Assessments and Targeting What a match!

What the heck is a Biopsychosocial assessment?? It addresses biological/medical status It addresses psychological status It addresses social status

People are more than just their addiction!

Objective: Understand the role and importance of screening, assessments, and evaluations to the intervention & treatment process and to match them to your TARGET

Objective: Know what all those letters mean! Know what the limits of these tests are. Know when to ask for more!

Definitions Screening determines eligibility and appropriateness for participation in drug court, and to identify areas for services. (Legal & AOD) Assessment helps to identify specific types of services and determine the intensity of treatment (level) needed. (Peters & Peyton, 1998) Evaluation identifies psychological, cognitive, and social issues which affect treatment.

Screening Assessment Treatment When screening results are indicative of a substance abuse problem, the participant is accepted into the program and referred for a bio-psycho- social assessment. The assessment determines and clarifies the nature and extent of the participant’s diagnosis and clinical needs. Assessment data is also used to ascertain the appropriate level of care.

Screening Screening answers the “yes/no” question. If the answer is that the client needs treatment, will he/she benefit from this program? If the answer is that the client will not benefit from this treatment then the referral is made to another program. It may involve testing such as SASSI or other instruments which yields data concerning the client’s addiction.

Screening: Goals To identify potential candidates for intervention as early as possible in their criminal justice processing, and to interrupt their cycles of addiction and crime.

Who screens? It depends on the time of contact with the target individual!

Law Enforcement can screen! In fact, you already are! [Physical signs] “Have you ever done anything while drinking or using drugs that you regretted later?” Have you ever gotten into a fight with anyone because of your drinking or using drugs? Arrest is a crisis which provides an excellent stage for screening.

The prosecutor screens: Every time you look at a rap sheet, the priors, and the blood alcohol level-you’re screening. Ditto the Court!

Screening can (and should) occur all along the justice system path! Public Defenders Jail and O.R. systems Probation violations

CAGE Questionnaire Have you ever felt the need to cut down 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?

Seem too simple? Two “yes” answers will correctly identify 75% of the alcoholics who respond, and accurately eliminate 96% of non-alcoholics. Modify it by using “drug use” in place of drinking. It is simple!

There are some evidence based screening tools: AUDIT=the Alcohol Use Disorders Identification Test. It is designed for heavy drinkers or alcoholics. It is free. It takes 2-3 minutes. DUSI-R=Drug Use Screening Inventory Revised. It is designed for both adults and adolescents. Self administered, pen and paper or computer. Not free RIASI-Research Institute on Addiction Self Inventory. It looks at alcohol and drug problems, RECIDIVISM, and has a malingering detection section. Free.

Other quick alcohol screens- TCU Drug Dependence Screen (DDS; Simpson et al., 1997) MAST-25 questions-often used

Sometimes there are issues of veracity and denial… Question by dentist: “how often do you floss?” Answer: regularly [….once a year before seeing you] Human nature still applies!

Follow up to positive screening response: Relationship of the current crime to AOD use Recent or past AOD use Past treatment history Health problems Criminal Justice History History or evidence of mental illness

Results of urine, breath or blood testing Problems with  family  Social integration  Employment  Housing  Financial instability  homelessness

Screening & Assessment Issues Screening should be completed as early as possible. Motivation for change is elevated in the beginning. We want to capitalize on it. Legal screening is sometimes in conflict with screening for addiction and health issues!

Note! A person’s receptiveness and motivation changes…so their answers on screening may change. This is why it is important to screen all along the pathway through the legal system.

Assessment Assessment ascertains what areas need to be addressed in the client’s life for treatment to be effective. It may include testing such as the ASI or other instrument that yields whole life data. Areas of concern may be work, family, marriage, past trauma, legal problems, psychological history, living situation as well as level and severity of addiction.

The absolute rule: Continuing assessment is necessary

While in treatment, our participants are changing ! Their lives are not static! As they change-new strengths, threats & challenges emerge! Assessments must be ongoing…not just a snapshot. Sobriety Courts are about high speed change…and we need to measure it!

Stages-of-Change 1. Pre-contemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance Di Clemente, C.C., Prochaska, J.O..Self-change and therapy change of smoking behavior: A comparison of processes of change in cessation and maintenance. Addictive Behaviors Vol7(2) Montague, D.D. (2000) Brief therapy: Using stages-of-change. The addiction Messenger, 3,

Assessments Are more in depth. Can take up to 3 hours Provide more detailed information

Assessment issues to cover Personal and family history Legal history-arrests, domestic violence, violent convictions, and juvenile history History of substance abuse and treatment- types of drugs used and preferences Mental health history, suicide, psychiatric hospital admissions, and counseling Known developmental problems

Assessment issues continued… Educational history, literacy, and current status Employment history and status-job losses and why, were they substance abuse related? Motivation Participant’s conception of needs Client goals and aspirations

Read this article ob/ /risk.html OR, google DWI-R ! Great study. DWI Recidivism: Risk Implications for Community Supervision

Assessment Instruments (validated) ASMAST-parental history of alcoholism ASI-standard instrument of choice in many places. Substance Abuse Subtle Screening Inventory (SASSI) Beck Depression Inventory Alcohol Dependence Scale LSI-R Level of Services Inventory AND! THE IDA, Impaired Driving Assessment is now out!!!

Risk factors for continued abuse, such as family history, 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 Client motivation and readiness for treatment Client attitudes and behavior during assessment. So, what are they looking at?

Extent and severity of AOD abuse problem Determine the client’s level of maturation and readiness for treatment Ascertain concomitant problems such as mental illness Determine the type of interventions that will be necessary to address the problems Evaluate the resources the client has to help solve the problems. Includes: family support, social support, education and vocation, personal qualities such as motivation. Engage the client in the treatment process.

Components of Assessment Archival data on client: prior arrests, rap sheet, previous assessments, treatment records. Patterns of AOD use Impact of AOD use on major life areas such as marriage, family, employment record, and self-concept. Criminogenic needs and issues

ORAS/TRAS Texas region specific instruments coming! Roll out soon! T-RAS is based on the Ohio instrument  Ohio’s does four discreet target opportunities at intake/phase of conduct Pretrial Community Supervision Prison Intake Community Reentry. Parole Supervision

ASAM Placement Criteria Early Intervention Opioid Maintenance Outpatient Intensive Outpatient Clinically Managed Low Intensity Residential Medium Intensity Residential High Intensity Residential Med Monitored Intensive Inpatient Med Managed Intensive Inpatient

The ASAM PPC provides two sets of guidelines, one for adults and one for adolescents, and five broad levels of care for each group.

The levels of care are: Level 0.5, Early Intervention; Level I, Outpatient Treatment; Level II, Intensive Outpatient/Partial Hospitalization ; Level III, Residential/Inpatient Treatment; and Level IV, Medically-Managed Intensive Inpatient Treatment. Within these broad levels of service is a range of specific levels of care.

For each level of care, a brief overview of the services available for particular severities of addiction and related problems is presented; as is a structured description of the settings, staff and services, and admission criteria for the following six dimensions:

acute intoxication/withdrawal potential; biomedical conditions and complications; emotional, behavioral or cognitive conditions and complications; readiness to change; relapse, continued use or continued problem potential; and recovery environment.

ASAM Placement Criteria LEVEL of CAREI OUTPT II INT OP III MED MON INPT IV MED MGD INPT WithdrawalNo riskMinimalSome riskSevere risk Medical Complications No riskManageableMedical monitoring 24 hr acute med care Psych/Behav Complications No riskMild severityModerate24 hr psy & addiction tx required Readiness for Change CooperativeCooperative but requires structure High Resist, needs 24 hr monitoring Relapse PotentialMaintains Abstinence Needs close monitoring Unable to control use Recovery Environment SupportiveDifferentialDanger to recovery

Psychopathy Scales Hare Psychopathy Checklist- Revised (PCL-R), (and screening version) is a 20 item symptom rating scale designed to assess antisocial personality disorders in forensic populations.

Beck Depression Inventory Copyrighted Accurate

Resources for Screening and Assessment and Assessment Instruments Peters, R.H. & Peyton, E., Guideline for Drug Courts on Screening and Assessment, Drug Courts Program Office, Washington, DC 20531, 1998 Winters K.C. & Zenilman, J.M. Simple Screening Instruments for Outreach for Alcohol And Other Drug Abuse and Infections Diseases, US Department orf Health and Human Services,Center for Substance abuse Treatment, Rockwell II, 5600 Fishers Lane, Rockville, MD 20857, 2000

Bio-medical Issues Medical History-Illness, hospitalizations, injury Past diagnoses of physical problems Current medications Under whose care are the conditions monitored? Psychotropic medication present and past

Bio-medical Issues continued Referral to an MD for a physical or medication check Are there Axis III issues (physical issues that affect psychological function)? Untreated disease is a danger to the client and others—AIDS, Hepatitis, STD’s, may need to be reported (depending on jurisdiction). Co-existing psychiatric disorders (Axis I).

Psychological Evaluation The Psychological Evaluation makes a diagnosis of the client’s mental condition based on history, testing, and interview. It provides insight into the severity of the problems that may have been addressed in the assessment. It is usually done by a psychologist.

Uses of Psychological Information With objective and helpful recommendations, the psychological evaluation make the treatment plan easy for the counselor to construct. Use for treatment Often needed for referral to a higher level of care An excellent treatment tool with the client Labeling –watch out!

Evaluation/Treatment Linkage Without knowing what is wrong with the client, we cannot possibly treat him. Without knowing what treatment components to use, we cannot effectively evoke change in the lives of our clients. Sanctioning (jail, etc.) cannot change the client in the absence of effective treatment. Unraveling “What Works” For Offenders in Substance Abuse Treatment Services Faye S. Taxman, Ph.D.

Admission Criteria Potential for change Ability to handle verbal information Education advancement potential Compliance and change potential of family Severity of addiction (or lack of addiction) Age Probation’s relation to program length

Admission criteria continued… Mental health (co-occurring disorders) Strengths and weakness Employment resources Cognitive deficits Security and public safety Motivation- (not so much) Bio-social Issues

Other Information Necessary for Treatment Current test results and probation status Judgment and summary-crime facts Legal history Medical history and current medication Information from other treatment programs Court order

Then what….? We use all that information to create an ongoing, individualized, and updated case & treatment plan. Then, we do it again.

Who should be in drug court, and what to do with them when they are in your court. Douglas B. Marlowe, J.D., Ph.D. © Douglas Marlowe, May 10, 2011 The following presentation may not be copied in whole or in part without the written permission of the author or the National Drug Court Institute. Written permission will generally be given without cost, upon request. Targeting Dispositions by Risks & Needs Helen HarbertsChico

Dispositions for Drug Offenders Pre-plea diversion (ARD) Incarceration Drug Courts Intermediate sanctions Psychosocial Functioning $$$$$$ Costs $$$$$$$$$ Public Safety Risks Disposition before judgment (Prop. 36)

Drug Courts target select populations: High Risk/ High Need. Putting the wrong people into a drug court can do harm. Keeping the right people out of drug court will do harm. You need to focus on reaching the high impact client.

Prognostic Risks Current age < 25 years Delinquent onset < 16 years Substance abuse onset < 14 years Prior rehabilitation failures History of violence Antisocial Personality Disorder Psychopathy Familial history of crime or addiction Criminal or substance abuse associations

Criminogenic Needs Substance Dependence or Addiction 1. Binge pattern 2. Cravings or compulsions 3. Withdrawal symptoms Substance Abuse Collateral needs  Co occurring disorder diagnosis  Chronic medical condition (e.g., HIV+, HCV, diabetes)  Homelessness, chronic unemployment } Abstinence is a distal goal Abstinence is a proximal goal } Stabilize first!

High Risk Low Risk HighNeeds LowNeeds Risk & Needs Matrix

High Risk Low Risk HighNeeds LowNeeds Accountability, Treatment & Habilitation

Risk & Needs Matrix High Risk Low Risk HighNeeds LowNeeds Treatment & Habilitation Accountability, Treatment & Habilitation

Risk & Needs Matrix High Risk Low Risk HighNeeds LowNeeds Accountability & Habilitation Treatment & Habilitation Accountability, Treatment & Habilitation

Risk & Needs Matrix High Risk Low Risk HighNeeds LowNeeds Prevention Accountability & Habilitation Treatment & Habilitation Accountability, Treatment & Habilitation

Practice Implications High Risk Low Risk HighNeeds LowNeeds Status hearings Treatment & habilitation Treatment & habilitation Compliance is proximal Compliance is proximal Restrictive consequences Restrictive consequences Positive reinforcement Positive reinforcement Agonist medication Agonist medication Noncompliance hearings Treatment & habilitation Treatment & habilitation Treatment is proximal Treatment is proximal Positive reinforcement Positive reinforcement Agonist medication Agonist medication v.o.p. / status calendar v.o.p. / status calendar Abstinence is proximal Abstinence is proximal Psychosocial habilitation Psychosocial habilitation Restrictive consequences Restrictive consequences No AA or MET No AA or MET Antagonist medication Antagonist medication Secondary prevention Secondary prevention Abstinence is proximal Abstinence is proximal No AA or MET No AA or MET Individual counseling Individual counseling or stratified groups or stratified groups

Dispositions for Drug Offenders Incarceration Drug Courts Intermediate sanctions Low risk Low needs Low risk High needs High risk High needs High risk Low needs Risk of Dangerousness Pre-plea diversion (ARD) Disposition before judgment (Prop. 36)