Transcript Screening Assessment and Targeting Vermont

Assessments
and Targeting
What a match!
What the heck is a
Biopsychosocial assessment??
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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!
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Definitions
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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
When screening results are
indicative of a substance
abuse problem, the participant
is accepted into the program
and referred for a bio-psychosocial assessment.
Treatment
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
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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
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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?
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It depends on the time of contact with the
target individual!
Law Enforcement can screen!
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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:
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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!
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Public Defenders
Jail and O.R. systems
Probation violations
CAGE Questionnaire
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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?
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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!
www.alcoholscreening.org
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.
www.alcoholscreening.org
Other quick alcohol screens
TCU Drug Dependence Screen (DDS;
Simpson et al., 1997)
MAST-25 questions-often used
 www.alcoholscreening.org
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Sometimes there are issues
of veracity and denial…
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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:
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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
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Results of urine, breath or blood testing
Problems with
 family
 Social integration
 Employment
 Housing
 Financial instability
 homelessness
Screening & Assessment Issues
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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!
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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
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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 !
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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.
2.
3.
4.
5.
Pre-contemplation
Contemplation
Preparation
Action
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. 1992 Vol7(2) 133-142.
Montague, D.D. (2000) Brief therapy: Using stages-of-change. The addiction
Messenger, 3, 23-25.
Assessments
Are more in depth.
 Can take up to 3 hours
 Provide more detailed information
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Assessment issues to cover
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Personal and family history
Legal history-arrests, domestic violence,
violent convictions, and juvenile history
History of substance abuse and treatmenttypes of drugs used and preferences
Mental health history, suicide, psychiatric
hospital admissions, and counseling
Known developmental problems
Assessment issues
continued…
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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
DWI Recidivism: Risk
Implications for Community
Supervision
http://www.uscourts.gov/uscourts/FederalCourts/PPS/Fedpr
ob/2011-12/risk.html
OR, google DWI-R ! Great study.
Assessment Instruments
(validated)
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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!!!
So, what are they looking at?
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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.
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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
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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
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Texas region specific instruments coming!
Roll out soon!
T-RAS is based on the Ohio instrument
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Ohio’s does four discreet target opportunities at
intake/phase of conduct
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Pretrial
Community Supervision
Prison Intake
Community Reentry.
Parole Supervision
ASAM Placement Criteria
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Early Intervention
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Opioid Maintenance
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Outpatient
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Intensive Outpatient
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Clinically Managed
Low Intensity
Residential
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Medium Intensity
Residential
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High Intensity
Residential
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Med Monitored
Intensive
Inpatient
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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.
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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:
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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 CARE
I
OUTPT
II
INT OP
III
MED MON
INPT
IV
MED MGD INPT
Withdrawal
No risk
Minimal
Some risk
Severe risk
Medical
Complications
No risk
Manageable
Medical
monitoring
24 hr acute med
care
Psych/Behav
Complications
No risk
Mild severity
Moderate
24 hr psy &
addiction tx
required
Readiness for
Change
Cooperative
Cooperative
but requires
structure
High Resist,
needs 24 hr
monitoring
Relapse Potential
Maintains
Abstinence
Needs close
monitoring
Unable to
control use
Recovery
Environment
Supportive
Differential
Danger to
recovery
Psychopathy Scales
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Hare Psychopathy ChecklistRevised (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
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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
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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
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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…
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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
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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.
Targeting Dispositions
by Risks & Needs
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.
Helen Harberts
Chico CA
[email protected]
Dispositions for Drug Offenders
Psychosocial Functioning
Pre-plea diversion
(ARD)
Incarceration
Drug Courts
Disposition before
judgment (Prop. 36)
Intermediate
sanctions
Drug Courts target select populations:
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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.
2.
3.
Binge pattern
Cravings or compulsions
Withdrawal symptoms
Substance Abuse
}
Abstinence is a distal goal
}
Abstinence is a proximal goal
Collateral needs
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Co occurring disorder diagnosis
Chronic medical condition (e.g., HIV+, HCV, diabetes)
Homelessness, chronic unemployment
Risk & Needs Matrix
High Risk
High
Needs
Low
Needs
Low Risk
Risk & Needs Matrix
High Risk
High
Needs
Low
Needs
Accountability,
Treatment &
Habilitation
Low Risk
Risk & Needs Matrix
High
Needs
Low
Needs
High Risk
Low Risk
Accountability,
Treatment &
Habilitation
Treatment
&
Habilitation
Risk & Needs Matrix
High Risk
Low Risk
High
Needs
Accountability,
Treatment &
Habilitation
Treatment
&
Habilitation
Low
Needs
Accountability
&
Habilitation
Risk & Needs Matrix
High Risk
Low Risk
High
Needs
Accountability,
Treatment &
Habilitation
Treatment
&
Habilitation
Low
Needs
Accountability
&
Habilitation
Prevention
Practice Implications
High Risk
High
Needs
Low
Needs
Low Risk
 Noncompliance hearings
 Status hearings
 Treatment & habilitation  Treatment & habilitation
 Compliance is proximal  Treatment is proximal
 Restrictive consequences
 Positive reinforcement
 Positive reinforcement
 Agonist medication
 Agonist medication
 v.o.p. / status calendar
 Abstinence is proximal
 Secondary prevention
 Psychosocial habilitation  Abstinence is proximal
 Restrictive consequences  No AA or MET
 No AA or MET
 Individual counseling
or stratified groups
 Antagonist medication
Dispositions for Drug Offenders
Risk of
Dangerousness
High risk
High needs
Low risk
Low needs
Low risk
High needs
Pre-plea diversion
(ARD)
High risk
Low needs
Drug Courts
Disposition before
judgment (Prop. 36)
Incarceration
Intermediate
sanctions