SCREENING DIAGNOSING TREATING Dr. Geoffrey Twitchell, Director of Treatment and Clinical Services San Diego County Probation Department California Association of Pretrial Services Conference May 15, 2015

Goals Substance Abuse and Mental Illness in Offender Populations Screening Tools Interviewing and Brief Interventions

Disproportionate Offender Rates for SMI and SUD Sources: “The Numbers Count: Mental Disorders in America,” National Institute of Mental Health, 2006. “Prevalence and Co-Occurrence of Substance Use Disorders and Independent Mood and Anxiety Disorders,” National Institute of Health, 2006. “Substance Dependence, Abuse, and Treatment of Jail Inmates – 2002,” Bureau of Justice Statistics, July 2005. “Characteristics of Parole and Probation Admissions Aged 18 or Over,” The TEDS Report, Substance Abuse and Mental Health Services Administration, March 2011

Jails: The New Psych Hospitals Source: “More Mentally Ill Persons are in Jails or Prisons Than Hospitals,” Treatment Advocacy Center and National Sheriff’s Association, May 2010.

MAYSI-2 Data at KMJDF

Screening Versus Assessment Screening Tools- Instruments designed to identify individuals who are at-risk of having a particular problem and/or need and determine if a further assessment is warranted. Standardized instrument Typically quick Easy to administer and score by anyone Does not provide a diagnosis Assessment Tools- Instruments that are used to define the nature of a problem and assists with developing specific treatment recommendations for addressing the problem. Conducted by a qualified individual with the appropriate credentials Can be used to assist with diagnosing an individual Can be used to link individuals to the appropriate services based on diagnosis

Screening Tools AOD Screening Tools Mental Health Screening Tools CAGE-AID- 2 minutes TCUDS-II- 5 minutes SSI-SA- 10 minutes Mental Health Screening Tools BJMHS- 5 minutes CMSH-M/W- 5 minutes Mental Health Screening Form III Modified Mini Screen Co-occurring Disorders Screening Tools GAIN-SS- 5 minutes PRISM- 60 minutes Risk/Need Screening Tools ORAS-PAT- 2 minutes RANT- 15 minutes LSI-R:SV 5 minutes

AOD Screening Tools CAGE-AID

AOD Screening Tools TCUDS V

AOD Screening Tools TCUDS V Scoring

Mental Health Screening Tools

Mental Health Screening Tools CMHS-M CMHS-W

Mental Health Screening Tools Mental Health Screening Form III

Mental Health Screening Tools Modified Mini Screen (MMS)

Mental Health Screening Tools Modified Mini Screen (MMS)

Mental Health Screening Tools Modified Mini Screen (MMS)

Co-occurring Disorder Screening Tool GAIN-SS

Risk/Need Screening Tool ORAS-PAT

Risk-Need-Responsivity (RNR Model) Risk Principle- Interventions to match assessed level of risk Need Principle- Interventions to target criminogenic factors associated with behaviors Responsivity Principle- Interventions to match offender characteristics *Use validated assessment tools for identifying Risk and Need; Static and Dynamic (e.g. COMPAS, Static 99, RM2000)

COMPAS Assessment Probation assesses for Risk and Need using the COMPAS assessment Probation then links offenders to treatment and intervention services based on their specific Risk and Needs Risk- Violence and Recidivism Need- Criminogenic Needs

Criminogenic Needs Assessment Analysis 75% of realigned offenders supervised by Probation have needs related to substance abuse 64% have needs related to criminal thinking 52% have needs related to residential instability 44% have needs related to vocational/educational *Data from Probation’s Needs Assessment Analysis for High Risk Offenders, San Diego County Probation Department, 2013

Linking Offenders to Services The referral is made through COMPAS and the Provider receives the referral through Probation’s Community Resource Directory.

Community Resource Directory (CRD) The CRD is an electronic catalog of service providers Probation officers make online referrals to community services based on assessed risk and highest criminogenic needs according to evidence based principles GOALS of the CRD Supports probation officer’s role as a case manager Assists in the delivery of services to offenders in pursuit of rehabilitation Allows for measurement of offender participation and progress in treatment

CRD Referral to Treatment/Services

Dual Diagnosis/ Co-occurring Disorders Approximately 8.9 million adults have co-occurring disorders Bipolar Disorder, Schizophrenia and PTSD show higher rates of substance abuse Only 7.4 % receive treatment for both conditions; 55.8 % receive no treatment at all Integrated, simultaneous treatment produces better outcomes for individuals with co- occurring mental and substance use disorders.

Services Integration for Co-occurring Disorders Means providing at a minimum: Integrated screening for substance use and mental health disorders Integrated assessment Integrated treatment planning Integrated or coordinated treatment Continuing care

Screening, Brief Intervention and Referral to Treatment (SBIRT) Comprehensive, integrated public health approach to early intervention and treatment Screening: quickly assesses severity of substance use and identifies appropriate level of treatment Brief intervention: focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change. Referral to treatment: provides those identified as needing more extensive treatment with access to specialty care

Screening Simple method of identifying individuals who are drinking/using drugs at at-risk levels as well as those who are already experiencing AOD-related problems Gives specific information and feedback about AOD Provides opportunity to educate the individual about their use and the consequences it has/will generate It offers the individual an opportunity to change their behavior to prevent progression

SBIRT Process

Brief Intervention Providing information and feedback about results Understanding individuals’ views of their use Encouraging the individual to discuss their views on their likes and dislikes about use, and how they may consider changing. Respectfully advising individual to decrease or abstain Teaching behavior change skills Establishing a method for follow-up with the individual.

Referral to Treatment Consists of assisting individuals with: Accessing specialized treatment Selecting treatment facilities Obtaining authorizations from insurance if needed And, in some cases, providing transportation

SBIRT Effectiveness

SBIRT Videos How to do SBIRT ? How NOT to do SBIRT

Stages of Change

Motivational Interviewing Motivational Interviewing Techniques:  MI Principles: Express Empathy Develop Discrepancy Roll with Resistance Support Self-Efficacy   MI Fundamental Skills (OARS): Open Ended Questions Affirmations Reflections Summarizations      Bill Miller

MI Videos How to do MI How NOT to do MI

References Brief Jail Mental Health Screen (BJMHS) http://gainscenter.samhsa.gov/pdfs/disorders/bjmhsform.pdf Correctional Mental Health Screen - Men and Women (CMHS-M/W) http://www.asca.net/system/assets/attachments/2639/MHScreen-Men082806.pdf?1300974667 http://www.asca.net/system/assets/attachments/2640/MHScreen-Women082806.pdf?1300974694 Cutdown, Annoyed, Guilty, Eye-Opener: Adapted to Include Drugs (CAGE-AID) http://www.agencymeddirectors.wa.gov/Files/cageover.pdf Global Appraisal of Individual Needs-Short Screener (GAIN-SS) http://www.gaincc.org/products-services/instruments-reports/ Level of Service Inventory-Revised: Screening Version (LSI-R:SV) http://www.mhs.com/product.aspx?gr=saf&prod=lsi-rs&id=overview Mental Health Screening Form III https://www.idph.state.ia.us/bh/common/pdf/substance_abuse/integrated_services/jackson_mentalhealth_screeningtool.pdf Modified Mini Screen http://www.nyc.gov/html/doh/downloads/pdf/qi/qi-mms-scoringsht.pdf Ohio Risk Assessment System: Pretrial Assessment Tool (ORAS-PAT) http://www.pretrial.org/download/risk-assessment/Ohio%20Pretrial%20Risk%20Assessment%202009.pdf Psychiatric Research Interview Substance and Mental Disorders (PRISM) http://www.columbia.edu/~dsh2/prism/ Risk and Needs Triage (RANT) http://www.tresearch.org/tools/for-courts/rant/about-rant/ Simple Screening Instrument for Substance Abuse (SSI-SA) http://www.prairie-center.com/files/images/sasf.pdf Texas Christian University Drug Screen (TCUDS-II) https://www.dpscs.state.md.us/publicservs/procurement/QA_5_ATTACHMENT_1_TCU_DRUG_SCREEN.pdf

Director of Treatment and Clinical Services THANK YOU! Geoff Twitchell, Ph.D. Director of Treatment and Clinical Services Geoff.Twitchell@sdcounty.ca.gov Telephone: (858) 514-3175