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What’s New in Screening and Assessment Instruments for CoOccurring Disorders in the Justice System? Florida Partners in Crisis, 2014 Annual Conference and Justice Institute July 1, 2014 Roger H. Peters, Ph.D., [email protected] Goals of this Presentation Review: • Challenges in screening and assessment of cooccurring disorders in the justice system • Evidence-based screening, assessment, and diagnostic instruments • Risk assessment approaches • Strategies to enhance accurate assessment of co-occurring disorders 2 Importance of Screening and Assessment for CODs High prevalence rates of behavioral health and related disorders in justice settings Persons with undetected disorders are likely to cycle back through the justice system Allows for treatment planning and linking to appropriate treatment services Offender programs using comprehensive assessment have better outcomes 35 Prevalence of Mental Illness in Jails and Prisons Percentage of Population Serious Mental Disorders among Offenders and the General Population Sources: General Population (Kessler et al.,1996), Jail (Steadman et al., 2009), Prison (Ditton 1999) Co-Occurring Substance Use Disorders 74% of state prisoners with mental problems also have substance abuse or dependence problems Source: U.S. Department of Justice, 2006 Eligibility Screening and Co-Occurring Disorders • Excluding offenders with mental disorders is NOT a viable option • You already work with these individuals AND can be more effective • Determine eligibility for services • Triage to specialized COD services Challenges in Selecting Screening Instruments • • • • • Proliferation of screening instruments Use of non-standardized instruments Instruments not validated in justice settings Absence of comparative data Direct to consumer marketing of instruments with poor psychometric properties (e.g., SASSI) Use of Self-Report Data • Provides unique information regarding substance use, mental health, and CODs • Accuracy of self-report information from offenders is moderately good • Increased accuracy when collateral sources (e.g., drug tests) compiled before self-report • Mediators of accuracy: Type of substance use, age, race/ethnicity, gender, perceived consequences of reporting, prior SA tx How to Select Screening and Assessment Instruments • • • • Reliability and validity of instruments Ease of use and training requirements Cost and availability Examine use and psychometric properties in justice settings Key Screening Domains for Co-Occurring Disorders • • • • • • Mental disorders Substance use disorders Trauma/PTSD Suicide risk Motivation Criminal risk level Focus on High Needs for Substance Abuse Treatment • The higher the severity of substance use problems, the higher the level of treatment services needed • Offenders with low severity substance use problems may not require treatment • Mixing persons with high and low levels of substance use treatment needs is contraindicated How do you Determine High Needs for SA Treatment? • Use of screening and assessment - Screening to flag severe substance use problems - Assessment to determine level of services needed - Usually involves used of formal instruments • Identify a “problematic pattern of use, leading to significant impairment or distress” (DSM-V) - Formerly - drug or alcohol “dependence” - New severity ratings: “mild”, “moderate”, “severe”, based on number of symptoms related to substance use Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) Substance Use Screening Instruments Simple Screening Instrument (SSI) Texas Christian University Drug Screen-II (TCUDS-II) Correctional Mental Health Screen (CMHS) Mental Health Screening Instruments Mental Health Screening Form-III (MHSF-III) Correctional Mental Health Screen (CMHS) and Texas Christian University Drug Screen-II (TCUDS-II) Screening Instruments for CoOccurring Disorders Mini International Neuropsychiatric Interview-Screen (MINI Screen) Screening for Trauma and PTSD • All offenders should be screened for trauma history; rates of trauma > 75% among female offenders and > 50% among male offenders • The initial screen does not have to be conducted by a licensed clinician • Many non-proprietary screens are available • Positive screens should be referred for more comprehensive assessment Trauma and PTSD Screening Issues • PTSD and trauma are often overlooked in screening • Other diagnoses are used to explain symptoms • Result - lack of specialized treatment, symptoms masked, poor outcomes Trauma History Screen (THS) Life StressorChecklist (LSC-R) Posttraumatic Symptom Scale (PSS-I) Trauma and PTSD Screening and Assessment Instruments Posttraumatic Diagnostic Scale (PDS) Primary Care PTSD Screen (PC-PTSD) PTSD Checklist – Civilian Version (PCL-C) Screening and Assessment of Criminal Risk Level • Goal is to match level of services to risk level • Improved outcomes if focus on moderate to high risk offenders - Providing intensive treatment and supervision for low risk offenders can increase recidivism - Mixing risk levels is contraindicated • Higher risk offenders require greater structure, and more intensive treatment and supervision How is Level of Risk Determined? • Risk for criminal recidivism • Use of risk assessment - ‘Static’ factors (e.g., criminal history) - ‘Dynamic’or changeable factors that are targets of interventions in the criminal justice system Risk-Need-Responsivity Approach • Interventions should target Dynamic Risk Factors for criminal recidivism (e.g., antisocial attitudes, criminal peers, substance use) • Focus on offenders who have a High Need for substance use treatment • Responsivity - Tailor services to enhance engagement in evidence-based interventions (e.g., by addressing mental health needs) Dynamic Risk Factors for Criminal Recidivism 1. Antisocial attitudes 2. Antisocial friends and peers 3. Antisocial personality pattern 4. Substance use 5. 6. 7. 8. Family and/or marital problems Lack of education Poor employment history Lack of prosocial leisure activities Offenders with Mental Illness have Higher Levels of Criminogenic Risk Key Criminogenic Risks ** Antisocial attitudes and beliefs Antisocial peers Antisocial personality features Substance use disorders Family/marital problems Lack of education Poor employment history Few prosocial/leisure skills Skeem, Nicholson, & Kregg (2008), National Reentry Resource Center, 2012 Risk Assessment Instruments Historical-Clinical-Risk Management - 20 (HCR-20) Level of Service Inventory - Revised – Screening Version (LSI-R-SV) Ohio Risk Assessment System (ORAS) Psychopathy Checklist - Screening Version (PCL-SV) Risk and Needs Triage (RANT) Short-Term Assessment of Risk and Treatability (START) Violence Risk Scale (VRS): Screening Version Texas Christian University Motivation Form (TCUMot) Motivation and Readiness for Treatment University of Rhode Island Change Assessment (URICA) Adult Suicidal Ideation Questionnaire (ASIQ) Screening for Suicide Risk Beck Scale for Suicide Ideation (BSS) Interpersonal Needs Questionnaire (INQ) and Acquired Capability Suicide Scale (ACSS) Screening and Assessment for Risk, Need, and Responsivity What’s the difference between: - Risk screening and assessment - Screening for high substance use needs - Screening/assessment related to responsivity issues - Clinical assessment Assessment Considerations – Psychosocial Functioning • Cognitive impairment • Reduced motivation • Impairment in social functioning (Bellack, 2003) Assessment Considerations – Substance Use • Substance use can mimic all major mental disorders • Strategies to gauge the potential effects of substance use on psychiatric symptoms: - Use drug testing to verify abstinence - Take a longitudinal history of MH and SA symptom interaction - Compile diagnostic impressions over a period of time - Repeat assessment over time Enhancing Accuracy of Screening and Assessment • Maintain high index of suspicion for mental disorders • Use non-judgmental approach and motivational interviewing techniques • Gather substance use information before mental health information • Supplement self-report with collateral information 30 Target Areas for Assessment - I • Scope and severity of MH and SU disorders • Pattern of interaction between the disorders • Conditions associated with occurrence and maintenance of the disorders • Antisocial attitudes, peers, personality features • Motivation for treatment • Family and social relationships • Physical health status and medical history Target Areas for Assessment - II • Education and employment history • Personal strengths and skills • Areas of functional impairment: • Cognitive capacity • Communication and reading skills • Capacity to handle stress • Ability to participate in group interventions • Level of care required (e.g., ASAM) Substance Use Disorders Mental Disorders Psychosocial Background and History Clinical Assessment Domains for CODs Interactive Nature of Disorders Risk Assessment Functional Impairment Substance Use Assessment Instruments Addiction Severity Index (ASI) Global Appraisal • GAIN-Quick of Individual • GAIN-Initial Needs (GAIN) Texas Christian University - IBR • Short Forms • Brief Intake Interview • CJ Comprehensive Intake Personality Assessment Inventory (PAI) Alcohol Use and Associated Disabilities Interview-IV (AUDADIS-IV) Instruments to Assess and Diagnose CoOccurring Disorders MINI International Neuropsychiatric Interview (MINI) Structured Clinical Interview for DSM-5 (SCID-5) Quadrant Model for Prioritizing COD Services in the Justice System High Alcohol and Other Drug Abuse Severity III Low severity mental disorder IV High severity SU disorder High severity mental disorder II I Low severity mental disorder Low Low severity SU disorder High severity mental disorder Low severity SU disorder High Severity Mental Illness Source: Adapted from NASADAD and NASMHPD, 1999 High severity SU disorder Severity Summary of Key Points • Several key challenges in screening and assessment • Screen across multiple domains related to cooccurring disorders: MH, SA, trauma/PTSD, criminal risk • Many evidence-based instruments available for: - Mental disorders - Substance use disorders - Co-occurring disorders - Criminal risk • Several strategies to enhance accuracy of screening and assessment