge and development of skills in working with members of special groups such as minorities and women. The individual who is assessing clients who belong to minority ethnic or cultural groups should be trained and experienced in cultural competence and sensitivity issues. A curriculum designed for the training of assessors should address the different patterns of alcohol and other drug (AOD) use in different populations, the historical and cultural aspects of AOD use, and the effects of the different drugs of abuse in different populations. Laying the Groundwork For Assessment Ideally, an assessor should provide clients with preassessment information that is designed to educate them about the value of assessments and motivate them to participate in the assessment process. Preassessment education should include information about the effects of AOD abuse on society and on the client's specific group, if appropriate. Generally, information about the effects of AOD abuse is easier for clients to accept if it is not directed to them personally as individuals but is of a general nature. The educational effort should include information on: · The impact of AOD abuse on relationships with significant others · Empowerment issues: How addiction and abuse diminish an individual's self-determination · HIV/AIDS, other sexually transmitted diseases, and tuberculosis. In the absence of preassessment education, the assessor should attempt to gather information regarding several specific areas of the client's sense of self that can be relevant to treatment success: · The overall belief system or world view of clients: whether they see themselves as victims of circumstances or as agents of their own fate. · Whether they have a relationship with a higher spiritual power. · Their sense of self-esteem. Eliciting a sense of clients' self-perceptions is an early step in the establishment of a sound relationship between the interviewer and the client -- a relationship that will facilitate meaningful assessment and treatment. Addressing the Client's Basic Needs In an assessment for AOD abuse, the assessor should determine the immediate concerns of the client. These may range from issues of survival and self-preservation in the correctional system to the safety of dependents at home while their primary caretaker, the client, is in prison. Attempts to address the client's basic needs prior to treatment will help to ensure the client's cooperation in assessment. The primary concerns of the client may be related to: Basic Considerations Underlying Assessment Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System · The trial date and what can be expected in court. · Fears of sexual victimization in jail or prison. · Basic survival issues such as homelessness, hunger, and lack of employment. · Health issues. Women may be very anxious about such conditions as pregnancy, pelvic inflammatory disease, or other gynecological problems. Both men and women are likely to be concerned about contracting HIV infection -- if they are not already · infected -- and other sexually transmitted diseases. · Withdrawal symptoms. · Physical disability. Addressing such concerns is very important in building the relationship of trust that is essential for conducting an effective and useful assessment. Literacy Level and Linguistic Competence Some innovative programs provide bilingual services in English and Spanish or Portuguese. Increasingly, people who speak languages other than English or who are learning English are entering the criminal justice system with AOD problems. In addition to assessment problems that can be created because of a client's poor grasp of English and the assessor's inability to understand a second language, the accuracy of an assessment can be compromised if the client has literacy problems in his or her own native language. It should not be assumed that the client has an adequate level of literacy in any language. The literacy level of the client should be assessed prior to the selection of terminology used in the assessment. A good example of miscommunication created by inadequate language competence is the mistaken understanding of the term "positive" when applied to the results of HIV testing. An individual who is informed that an HIV test has come back "positive" may take this to mean a "good" result, and mistakenly believe that the virus was not found. The Assessor-Client Relationship The process of assessment is more than just obtaining a client's responses to predetermined questions. The process involves engaging the client in a meaningful dialogue. A two-way dialogue must take place between two motivated participants in order to build a relationship based on mutual trust, acceptance, and respect. To build such a relationship, the assessor must find a way to bond with the client. The assessor must have an attitude of sincerity, empathy, and understanding, and find ways to communicate these qualities to the client. One way to begin this is to elicit the client's "story." The assessor could ask the client to describe the circumstances leading to his or her criminal justice system involvement. The assessor can write this information on paper, give the document to the client, and ask the client to modify or expand it. The act of "owning" one's "story" can be the client's first step in realizing that he or she can take responsibility for his or her role in the process that led to AOD abuse and criminal justice system involvement. Thus, the client can begin to take some measure of control. This can be a first step toward self-determination. The story notes taken by the assessor and given to the client can become the first page of a journal or diary kept by the client. The client can be encouraged to take notes on his or her experiences while in treatment. This journal can be reviewed periodically with the client. If the client is concerned about divulging illegal activities in such a journal, the interviewer may suggest the use of code language to ensure confidentiality. Another useful technique is to suggest that the journal have two parts, with one part describing AOD abuse-related issues and another part describing "good" or positive issues. Literacy Level and Linguistic Competence Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Ethnic Origin, Culture, And Gender Issues of Diversity The assessor's knowledge of AOD abuse patterns in specific cultures is an important consideration in assessment among culturally diverse populations; the assessor needs to be familiar with cultures other than his or her own. Few clinicians are adequately trained to handle issues related to ethnic and class bias, gender and