Title : QGcover tip7 9-7-01ph.qxd (Page 2) Description : Keywords : Author : ----------------------------------------------- Quick Guide For Clinicians Based on TIP 7 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System ----------------------------------------------- Contents Why a Quick Guide? . . . . . . . . . . . . . . . . . . . 2 What is a TIP? . . . . . . . . . . . . . . . . . . . . . . . 3 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 4 Criminal Justice and Assessment . . . . . . . . 6 Screening, Assessment and Readiness for Treatment . . . . . . . . . . . . . . . . . . . . . . 14 Treatment Planning and Treatment Progress . . . . . . . . . . . . . . . . . . .23 Special Assessment Issues . . . . . . . . . . . . .30 Legal and Ethical Issues . . . . . . . . . . . . . . 37 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 ----------------------------------------------- Quick Guide For Clinicians This Quick Guide is based almost entirely on information con tained in TIP 7 published in 1994 and based on information updated through approximately 1992. No additional research has been conducted to update this topic since publication of the original TIP. Based on TIP 7 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System ----------------------------------------------- 2 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System WHY A QUICK GUIDE? This Quick Guide was developed to accompany Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System, Number 7 in the Treatment Improvement Protocol (TIP) Series published by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration. This Quick Guide is based entirely on TIP 7 and is designed to meet the needs of the busy clinician for concise, easily accessed "how-to" information. The Guide is divided into seven sections, (see Contents) to help readers quickly locate relevant material. Terms related to screening and assessment for alcohol and other drug abuse among adults in the criminal justice system are listed on page 39 in the Glossary. These terms are included to enable clinicians to talk knowledgeably with their clients and other providers. For more information on the topics in this Quick Guide, readers are referred to TIP 7. ----------------------------------------------- What Is a TIP? 3 WHAT IS A TIP? The TIP series has been in production since 1991. This series provides the substance abuse treat ment and related fields with consensus-based, field-reviewed guidelines on substance abuse treatment topics of vital current interest. TIP 7, Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System • Addresses concerns of a broad range of readers including clinicians, social workers, medical per sonnel, mental health workers, program admin istrators, and policymakers • Includes extensive research • Is a comprehensive reference for clinicians on screening and assessment for alcohol and other drug abuse among adults in the criminal justice system See the inside back cover for information on how to order TIPs and other related products. ----------------------------------------------- 4 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System INTRODUCTION Practical screening, assessment, and treatment planning can help to improve care and treatment outcomes. The goal of this Quick Guide is to pro vide guidelines that can be easily used by clini cians in order to • Identify substance abuse screening and assess ment services that need to be provided to offenders with various levels of substance abuse problems and concurrent needs for cor rectional 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 It is important to understand that this Quick Guide prescribes no particular screening or assessment tool. It is only a starting point for better coordina tion between substance abuse service providers and other providers at various points in the crimi nal justice process. ----------------------------------------------- Introduction 5 The three basic principles that should guide a counselor's efforts are to assure that • Adult offenders should have effective and appropriate care • Adult offenders have a right to privacy and to confidential handling of any and all information they provide • Cultural, racial, ethnic, and gender concerns must be considered in all aspects of the screen ing and assessment process For more detailed information, see TIP 7, pp. 1–3. ----------------------------------------------- 6 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System CRIMINAL JUSTICE AND ASSESSMENT Classification, Screening, and Clinical Assessment Classification The criminal justice system relies on the classifi cation process to determine the social service needs of the offender and assess his potential security risk. Ideally, the system should fit the rehabilitation and security programs of the institu tion to the requirements of the individual. Clinical Screening With limited funding for clinical assessment, the clinical screening process is imperative to deter mine if an individual has a substance abuse prob lem and whether he can benefit from treatment. Medical, legal, and psychological problems are fil tered out at this point and will need to be addressed before treatment begins. Questions during the screening process should be designed to • Identify the existence of a substance use prob lem • Identify individuals with a history of violent offenses or severe medical or psychiatric prob lems • Identify individuals with mental retardation ----------------------------------------------- Criminal Justice and Assessmment 7 • Identify individuals who would not be eligible for release to treatment or accepted by a treatment program Clinical Assessment Clinical assessment is a more detailed gathering of information on the client's substance abuse patterns and history. This includes data on the individual's emotional, psychological, and physical health so that an appropriate treatment regimen can be prescribed. If the client is actively engaged in the assessment process, the treatment process can be initiated. This assessment requires the client to confront the consequences of his substance abuse and to understand that continuance of this behavior is a personal choice. If the client desires change, he will work with the clinician to decide upon treat ment. Elements of Clinical Assessment For multidimensional information gathering, these three domains are used for clinical assessment: Sociobehavioral Domain • History of substance abuse • Involvement in the criminal justice system ----------------------------------------------- 8 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System • Social support and social roles (family members and friends, the individual's care-giving respon sibilities) • Educational and vocational needs (education level and marketable skills for employment) • Spirituality; can help match the client with the appropriate services Psychological Domain To benefit from treatment, the client's emotional disorders must be treated. An interview should assess • Levels of anxiety and depression • Personality disorders • Locus of control • Level of psychological development • Organic brain syndromes • Central nervous system function and impair ment • History of sexual, emotional, and/or physical abuse • History of violent behavior Biomedical Domain • Medical/dental health • Medical problems ----------------------------------------------- Criminal Justice and Assessmment 9 The training for all portions of the clinical and medical assessments includes • The ability to establish rapport • The ability to conduct nonjudgmental, nonthreat ening interviews • The ability to document information throughout the assessment • Cultural competence • Nutritional deprivation • Infectious and contagious diseases Qualifications for Individuals Conducting Screening and Assessment • Any professional staff member of a treatment or criminal justice program can be trained to con duct the initial clinical screening. • In-depth clinical assessments require the indi vidual to have training, professional experience working with substance abusers, and an ability to engage the client's active participation. • Psychological and sociobehavioral portions of the assessment must be done by appropriate professionals for the task, including psycholo gists, social workers, certified substance abuse counselors, and clinical nurse specialists. • The biomedical assessment must be conducted by a physician, physician's assistant, nurse prac titioner, or nurse clinical specialist. ----------------------------------------------- 10 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System For consistency, programs should utilize standard ized, culturally appropriate assessment instru ments, to be used in combination with the inter- viewer's structured, clinical, and intuitive assess ment of the client. All assessments should be valid, reliable, and widely recognized. Coordinating Treatment and Criminal Justice Programs Assessment and treatment programs are more effective with coordination between the two sys tems, as it puts scarce treatment resources to the best possible use. A formal agreement to collabo rate is not enough; cross-training is essential to maximize efforts and minimize duplication. At the institutional level... Who should be involved in the team managing coordination between the two sys tems? • The director of probation or prison director • Judges, prosecutors, representatives of the defense bar where appropriate • The treatment director The two systems should develop working policies that specify principles and rationales guiding col laboration. Detailed documents should include ----------------------------------------------- Criminal Justice and Assessmment 11 • Needs and goals of each institution • Means by which the goals will be met (including time frames) • Guidelines for sharing information at various points in the assessment and treatment process • Guidelines for providing a continuum of care Case Management The client's case management team must include representatives from each institution involved and at every stage of the treatment process. A formal agreement should be reached by the team on the following questions: • What are the goals and time frame for treat ment? • What are the guidelines for sharing information? • What process will be followed to reach decisions concerning whether pretrial release, probation, or parole should be revoked; when treatment should be considered a failure; and how person nel in both systems will respond in the event of specific treatment problems? ----------------------------------------------- 12 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Special Issues in Assessment A broad range of sociocultural characteristics that play a large role in assessment include • Literacy and communication skills cannot be presupposed based on the client's social class, race, or ethnicity. The client should still be able to take an active part in the assessment despite an inability to read or write. • Language (the individual's primary, lay, or street language) is essential to make a true connec tion with the individual. Avoid clinical jargon. • A client's cultural identity and ethnicity must be addressed by a culturally and linguistically competent staff. The assessor should under stand the client's own cultural perspective. • Treatment programs must address gender issues and guard against sexism. Treatment tools need to be separately tailored for men and women based on the differences that the abuse of substances is manifested in each gender. • Assessing the client's sexual orientation and her attitude towards it will help place her in the appropriate treatment program. • People with a lower socioeconomic status may require more intensive services due to biases that have denied them adequate food, shelter, or medical treatment. ----------------------------------------------- Criminal Justice and Assessmment 13 • Assessors must respect and be familiar with all religious affiliations and the nonreligious clients in the community. • Clients with physical disabilities must be screened and placed in a treatment program that is physically accessible. • The risk factors for HIV infection should be assessed, including • Frequency of drug injections • Sharing of drugs and injection equipment • Use of bleach to sterilize needles • Number of sexual partners • Patterns of condom use • Sex-for-drug exchanges • History of sexually transmitted diseases For more detailed information, see TIP 7, pp. 5–11. ----------------------------------------------- 14 Eight percent of street crime in the U.S. involves substance use. By screening and treating an increasing number of substance abusers, there is a potential to reduce associated crimes, deaths, and accidents. Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System SCREENING, ASSESSMENT, AND READINESS FOR TREATMENT Why Screen? Screening offenders for substance abuse helps to identify potential candidates for treatment inter vention at the early stages of their criminal justice processing. Addressing the problem early may also curb the cycles of addiction and crime. Officials in the criminal justice system should be taught basic screening techniques and apply them as the offender moves through the system (lock up, arraignment, pretrial investigation, etc.). Considerations Substance abuse is not always apparent during the initial screening interview. Officers must learn to look for signs of substance use, to trust their instincts and intuition, and to pass these impres sions on to the next official handling the case. ----------------------------------------------- Screening, Assessment, and Readiness for Treatment 15 Components When a client acknowledges and recognizes the extent of a personal substance abuse problem, the screening process ends and further assess ment begins. If the individual denies problems, the screener should try to seek evidence in major life areas by investigating certain aspects of the client's life, such as • Relationship of the current charge to substance use • Recent or current substance use • Past treatment history • Health problems (HIV, TB, hepatitis B) • Criminal justice system history • History or evidence of mental illness • Results of urine, breath, or blood testing • Family problems, employment, housing or finan cial instability Screening Instruments Screening instruments provide uniformity, quality control, and structure to the process. This includes Breathalyzer, blood-alcohol, and urine tests as well as the other commonly used instru ments listed below. ----------------------------------------------- 16 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System The CAGE Questionnaire This is a simple, four-question test designed to screen for alcohol abuse and can correctly identify 75 percent of alcoholics: • 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 show that two or more "yes" answers to the CAGE questionnaire will correctly identify 75 percent of the alcoholics who so respond and eliminate 96 percent of nonalcoholics. The questionnaire can be modified for drug use by substituting "drug use" for "drinking" and replacing the fourth question with "Do you ever use drugs first thing in the morning to 'take the edge off'?" The Michigan Alcoholism Screening Test (MAST) This is a 25-question test. It can be used as an indicator of alcoholism and is used during longer interviews or in holding and confinement situa tions. (See TIP 7, p. 57.) ----------------------------------------------- Screening, Assessment, and Readiness for Treatment 17 The Offender Profile Index (OPI) The OPI measures the client's drug use severity and uses a grading guide to interpret the serious ness of the problem. It must be administered by an experienced probation officer, counselor, or other trained clinician. (See TIP 7, pp. 61–76.) Assessment Assessment identifies the client's individual strengths, weaknesses, and readiness for treat ment. It also recommends appropriate treatment based on the client's problems. An assessment should be conducted by qualified human services professionals with a demonstrat ed competence in treatment programs (addiction counselor, licensed social worker). In addition, a credentialed and/or certified alcoholism, sub stance abuse, or chemical dependency counselor should be available. Components of Assessment A variety of components will yield the most com prehensive evaluation of the client and will recom mend the most appropriate treatment. • Archival data on the client (prior arrests, previ ous assessment and treatment records, etc.) ----------------------------------------------- 18 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System • Patterns of substance abuse (tolerance, attempts to hide use, history of withdrawal symptoms) • Impact of substance abuse on major life areas such as marriage, family, employment record, and self-concept • Risk factors for continued substance abuse • Available health and medical findings • Psychological test findings • Educational and vocational background • Suicide, health, or other risk appraisal • Client motivation and readiness for treatment • Client attitudes and behavior during assess ment Assessment Instruments In conjunction with the client's personal history, assessment instruments can provide another data source for evaluating the individual. The following instruments can provide valuable information. • The Addiction Severity Index (ASI): Evaluates addiction based on the problems that resulted from the substance use. Measures the client's level of discomfort in: alcohol use, medical con dition, drug use, employment, financial support, ----------------------------------------------- Screening, Assessment, and Readiness for Treatment 19 illegal activity, family and social relations, and psychiatric problems. • Biological Testing: The use of urinalysis, Breathalyzer tests, blood tests, and all other available physical tests when substance use is denied by the client or he is unclear about what drug or drugs have been used. If possible, self reports should be corroborated by biological testing. Presenting Findings of Screening and Assessment Assessment results contain data that will be rele vant in treatment. The client should not be reduced to a number or a label in this assess ment. The language of the data should not be difficult for any personnel or the client to understand. All acronyms should be explained. The client and client's attorney are entitled to review the assess ment findings, and they should be able to read and fully understand the document. A narrative document based on the data gathered from the screening and assessment tool and the client's clinical interview should be created, having three sections: ----------------------------------------------- 20 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System • An introduction explaining how the 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 presentation of the data relating to the com ponents of assessment and followed by clinical impressions and recommendations Confidentiality and Client Consent In many cases, results of the assessment cannot be released without the signed consent of the client. The client should fully understand the rea son for the release, including the recommenda tions made in the assessment report. The client has a right to disagree with the report, and any ruling officer (such as a judge) should be made aware of such disagreement. Quality Assurance and Improvement This is designed to evaluate, and possibly improve, the quality of client care services. The external reviews should consist of intermittent or annual evaluations done by an outside source. Internal reviews should be an ongoing process done by both peer and supervisory personnel, helping to improve the assessment process for that agency. ----------------------------------------------- Screening, Assessment, and Readiness for Treatment 21 Readiness for Treatment This is based on • The client's insight into his own condition • A willingness to effect change • The understanding that prior attempts at effect ing change have not consistently yielded desir able results Increasing a client's readiness for treatment begins with the assessment process and can be prompted in two different ways: • Circumstances or pressures relating to loss (job, family support, money) • Fear (of incarceration, violence, health risks) Assessing Readiness Clients whose perception includes an acknowl edged substance abuse problem and the need for assistance are ready for treatment. Nonvoluntary participants can become aware of measures that can be employed to create a motivational crisis that makes them amenable to treatment. Clients need to understand the severity of the substance abuse and the available treatment options. ----------------------------------------------- 22 The "Unready" Client Research has shown that coerced treatment is as effective as voluntary treatment, suggesting the importance of connecting all substance abuse- involved offenders with assessment and treat ment resources. For more detailed information, see TIP 7, pp. 13–19. Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System ----------------------------------------------- Treatment Planning and Treatment Progress 23 TREATMENT PLANNING AND TREATMENT PROGRESS The Treatment Plan The treatment plan is the overall management strategy for treating people with substance abuse problems and is based on the client's needs, prob lems, and resources. The plan should develop from the assessment process, be individualized, have clearly-stated goals and objectives, and include documented participation by the client. What is a Good Treatment Plan? • A set of tools that identifies the client's strengths and problems • An approach for sequencing resources and activities, and identifying benchmarks of progress to help guide evaluation • A plan that addresses the need for rehabilita tion as well as habilitation (the client's initial socialization into a productive way of life) • A plan that is designed to address three types of potential problems: • Attrition • Noncompliance • Inadequate progress ----------------------------------------------- 24 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Components of the Treatment Plan • The plan should be individualized; that is, the plan should address the client's specific prob lems and needs, but should not be over-influ enced by the counselor's values. • The plan should be participatory; that is, the plan should be a shared effort between the client and counselor working toward a common goal. Treatment Planning Goals and Objectives These goals should be specific, measurable, quantitative, and have realistic end points. • The plan should help the client establish a posi tive sense of self and self-esteem. • Although abstinence-based goals are custom ary, the plan should have some flexibility to accommodate relapses or slips during treat ment. • Early goals can be set so they can be realistical ly met ("Fewer dirty urines a month for the next 3 months"). Client Accountability Clients must be accountable for the rules of the treatment program and should understand the penalties for breaking them. These rules must be specifically spelled out for the client, leaving no doubt about the consequences of infractions. ----------------------------------------------- Treatment Planning and Treatment Progress 25 The Treatment Team Ideally, this should consist of whatever specialists are necessary to address the client's problems, including • Drug and alcohol counselor • Clinical director • Licensed social worker • Medical personnel to address diagnosed illnesses • Registered nurse At a minimum, the treatment teams need a case manager and counselor who are certified and experienced in providing substance abuse treatment. Potential Conflicts Between Treatment and Criminal Justice Agencies Problems can be avoided if certain points are clar ified in a memorandum of understanding (MOU) before the treatment process begins. This formal agreement should contain • Specific actions of the client that can result in a dismissal from the treatment program • Clearly defined expectations • Definition of terms ----------------------------------------------- 26 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System • Methods of communication • Deliverables, roles, grievance procedures, and crisis management (For more information on the MOU, see TIP 7, p. 23.) 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 essen tial tool that can determine • The value of the course of treatment chosen • How that course should be adjusted • How realistic are the goals that have been set • What linkages need to be made to other agen cies to obtain services for the client • When maximum benefit of the intervention has been achieved • The plan for further intervention Criteria for Measuring Treatment Progress Treatment plans are reviewed, assessed, updated, and revised throughout the course of treatment and become the basis for a discharge plan. Individualized plans will have addressed specific substantive issues such as ----------------------------------------------- Treatment Planning and Treatment Progress 27 • Employment, vocational, and educational needs • Housing environment that is free from abusable substances • Medical and psychological concerns • Recovery support • Self-esteem development • Relapse prevention • Stress management • Abstinence or reduced substance use These and other issues should be addressed at different points of assessment and are used to help clients make changes in the way they view the world and themselves. Sources of Information To avoid misinformation when assessing a client (who may only be saying what he thinks the clini cian wants to hear), the assessor should try to gather information from the individual based on • Current events in the client's life (living arrange ments, etc.) • Input from family members and significant others ----------------------------------------------- 28 All information should be written whenever possi ble, but oral verifications from the client are also acceptable in certain circumstances. Clients who attend self-help meetings should be able to describe the meeting format, their reactions to the meetings, and the issues addressed. Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System • What the client has learned throughout the treatment process (do not just assume the client has learned something) • Observation of appearance (if the client is unemployed but wears expensive clothes and jewelry, drug dealing is suspect) • The impact treatment has had on the client (is he no longer associating with drug users?) • Information from sources in the criminal justice system (who can also verify information from other sources, such as a social services agency) Potential Conflict Between Systems With the same clients passing through both sys tems, coordination is imperative between treat ment and criminal justice. Information must be shared and kept up to date in order to address new client problems (arrests, parole violation, con tinued substance use). This will help allocate resources where they are most needed and avoid ----------------------------------------------- Treatment Planning and Treatment Progress 29 duplication of effort when handling such concerns as Social Security and Medicaid eligibility. Attrition and Non-Compliance Issues These problems should be anticipated early in treatment so that a criminal justice representative is aware and the problems may be prevented. There will always be certain nonnegotiable rules for a client in treatment, and the client must fully understand these rules and the consequences for violations. For more detailed information, see TIP 7, pp. 21–26. ----------------------------------------------- 30 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System SPECIAL ASSESSMENT ISSUES Guidelines to Use When Conducting Assessments • Determine who should do the assessment (see p. 9 for details) • Lay the groundwork for assessment first by providing the client with enough clear informa tion to motivate a participation in the assess ment process. Include information on the effects of substance abuse on society in a gen eral way (don't direct it towards the client) - The impact of substance abuse on relation ships with significant others - Empowerment issues: How addiction and abuse diminish an individual's self-determi- nation - HIV/AIDS, other sexually transmitted diseases, tuberculosis (If preassessment education is unavailable, gather information on the client's sense of self that can help with successful treatment.) - The belief system or world view of the client; whether he sees himself as a victim of cir cumstances or as an agent of his own fate ----------------------------------------------- Special Assessment Issues 31 - Whether the client has a relationship with a higher spiritual power - The client's sense of self-esteem • Address the client's basic needs: Some concerns may be related to - The trial date and what is expected in court - Fear of sexual victimization in jail or prison - Basic survival issues (homelessness, hunger, lack of employment) - Health issues (pregnancy, HIV, other STDs) - Withdrawal symptoms - Physical disability • Test the client's literacy level and English competence: Miscommunication can compro mise assessment if the client's native language and/or English skills are not properly assessed. • A two-way dialog between an equally motivated assessor and client must take place in order to build a trusting relationship. - The assessor must communicate an attitude of sincerity, empathy, and understanding to the client. - Help elicit the client's "story," write it down, and ask the client to modify it, thereby taking responsibility for his role in the substance ----------------------------------------------- 32 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System abuse and involvement in the criminal jus tice system. • Ethnicity and Culture: The assessor must be familiar with cultures other than her own and have a knowledge of the substance abuse pat terns in these specific cultures. The assessor must be able to handle issues related to ethnic and class bias, gender and sexual bias, sexual harassment, and cultural and linguistic sensitivi ty, competency, and diversity. • Gender: Understand the differences between the genders, especially the roles in which they view themselves, and address them accordingly. Many incarcerated men feel a loss of identity in the traditional roles—as men, as fathers, hus bands, providers. Their loss of freedom and access to alcohol and drugs leads to feelings of vulnerability and powerlessness. Women may also feel levels of incompetency (as mothers, working women, wives). An assessment of parenting skills and responsibility for child care should be included in the assessment of all women clients. Other issues to consider during assessment are - Whether the woman is in substance abuse withdrawal - History of violence or rape ----------------------------------------------- Special Assessment Issues 33 - Underemployment, poor and hazardous working patterns (prostitute, drug dealer) - Poor health care, inadequate birth control - Limited educational opportunities - Inadequate support for aging and single parents - Guilt associated with concept of a "bad mother" • Age: Factors vary when substance abuse begins at different ages. Rehabilitation may be more difficult for those who began substance use at an early age. • Spirituality: Treatment can be enhanced by a client's spirituality, and although spiritual and creative development can't be assessed, it is possible to determine a client's external value system and incorporate that into assessment. • Health issues have an impact on recovery from substance abuse. The following are health areas requiring special assessment: - Nutrition, weight, and eating disorders - Dental hygiene - HIV/AIDS and other STDs - Endocrine disorders (diabetes) - Sleep disorders ----------------------------------------------- 34 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System - Cardiovascular disorders - Mental status (depression, withdrawal, etc.) • A history of physical or sexual abuse should be taken and the treatment plan individualized based on the client's situation. It is recommend ed that the assessor be from outside the facility to ensure confidentiality and objectivity. • Risk for HIV and STDs: (See TIP 7, p. 33 for questionnaire to gather information for assess ment of risk.) • There is a close relationship between mental health issues and substance abuse. The men tal health assessment, conducted by a trained mental health clinician, should look for the fol lowing: - Signs and symptoms of depression - Sleeping disorders - Recurrent dreams and nightmares - Symptoms of psychotic disorders, such as hallucinations - Symptoms of dissociative disorders, such as "losing time" - Self-mutilation and thoughts of self-injury - Suicidal thoughts ----------------------------------------------- Special Assessment Issues 35 • The individual safety of the client has direct bearing on the client's chance for relapse. This includes while she is incarcerated (sexual abuse, gangs) and when she is released (going to a drug-free environment). • The potential for relapse in substance users is largely dependent upon three factors: - Duration of treatment (the longer, the better) - Duration of time before relapse (the longer the client stays abstinent, the better the chance for continued abstinence - Duration of substance use following relapse (if the client seeks treatment immediately after relapsing, the greater the chance for success) The potential triggers for relapse are • Availability of alcohol and drugs in home and neighborhood • Anger or stress • Situations that repeat past traumas • Sexual partners who are substance users • Reactions to anniversaries or holidays • Fears of failure or actual failure in critical life experiences • Newfound freedom to have choices ----------------------------------------------- 36 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System • Having money for the first time in a long while For more detailed information, see TIP 7, pp. 27–35. ----------------------------------------------- Legal and Ethical Issues 37 LEGAL AND ETHICAL ISSUES It is the responsibility of the courts, correctional systems, and treatment programs to make screen ing, assessment, and treatment choices available to people with substance abuse problems. Coordination among these systems raises legal and ethical issues including • The responsibility of the systems to advocate for more substance abuse treatment services • The guidelines used to allocate treatment slots • The need to avoid overzealous participation by law enforcement in the "recruitment" of poten tial clients for treatment • The courts' responsibility to determine the effec tiveness of mandated treatment • The need to protect the confidentiality rights and other rights of criminal justice clients in treatment Priorities for Use of Scarce Resources Criminal justice clients can be grouped into four categories when setting resource priorities: 1. Young people who have been abusing alcohol and drugs for a brief period of time and have not experienced serious negative consequences of substance abuse. ----------------------------------------------- 38 Confidentiality: Protecting the Rights of Clients There are many legal and ethical issues that the staff of substance abuse treatment programs need to know. For a complete description of the client's privacy rights and the rules staff must fol low, see TIP 7, pp. 38–45. Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System 2. Individuals whose substance abuse has caused a personal crisis that could motivate them to participate in treatment. 3. Individuals who have had substance abuse problems for 5 or more years and have experi enced negative consequences, but have not yet "hit bottom." 4. Career criminals with substance abuse prob lems. The first two categories are the early stages of substance-abusing careers. They are primary tar gets for assessment and services. Exceptions to the Federal Confidentiality Rule Federal regulations permit the disclosure of infor mation that identifies someone as a substance abuser without consent in the following circum stances: ----------------------------------------------- Legal and Ethical Issues 39 1. Communications that do not disclose patient- identifying information. 2. Court-ordered disclosures: State or Federal court may issue an order for a program to dis close information about an offender that would otherwise be forbidden. The court must find "good cause" for doing so. 3. Medical emergencies: Disclosures to medical personnel for the purpose of treating a condi tion which poses an immediate threat to the health of the offender or any other individual. The following information must be documented in the offender's records. • The name and affiliation of the recipient of the information • The name of the individual making the disclosure • The date and time of the disclosure • The nature of the emergency 4. Crimes on program premises or against pro gram personnel: Regulations permit the pro gram to report the crime to a law enforcement agency. 5. Sharing information with an agency that pro vides services to the program: If a program needs to do this, it can enter into a qualified ----------------------------------------------- 40 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System service organization agreement (QSOA). This acknowledges that • In receiving, storing, processing, or otherwise dealing with any patient records from the program, he or she is fully bound by the Federal confidentiality regulations. • The agency promises that, if necessary, it will resist in judicial proceedings any efforts to obtain access to patient records except as permitted by these regulations. 6.Internal program communications: some infor mation is permitted to be disclosed within the same program. 7. Reporting child abuse and neglect: If there is reasonable cause, the agency is required to report it. This includes educators and social workers as well as physicians. 8.Research, audit, or evaluation: Providing certain safeguards are met, information may be dis closed without patient consent. For more detailed information, see TIP 7, pp. 37–38; pp. 46–49. ----------------------------------------------- Glossary 41 GLOSSARY Arrest: Holding in legal custody, either at the scene of a crime or as a result of investigations. Assessment: Evaluation or appraisal of a candi date's suitability for substance abuse treatment and placement in a specific treatment modality/setting. Day reporting center: Place where offenders must report while on probation or parole to receive supervision. Day reporting centers may include educational services, vocational training, treatment, and other service deliveries. Drug testing: Technical examination of urine sam ples to determine the presence or absence of specified drugs or their metabolized traces. Infectious disease risk assessment: Evaluation of a substance abuser's risk for sexually transmit ted diseases, tuberculosis, HIV/AIDS, and other infectious diseases, including information regard ing current and past history, screening, and treat ment of such diseases. Testing and referral for treatment are recommended for the substance abuser assessed as at high risk for such diseases. The substance abuser assessed as at low risk should be reassessed intermittently. ----------------------------------------------- 42 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System Jail: To hold a person in lawful custody, usually while he or she is awaiting trial. In some jurisdic tions, jails are used punitively for offenders serv ing short-term sentences or sentences to work release or weekends in jail. Parole: Process of being released from prison before the completion of a sentence. Parole involves supervision and other stipulations and prohibitions on certain activities imposed by a board of parole. Prison: Secure institution in which offenders are confined after sentencing for crimes. Prisons are classified as minimum, medium, or maximum security facilities, based on the need for internal institutional fortification. Probation: Sentence of community-based supervi sion. Probation includes stipulations and prohibi tions on certain activities and often includes fines imposed by the court at the time of sentencing. Relapse prevention: Strategy to train substance abusers to cope more effectively and to overcome the stressors/triggers in their environments that may lead them back into drug use and dependency. Treatment: Any intervention that many change behavior. Substance abuse treatment involves planned, therapeutic intervention, with the ulti- ----------------------------------------------- Glossary 43 mate goal of the client discontinuing the sub stance use or abuse. Substance abuse treatment generally consists of specific modalities designed to meet a client's need for structure. For more detailed information, see TIP 7, Criminal Justice Treatment Planning Chart foldout. ----------------------------------------------- 44 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System ----------------------------------------------- Ordering Information TIP 7 Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System TIP 7-Related Products KAP Keys for Clinicians based on TIP 7 Do not reproduce or distribute this publication for a fee without spe cific, written authorization from the Office of Communications, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. Easy Ways to Obtain Free Copies of All TIP Products 1. Call SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI) at 800-729-6686, TDD (hearing impaired) 800-487-4889 2. Visit CSAT's Website at www.csat.samhsa.gov ----------------------------------------------- Other Treatment Improvement Protocols (TIPs) that are relevant to this Quick Guide: DHHS Publication No. (SMA) 01-3555 Printed 2001 TIP 12, Combining Substance Abuse Treatment With Intermediate Sanctions for Adults in the Criminal Justice System (1994) BKD144 TIP 17, Planning for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice System (1995) BKD165 TIP 21, Combining Alcohol and Other Drug Abuse Treatment With Diversion for Juveniles in the Justice System (1995) BKD169 TIP 23, Treatment Drug Courts: Integrating Substance Abuse Treatment With Legal Case Processing (1996) BKD205 TIP 30, Continuity of Offender Treatment for Substance Use Disorders (1998) BKD304