Screening and Assessment of Co-Occurring Disorders in the Justice System

Screening and Assessment of Co-occurring Disorders in the Justice System

U.S. Department of Health and Human Services and Mental Health Services Administration Acknowledgments This report was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) by Policy Research Associates, Inc. under SAMHSA IDIQ Prime Contract #HHSS283200700036I, Task Order #HHSS28342003T with SAMHSA, U.S. Department of Health and Human Services (HHS). The original report was authored by Roger H. Peters, PhD, Elizabeth Rojas, MA, and Marla G. Bartoi, PhD of the Louis de la Parte Florida Mental Health Institute, University of South Florida. David Morrissette, PhD, served as the Contracting Officer Representative.

Disclaimer The views, opinions, and content of this publication are those of the author and do not necessarily reflect the views, opinions, or policies of SAMHSA or HHS. Nothing in this document constitutes a direct or indirect endorsement by SAMHSA or HHS of any non-federal entity’s products, services, or policies, and any reference to non-federal entities’ products, services, or policies should not be construed as such.

Public Domain Notice All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS.

Electronic Access and Copies of Publication This publication may be downloaded at http://store.samhsa.gov. Or, call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

Recommended Citation Substance Abuse and Mental Health Services Administration. Screening and Assessment of Co-occurring Disorders in the Justice System. HHS Publication No. PEP19-SCREEN-CODJS. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015.

Originating Office Office of Behavioral Health Equity and Justice Informed, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, MD 20852. HHS Publication No. PEP19-SCREEN-CODJS

Nondiscrimination Notice SAMHSA complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. SAMHSA cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad, o sexo.

Originally printed in 2015 Revised June 2019 Contents

Executive Summary...... 1

Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System...... 5

Prevalence and Significance of Co-occurring Disorders in the Justice System...... 5 Defining Co-occurring Disorders...... 7 Changes to the DSM-5 Diagnostic Classification System 8 Distinguishing between Co-occurring Disorders: Differential Diagnoses 10 Importance of Screening and Assessment for Co-occurring Disorders in Justice Settings.. 11 Opportunities for Screening and Assessment...... 13 Intercept 0: Community Services 13 Intercept 1: Law Enforcement 14 Intercept 2: Initial Detention/Initial Court Hearings 15 Intercept 3: Jails/Courts 16 Intercept 4: Reentry 17 Intercept 5: Community Corrections 17 Defining Screening and Assessment...... 18 Screening 19 Assessment 20 Developing a Comprehensive Screening and Assessment Approach...... 24 Key Information To Address in Screening and Assessment for Co-occurring Disorders...26 Risk Factors for Co-occurring Disorders 26 Observable Signs and Symptoms of Co-occurring Disorders 27 Indicators of Mental Disorders 27 Indicators of Substance Use Disorders 27 Cognitive and Behavioral Impairment 27 Other Psychosocial Areas of Interest 29 Criminal Justice Information 29 Drug Testing 30 Enhancing the Accuracy of Information in Screening and Assessment...... 36 Symptom Interaction between Co-occurring Disorders 36 Accuracy of Self-report Information 37 Use of Collateral Information 38

iii Screening and Assessment of Co-Occurring Disorders in the Justice System

Use of an Extended Assessment Period 39 Other Strategies To Enhance the Accuracy of Screening and Assessment Information 40 Special Clinical Issues in Screening and Assessment for Co-occurring Disorders in the Justice System...... 41 Risk Assessment 41 Evaluating Suicide Risk 44 Trauma History and Posttraumatic Disorder (PTSD) 47 Motivation and Readiness for Treatment 49 Cultural Issues Related to Screening and Assessment 52 Staff Training 54

Instruments for Screening and Assessing Co-occurring Disorders...... 57

Key Issues in Selecting Screening and Assessment Instruments...... 57 Comparing Screening Instruments...... 58 Recommended Screening Instruments...... 58 Issues in Conducting Assessment and Diagnosis 61 Recommended Instruments for Assessment and Diagnosis of Co-occurring Disorders...62 Screening Instruments for Substance Use Disorders...... 63 Changes to the DSM-5 Diagnostic Classification System 64 Screening Instruments 64 Recommendations for Substance Use Screening Instruments 86 Screening Instruments for Mental Disorders...... 86 Screening Instruments for 87 General Screening Instruments for Mental Disorders 91 Recommendations for Mental Health Screening Instruments 100 Screening Instruments for Co-occurring Mental and Substance Use Disorders...... 100 Recommendations for CODs Screening Instruments 108 Screening and Assessment Instruments for Suicide Risk...... 109 Suicide Risk Screening Instruments 110 Suicide Risk Assessment Instruments 114 Recommendations for Suicide Risk Screening Instruments 114 Screening and Diagnostic Instruments for Trauma and PTSD...... 115 Changes to the DSM-5 Diagnostic Criteria for PTSD 116 Screening Instruments for Trauma/PTSD 116 Screening Instruments for Traumatic Life Events and Associated Symptoms 124 Diagnostic Instruments for PTSD 130 Recommendations for Trauma/PTSD Screening, Assessment, and Diagnostic Instruments 134 Screening Instruments for Motivation and Readiness for Treatment...... 135

iv Contents

Screening Instruments for Motivation and Readiness for Treatment 135 Recommendations for Motivational Screening Instruments 146 Assessment Instruments for Substance Use and Treatment Matching Approaches..... 146 Identifying Gaps in Offender Services 147 Treatment Matching Approaches 147 Substance Use Assessment Instruments and Treatment Matching 153 Recommendations for Assessment of Substance Use and Treatment Matching 163 Assessment Instruments for Mental Disorders...... 163 Recommendations for Assessment of Mental Disorders 172 Assessment and Diagnostic Instruments for Co-occurring Mental and Substance Use Disorders...... 172 Assessment Instruments for Co-occurring Mental and Substance Use Disorders 172 Diagnostic Instruments for Co-occurring Mental Health and Substance Use Disorders 178 Recommendations for Assessment and Diagnosis of CODs 188

Suggested Reading...... 189

References...... 191

Contributors...... 257

Figures and Tables

Figure 1. The Sequential Intercept Model...... 13 Figure 2. Intercept 0: Community Services...... 14 Figure 3. Intercept 1: Law Enforcement...... 14 Figure 4. Intercept 2: Initial Detention/Initial Court Hearings ...... 15 Figure 5. Intercept 3: Jails/Courts...... 16 Figure 6. Intercept 4: Reentry...... 17 Figure 7. Intercept 5: Community Corrections...... 18 Table 1. Comparison of Alternate Drug Testing Methodologies...... 34 Figure 8. Recommended Screening Instruments...... 59 Figure 9. Recommended Assessment Instruments...... 63

v

Executive Summary

This monograph examines a wide range of evidence-based practices for screening and assessment of people in the justice system who have co-occurring mental and substance use disorders (CODs). Use of evidence-based approaches for screening and assessment is likely to result in more accurate matching of offenders to treatment services and more effective treatment and supervision outcomes (Shaffer, 2011). This monograph is intended as a guide for clinicians, case managers, program and systems administrators, community supervision staff, jail and prison booking and healthcare staff, law enforcement, court personnel, researchers, and others who are interested in developing and operating effective programs for justice-involved individuals who have CODs. Key systemic and clinical challenges are discussed, as well as state-of-the art approaches for conducting screening and assessment.

The monograph also reviews a range of selected instruments for screening, assessment, and diagnosis of CODs in justice settings and provides a critical analysis of advantages, concerns, and practical implementation issues (e.g., cost, availability, training needs) for each instrument. A number of the evidence-based instruments described in this monograph are available in the public domain (i.e., are free of charge) and can be downloaded on the internet.

Not all of the instruments described in this monograph are designed for universal use in screening or assessing for both mental and substance use disorders, and some may not be suitable for use with special populations or in specific justice settings. For example, the screening and assessment instruments described here are primarily designed for use with adults in the justice system, and many have not been validated for use with juveniles. Many of the assessment instruments reviewed in this monograph also require specialized training and clinical expertise to administer, score, and interpret. These considerations are explored in more detail in later sections of this monograph that review specific instruments.

A significant and growing number of people in the justice system have CODs. For example, over 70 percent of offenders have substance use disorders, and approximately 17–34 percent have serious mental illnesses—rates that greatly exceed those found in the general population (Baillargeon et al., 2010; Ditton, 1999; Lurigio, 2011; SAMHSA’s GAINS Center, 2004; Peters, Kremling, Bekman, & Caudy, 2012; Steadman, Osher, Robbins, Case, & Samuels, 2009; Steadman et al., 2013). Several populations, such as juveniles, female offenders, and veterans, are entering the justice system in increased numbers and have elevated rates of CODs, including substance use, trauma, and other mental disorders (Houser, Belenko, & Brennan, 2012; Pinals et al., 2012; Seal et al., 2011). These individuals often require specialized interventions to address their CODs and staff who are familiar with their unique needs.

People with CODs present numerous challenges within the justice system. These individuals can at times exhibit greater impairment in psychosocial skills and are less likely to enter and successfully complete treatment. They are at greater risk for criminal recidivism and relapse. The justice system is generally ill- equipped to address the multiple needs of this population, and few specialized treatment programs exist in jails, prisons, or court and community corrections settings that provide integrated mental health and substance use services (Lurigio, 2011; Peters et al., 2012; Peters, LeVasseur, & Chandler, 2004).

1 Screening and Assessment of Co-Occurring Disorders in the Justice System

A major concern is that the justice system does not have a built-in mechanism for personnel to identify individuals with these types of behavioral health issues, and there is all too often a failure to effectively screen and assess people with CODs who are in the justice system (Balyakina et al., 2013; Chandler, Peters, Field, & Juliano-Bult, 2004; Hiller, Belenko, Welsh, Zajac, & Peters, 2011; Lurigio, 2011; Peters et al., 2012; Taxman, Cropsey, Young, & Wexler, 2007; Taxman, Young, Wiersema, Rhodes, & Mitchell, 2007). The absence of adequate screening for CODs prevents early identification of problems; often undermines successful progress in treatment; and can lead to substance use relapse, recurrence of mental health symptoms, criminal recidivism, and use of expensive community resources such as crisis care and hospital beds (Peterson, Skeem, Kennealy, Bray, & Zvonkovic, 2014). Lack of screening for CODs also prevents comprehensive treatment/case planning, matching justice-involved people to appropriate levels of treatment and supervision, and rapid placement in specialized programs to address CODs (Lurigio, 2011; Mueser, Noordsy, Drake, & Fox, 2003; Peters et al., 2012).

Screening for CODs should be provided at the earliest possible point in the justice system to expedite consideration of these issues in decisions related to sentencing, release from custody, placement in institutional or community settings, and referral to treatment and other related services (Hiller et al., 2011). Screening provides a brief review of symptoms, behaviors, and other salient background information that may indicate the presence of a particular disorder or psychosocial problems. Results of screening are typically used to determine the need for further assessment. Assessment provides a lengthier and more intensive review of psychosocial problems that can lead to diagnoses and placement in different types or levels of treatment and supervision services.

Due to the high prevalence of CODs among offenders, screening and assessment protocols used in justice settings should address both types of disorders. The high prevalence of trauma and physical or sexual abuse among offenders indicates the need for universal screening in this area as well (Steadman et al., 2013; Steadman, Osher, Robbins, Case, & Samuels, 2009; Zlotnick et al., 2008). Mental health screening in the justice systems should include examination of suicide risk, as rates of suicidal behavior are elevated among offenders who have CODs. Motivation for treatment is an important predictor of treatment outcomes and can also be readily examined during screening in the justice system. Another important component of screening is drug testing, which can enhance motivation and adherence to treatment (Large, Smith, Sara, Paton, Kedzior, & Nielssen, 2012; Martin, 2010; Rosay, Najaka, & Hertz, 2007). Cultural differences should be considered when conducting screening and assessment, and staff training is needed to effectively address these issues.

Complexities in using certain screening and assessment tools early in criminal case processing include identifying issues that can be potentially incriminating (e.g., ongoing substance use). Jurisdictions may work out memoranda of agreement to ensure that screenings do not result in inadvertent further criminalization. The earlier in the criminal process a screening can be done (such as prior to arraignment), the better the chance of directing more individuals toward treatment without creating further legal difficulties.

Assessment and diagnosis are particularly important in developing a treatment/case plan and in determining specific problem areas that can be effectively targeted for treatment interventions and community supervision. Assessment tools generally involve somewhat more in-depth questioning than screening. Some can be administered by nonclinicians, while full assessments require someone with a clinical background to formulate diagnoses and develop robust treatment planning. Diagnostic instruments allow for a more focused and in-depth mechanism, the purpose of which is to delineate specific diagnoses to help codify what an individual may be experiencing symptomatically. The

2 Executive Summary diagnostic nomenclature can lead to “labeling,” but is utilized throughout health care to help communication among health professionals, inform treatment, and enhance consistency in therapeutic approaches. Key diagnostic instruments include the Structured Clinical Interview for DSM-IV (SCID). Use of this type of instrument results in identifying the diagnosis or diagnoses that most closely link to an individual’s reported symptom cluster.

Screening, assessment, and diagnostic information are vitally important in matching offenders to appropriate types of services, and to levels of intensity, scope, and duration of services. As described in more detail later in this monograph, key areas of information that contribute to effective treatment matching include (1) criminal risk level, and criminogenic needs that independently contribute to the risk for recidivism, (2) history of mental or substance use disorders and prior treatment, (3) functional assessment related to mental and substance use disorders, including the history of interaction between the disorders and the effects of these disorders on behaviors that lead to augmented risk for involvement in the justice system, (4) functional impairment related to the CODs that may influence ability to participate in different types of treatment or supervision services, and (5) other psychosocial factors that may affect engagement and participation in these services (e.g., transportation, housing, literacy, major medical problems). In the absence of a comprehensive and evidence-based assessment approach, CODs are often undetected in justice settings, leading to inappropriate placement (e.g., in low intensity services) and poor outcomes related to treatment and supervision.

In addition to the screening, assessment, and diagnostic instruments for use with offenders who have CODs, other instruments have been designed specifically to match people to different types of treatment modalities, or levels of care. Although traditionally considered a part of correctional supervision, the Risk, Need, and Responsivity (RNR) model (Andrews & Bonta, 2010a, 2010b) is increasingly used more systematically in the justice system to identify treatment and recovery needs that are related to criminal recidivism. The RNR model provides an important framework to assist in matching offenders to various levels of treatment and criminal justice supervision, and incorporates areas of criminal risk that are not addressed within typical clinical assessment tools.

Key issues related to screening and assessment of CODs in the justice system include failure to comprehensively examine one or more of the disorders, inadequate staff training to identify and assess the disorders, bifurcated mental health and substance use service systems that feature separate screening and assessment processes, use of ineffective and non-standardized screening and assessment instruments, and the absence of management information systems to identify people with CODs as they move from one point to another in the justice system. Another challenge in conducting screening and assessment is determining whether symptoms of mental disorders are caused by recent substance use or reflect the presence of an underlying (American Psychiatric Association [APA], 2013). Other important threats to the accuracy of screening and assessment information include the potentially disabling effects of CODs on memory and cognitive functioning and the perceived and sometimes real consequences in the justice system related to self-disclosure of mental health or substance use problems (Bellack, Bennett, & Gearon, 2007; DiClemente, Nidecker, & Bellack, 2008; Drake, O’Neal, & Wallach, 2008; Gregg, Barrowclough, & Haddock, 2007).

Staff training should be provided in the screening and assessment of CODs within the justice system. This training should address signs and symptoms of mental and substance use disorders; how symptoms are affected by recent substance use; strategies to engage offenders in the screening and assessment process; cultural considerations in conducting screening and assessment; approaches for enhancing

3 Screening and Assessment of Co-Occurring Disorders in the Justice System accuracy of information compiled; implementation of risk assessment; use of evidence-based screening, assessment, and diagnostic instruments; and use of assessment information to develop and update individualized treatment/case plans. A variety of online and other types of modules are available to train staff in the screening and assessment of CODs.

4 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System

Prevalence and Significance of Co- a quarter of offenders report other disorders, such occurring Disorders in the Justice as anxiety disorders (Grella et al., 2008; Zlotnick et al., 2008), and about half report any type of System mental disorder (James & Glaze, 2006). Use of The number of people entering the criminal conservative and more comprehensive diagnostic justice system has significantly increased in measures yields estimates of mental disorders that the past several decades. The population under range from 10 to 15 percent of people incarcerated correctional supervision in the United States rose in jails and prisons (Steadman et al., 2013). from 5.1 million adults in 1994 to a peak of 7.3 Rates of substance use disorders among justice- million in 2007 but has fallen each successive involved individuals are also significantly higher year (Brown, Gilliard, Snell, Stephan, & Wilson, than in the general population (Lurigio, 2011; 1996; Glaze & Kaeble, 2014). In 2013, the Steadman et al., 2013). Well over half of all total correctional population fell to 6.9 million incarcerated individuals have significant substance adults (Glaze & Kaeble, 2014). Approximately use problems (Baillargeon et al., 2010; Baillargeon 2.9 percent of the U.S. adult population is et al., 2009; James & Glaze, 2006; Lurigio, 2011; currently under some form of criminal justice Steadman et al., 2013). The lifetime prevalence supervision (Glaze & Herberman, 2013). The of DSM-IV The lifetime prevalence of DSM-IV significant growth in the justice system has substance use disorders among prisoners is over resulted from changes in drug laws and law 70 percent (Baillargeon et al., 2010; Baillargeon et enforcement practices and from the absence of al., 2009; Lurigio, 2011). These rates far surpass public services for people who have mental or those found in the general population (Robins substance use disorders, who are homeless, and & Regier, 1991; Lurigio, 2011; Steadman et al., who are impoverished. Mental disorders are 2013). Importantly, many of these individuals quite elevated in criminal justice settings such report that their crimes leading to the most recent as jails and prisons (Lurigio, 2011; Steadman et arrest were committed while using drugs or al., 2013). For example, individuals in prison are alcohol, and 86 percent of offenders report using diagnosed with at much higher rates illicit substances in their lifetime (Lurigio, 2011; than the general population (Grella, Greenwell, Mumola & Karberg, 2006). Prendergast, Sacks, & Melnick, 2008; Steadman et al., 2013). Recent estimates indicate that 17–34 An increasing number of individuals in jails, percent of jail inmates have a recent history of prisons, and community settings have both mental disorders (Steadman et al., 2009; Steadman mental and substance use disorders, or CODs, et al., 2013), including depressive disorders, which presents numerous challenges in providing bipolar disorders, and posttraumatic stress effective services (Baillargeon et al., 2010; James disorder (PTSD), while approximately 3 percent & Glaze 2006; Lurigio, 2011; Peters et al., 2012). of offenders have psychotic disorders (Grella et Studies indicate that 60–87 percent of justice- al., 2008; Steadman et al., 2013). Approximately involved individuals who have severe mental

5 Screening and Assessment of Co-Occurring Disorders in the Justice System disorders also have co-occurring substance use or even conflicting messages about recovery disorders (Abram & Teplin, 1991; Abram, Teplin, and interventions that are needed (e.g., use of & McClelland, 2003; Chiles, Cleve, Jemelka, medications). Integrated treatment approaches & Trupin, 1990; James & Glaze, 2006; Lurigio, that focus on the interactive nature of the two 2011; Peters et al., 2012; Steadman et al., 2013). types of disorders and that provide services by There are also high rates of co-occurring mental the same staff and within the same settings have disorders among offenders who have substance use been the most successful among non-offender and disorders, including those who are sentenced to offender samples (Lurigio, 2011; Mueser et al., substance use treatment (Baillargeon et al., 2010; 2003; Peters et al., 2012). Hiller, Knight, Broome, & Simpson, 1996; Lurigio et al., 2003; Lurigio, 2011; National Institute on Individuals with CODs present significant Drug Abuse [NIDA], 2008; Peters et al., 2012; challenges to those working in all areas of the Swartz & Lurigio, 1999). Overall, an estimated criminal justice system and other social service 24–34 percent of females and 12–15 percent of systems (National Alliance on Mental Illness, males in the justice system have CODs (Steadman Ohio, 2005; Peters et al., 2012). People with et al., 2009; Steadman et al., 2013). CODs are significantly more likely to be arrested (Balyakina et al., 2013). People with CODs Despite the high rates of CODs, relatively few often engage in drug use to alleviate symptoms justice-involved individuals are receiving adequate associated with serious mental disorders, treatment services for these disorders in jails, including difficulty sleeping, depression, anxiety, prisons, or other justice settings (SAMHSA’s and paranoia (Lurigio, 2011; Mueser, 2005), in GAINS Center, 2004; Peters et al., 2004; Peters addition to use that is driven by an inherent shift et al., 2012). Moreover, few existing specialized in brain chemistry. A major challenge involves CODs treatment programs have been developed the rapid cycling of people with CODs through in justice settings (Peters et al., 2004; Peters different parts of the criminal justice and social et al., 2012). This is due in part to the lack of service systems, including law enforcement, jail, available integrated treatment programs (Lurigio, community emergency services, and shelters. 2011). Traditionally, treatment programs in the These individuals are frequently unemployed, community and in correctional settings have homeless, and lacking in vocational skills, and adhered to either sequential or parallel treatment have few financial or social supports (Peters et models to address mental illness and substance al., 2012; Peters, Sherman, & Osher, 2008). This use. Sequential treatment involves treating one is due in part to functional impairment related to type of disorder at a time, with the underlying social, occupational, and cognitive functioning. assumption that either the mental health or For some individuals who have CODs, using is “primary” and must be and selling drugs is a way to experience social treated first. However, since this model does not connectedness and to create structure and a sense address the interactive nature of CODs, treating of meaning, in the absence of social contact related each type of disorder sequentially does not lead to employment, education, or activities with to positive long-term outcomes (Horsfall, Cleary, family and friends (Lurigio, 2011). Hunt, & Walter, 2009). Another approach involves parallel or concurrent treatment of both types of CODs are also associated with compromised disorders, allowing offenders to participate in psychosocial functioning, which places offenders treatment for these disorders simultaneously but at risk of a range of negative outcomes (Lurigio, with treatment services typically provided by 2011; Peters et al., 2012), including the following: different agencies. This approach has also led to ■■ Pronounced difficulties in employment, poor outcomes, does not deal with the intertwined education, family, and social relationships nature of CODs, and can provide confusing (e.g., social isolation)

6 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System

■■ Serious medical problems consistent with evidence-based practices ■■ Reduced ability to refrain from substance developed in non-justice settings (National use Institute on Drug Abuse, 2006). These programs are typically intensive and highly structured, and ■■ Premature termination from treatment provide case management and adaptations to ■■ Rapid progression from initial substance clinical services that address the complicated use to substance use disorder needs of offenders, including integrated dual ■■ Frequent hospitalization for mental disorder treatment (IDDT) and interventions to disorders address criminogenic risk factors (Peters et al., ■■ Housing instability or homelessness 2012; Kleinpeter, Deschenes, Blanks, Lepage, & ■■ Poor prognosis for completion of treatment Knox, 2006; Pinals, Most comprehensive ■■ Temporal instability in severity of Packer, Fischer, & symptoms related to mental and substance Roy-Bujnowski, 2004; programs in justice use disorders Smelson et al., 2012). settings provide ■■ Noncompliance with medication and Participants in an integrated treatment interventions correction-based treatment approach, treatment programs for ■■ High rates of depression and suicide consistent with CODs often show ■■ Poor level of engagement and participation positive treatment evidence-based in treatment outcomes, including practices… (National ■■ Criminal recidivism lower dropout rates in Institute on Drug comparison to When released from prison, jail, or residential Abuse, 2006) community treatment treatment facilities, people with CODs may not programs (Lurigio, have access to the medications that stabilized them 2011; Peters et al., 2012). Research indicates that prior to release and often experience difficulties comprehensive prison treatment programs for engaging in community mental health and drug CODs can significantly reduce recidivism, and that treatment services (Osher, Steadman, & Barr, the addition of community reentry services can 2002, 2003; Weisman, Lamberti, & Price, 2004). augment these positive outcomes (Lurigio, 2011; Other barriers to community integration include Peters et al., 2012; Sacks, Sacks, McKendrick, lack of affordable housing and transportation, Banks, & Stommel, 2004). barriers to accessing employment once one has a criminal record, and the termination of income supports and entitlements. Coordinating the Defining Co-occurring Disorders diverse medical, mental health, substance use, Several different terms have been used to describe and supervision needs of these individuals can be mental and substance use disorders that are present a daunting task and often requires the ability to simultaneously, including co-occurring disorders navigate among service systems, institutions, and (CODs), comorbidity, dual disorders, and dual agencies that have very different missions, values, diagnosis. These terms vary in their meaning organizational structures, and resources (Chandler and use across criminal justice settings. The term et al., 2004; Lurigio, 2011; Peters et al., 2012). “co-occurring disorders” has achieved acceptance Despite these challenges, an increasing number of within the practitioner and scientific communities CODs treatment programs have been successfully and within federal agencies over the past 25 implemented in justice settings (Peters et al., 2004, years and is most commonly used to indicate the 2012). Most comprehensive programs in justice presence of at least one mental disorder and at settings provide an integrated treatment approach, least one substance use disorder, as defined by

7 Screening and Assessment of Co-Occurring Disorders in the Justice System

DSM-5 (Diagnostic and Statistical Manual of and borderline personality disorders [BPD]). Mental Disorders; APA, 2013). In fact, many offenders who are involved in substance use and mental health treatment in People in the justice system with CODs typically the justice system have personality disorders, experience more than one mental disorder, including ASPD and BPD, in addition to their in addition to more than one substance use other disorders (Grant et al., 2008; Ruiz, Pincus, disorder. Mental disorders can cause significant & Schinka, 2008; Walter et al., 2009). People psychosocial impairment, and disorders like with characterological problems can typically be , major depressive disorder, and accommodated within treatment programs that psychotic disorders (e.g., schizophrenia) and focus on addressing “criminogenic needs,” such as related disorders (e.g., ) antisocial attitudes, beliefs, behaviors, and peers. can be some of the more disabling, although However, mixing people who have more predatory severity can differ across individuals. Other characterological disorders in specialized CODs conditions such as anxiety disorders, adjustment programs with others who have significant disorders, and other forms of depression are impairment related to bipolar disorder, depression, very common among people in the justice or may be problematic. First, people system but do not typically require specialized with pronounced characterological disorders may interventions for CODs. People with these be at higher risk for criminal recidivism, and it disorders can frequently receive adequate care is contraindicated to combine offenders who are in traditional mental health or substance use at significantly different risk levels in treatment treatment settings. Several other issues deserve and supervision services (Andrews & Bonta, consideration in identification and treatment 2010a, 2010b; National Association of Drug Court of CODs within the justice system, including Professionals [NADCP], 2013). Second, people developmental disabilities, learning disabilities, with more severe impairment related to CODs are sexual disorders, and personality disorders. While frequently victimized while in the justice system all of these issues present valid focal areas to be and may be more vulnerable to emotional and addressed in case/treatment planning, treatment, physical abuse when placed with offenders who and supervision, they generally do not involve are at higher criminal risk levels. Third, people the same level of impairment as bipolar disorder, with more severe impairment related to their major depressive disorder, and psychotic disorders mental or learning disorders require distinctive that co-occur with substance use disorders. People interventions, including medication management, in the justice system who have CODs are also basic life skills training, crisis stabilization, and significantly more likely than those in the general intensive case management. As a result of these population to have other major health disorders, concerns, it is important to carefully define the such as HIV/AIDS, diabetes, Hepatitis C, and target population for CODs services and to provide tuberculosis (TB), creating unique challenges rigorous screening and assessment to ensure that and opportunities for involvement in specialized scarce treatment resources within justice settings services and in treatment programs for CODs. are reserved for those who are in the greatest need Although there is a growing recognition of the and who stand to benefit the most. need for specialized services among people who have CODs in the justice system, there are Changes to the DSM-5 Diagnostic often pressures to refer individuals to CODs Classification System treatment services who have severe behavioral There have been several major changes in problems or more pronounced characterological diagnostic and classification approaches from and interpersonal problems (referred to as DSM-IV-TR (Diagnostic and Statistical Manual personality disorders, such as antisocial [ASPD] of Mental Disorders–Text Revision; APA, 2000)

8 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System to the more recent DSM-5 (APA, 2013) that affect substance use disorders is “cravings,” reflecting definitions of substance use, mental disorders, factors surrounding the intensity of desire for and CODs. Previous versions of DSM classified ongoing substance use. Criteria for diagnosing mental disorders by different “axes,” with Axis substance use disorders along the continuum of I denoting a major mental disorder (including current severity are as follows: “mild” severity substance use disorders), Axis II denoting a requires 2–3 symptoms, “moderate” severity and requires 4–5 symptoms, and “severe” requires 6 or (formerly known as mental retardation), and Axis more from a total of 11 symptoms (APA, 2013). III denoting other health disorders. Distinctions have traditionally been made between axes to Mental Disorders assist in identifying the differential impact of these Major changes have also been made to DSM- disorders. With the advent of DSM-5, disorders 5 diagnoses of mental disorders, including are no longer defined in terms of axes, and instead changes to criteria related to schizophrenia, all disorders can be identified but are not labeled bipolar disorder, and depressive and anxiety with any multi-axial distinction. disorders (APA, 2013). Schizophrenia is no longer categorized by subtypes (e.g., paranoid), Substance Use Disorders as diagnoses involving these subtypes do not The most important change to DSM-5 in defining appear to be distinctive and have low reliability substance use disorders is that there is no longer and . Similar to the revised classification a differentiation between “dependence” and of substance use disorders, a dimensional system “abuse.” These terms were eliminated due to the is now available to assess the severity of core lack of concordance between their respective symptoms related to specific mental disorders. categorical diagnoses and the severity of substance Changes to Criterion A of bipolar disorders use problems. For example, withdrawal symptoms include the addition of “noticeable changes in were often present (e.g., among those abusing energy level” in addition to changes in mood prescription opiates) even if the person was not (e.g., irritability, hyperactivity). In order to meet diagnosed as having a “dependence” disorder. diagnostic criteria for bipolar I: mixed episode, Substance use disorders are diagnosed by the type an individual no longer has to simultaneously of substance used (e.g., “Stimulant Use Disorder”). meet both manic and major depressive criteria, Alcohol use disorders are subsumed under the and instead, the term “mixed features” is used category of substance use disorders. Criteria for when an individual has both manic and depressive achieving a “substance use disorder” now exist symptoms. Depressive disorders now include along a continuum of “mild,” “moderate,” and additional disorders, such as “disruptive mood “severe,” combining the previously distinctive dysregulation disorder” for children up to age 18, DSM-IV abuse and dependence symptoms to and “premenstrual dysphoric disorder.” make up this continuum. One symptom, “legal is now categorized as a persistent depressive difficulties from drug use,” which was formerly disorder, although there have been no significant listed as a criterion for “substance abuse” is no changes to the diagnosis of major depressive longer present. One reason for this change is the disorder. Obsessive-compulsive disorder is now growing inconsistency between state criminal included in a new category entitled “obsessive laws that made for diagnostic differences. As compulsive and related disorders.” PTSD and laws related to marijuana emerge, including the are now included in a legalization of “medical marijuana” in some states diagnostic category entitled “trauma and stressor- and the decriminalization of marijuana possession related disorders.” Trauma can include experiences in others, this is an important change in diagnostic of vicarious trauma (e.g., experiences at home, classification. An important new criterion for work, or other settings), and PTSD criteria in the

9 Screening and Assessment of Co-Occurring Disorders in the Justice System

DSM-5 have changed regarding symptomatic after engaging in substance use. Similarly, expression, cognitive processing, and the like. assessment should consider whether engaging Detailed information regarding specific changes to in substance use was motivated by attempts to PTSD criteria is provided later in this monograph. alleviate symptoms of mental disorders (e.g., Finally, panic and are now two agitation, anxiety, depression, sleep disturbance). separate disorders rather than being classified as Other strategies to ascertain an accurate diagnostic with or without agoraphobia (APA, picture include establishing a temporal framework 2013). to better understand the relationship between substance use and mental health symptoms; for Distinguishing between Co-occurring example, investigating the presence of mental Disorders: Differential Diagnoses health symptoms following periods of abstinence A hallmark of CODs is the highly interactive (either voluntary or coerced) can help determine if nature of mental and substance use disorders and there is a causal relationship between the mental how each disorder affects the symptoms, course, and substance use disorders. Similar steps during and treatment of the other disorder. The American assessment should be taken to rule out mental Psychiatric Association (2013) describes a disorders occurring due to a general medical number of different ways in which the two sets of condition. disorders are interdependent and interactive: Evidence-based screening and assessment ■■ One disorder may predispose a person to strategies for justice-involved individuals who another type of disorder have CODs recognize the interactive nature of the ■■ A third type of disorder (e.g., chronic health disorders and the need for ongoing examination condition, such as HIV/AIDS) may affect of the relationship between the two disorders. or elicit the onset of mental or substance Attention to the interactive nature of the disorders use disorders should be reflected in ongoing assessment ■■ Symptoms of each disorder may be activities and use of repeated measures to assess augmented, as these often overlap between changes in the diagnostic picture and in symptoms mental and substance use disorders (e.g., and levels of impairment related to the two sets anxiety, depression [APA, 2013]) of disorders. Treatment planning, provision of ■■ Other disorders, such as borderline clinical services, and community supervision personality disorder (BPD, as classified by strategies should consider the interdependent DSM-IV), may predispose individuals to nature of the disorders. This approach does not more severe mental disorders such as major necessarily entail providing concurrent services depressive disorder and substance use for the disorders in equal intensity, but instead disorders prioritizes the sequence of services according ■■ Alcohol or other drugs may induce, or more to the presence of acute crises (e.g., suicidal frequently mimic or resemble, a mental behavior, intoxication) and areas of functional disorder impairment (e.g., cognitive impairment) that affect treatment participation. The focus of treatment As a result of the intertwined nature of mental at any given time should be on remediating areas and substance use disorders among people in of functional impairment caused by one or both the justice system, it is critically important to disorders, and the sequence of interventions should assess the recent and historical use of substances be dictated accordingly. to determine whether there were direct effects (e.g., symptom exacerbation) that resulted from substance use. For example, it is important to determine if mental health symptoms appeared

10 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System

Importance of Screening and the level of treatment services and supervision that Assessment for Co-occurring are needed. Disorders in Justice Settings Unfortunately, screening and assessment of issues related to CODs are not routinely conducted in People in the justice system with CODs differ many justice settings, and as a result, mental widely in type, scope, and severity of symptoms and substance use disorders are underidentified and in complications related to their disorders. and underdiagnosed (Abram & Teplin, 1991; Screening and assessment provide the foundation Balyakina et al., 2013; Hiller et al., 2011; for identification, triage, and placement in Lurigio, 2011; Peters et al., 2012; Peters et al., appropriate treatment interventions. Early 2008; Taxman, Cropsey et al., 2007; Taxman, identification is vitally important for people Young et al., 2007). In some justice settings, who have CODs to determine specialized needs identification of CODs is hampered by parallel during the period of initial incarceration, pretrial screening and assessment activities for mental release, sentencing/disposition, and reentry to the and substance use disorders. This approach community. Use of comprehensive screening and often leads to non-detection of CODs and other assessment approaches has been found to improve related issues, inadequate information sharing, outcomes among criminal justice populations that poor communication regarding overlapping areas have mental or substance use disorders (Shaffer, of interest, and failure to develop integrated 2011). service goals that address both mental health Many areas of psychosocial problems are and substance use issues (Fletcher et al., 2009; augmented among justice-involved individuals Lehman, Fletcher, Wexler, & Melnick, 2009; who have CODs, including risk for suicide, acute Taxman, Henderson, & Belenko, 2009). Another symptoms of mental disorders, history of trauma/ common problem is that information gathered in PTSD, homelessness, and lack of financial support community-based or other justice settings may not and transportation. The absence of a front-end follow the individual as he or she moves through integrated screening may exacerbate behavioral different points in the system, making it more problems that require placement in specialized difficult to make sound decisions about treatment, custody or intensive supervision settings and sentencing, and community release. undermine the effectiveness of treatment provided Common reasons for non-detection of CODs in the and is likely to delay placement in specialized justice system (Balyakina et al., 2013; Chandler diversion or in-custody programs designed for et al., 2004; Taxman et al., 2009; Fletcher et al., people with CODs. Lack of initial screening for 2009) include the following: multiple psychosocial problems may also delay completion of a more comprehensive clinical ■ Lack of staff training assessment to determine the scope, intensity, and ■ Short duration of time and limited duration of specialized services that are needed. resources provided for screening and Given that many people in the justice system with assessment in many correctional settings CODs are at high risk for recidivism, screening ■ Lack of established protocols related to and assessment of risk level are needed in advance screening, assessment, diagnosis, and of classification to custody units, placement in treatment diversion programs, or sentencing and disposition. ■ Absence of electronic records that can be The combination of screening and assessment of shared across justice settings psychosocial needs and criminal risk is essential to ■ Perceived or real negative consequences the treatment planning process and in determining associated with self-disclosure of symptoms

11 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ Mimicking or masking of symptoms of require coordination between behavioral health one disorder by symptoms of the other co- and criminal justice system staff. Unfortunately, occurring disorder treatment and service practitioners in these two ■ Cognitive and perceptual difficulties areas often have different approaches to working associated with severe mental illness or with CODs. Finally, most jurisdictions have few toxic effects of recent alcohol or drug use resources to support community transition and follow-up treatment activities for justice-involved Low detection rates of CODs may also be individuals who have CODs (Lurigio, 2011; Sacks, attributable to the absence of screening procedures 2004; Potter, 2014; Sung et al., 2010; Travis, in justice settings to comprehensively examine Solomon, & Waul, 2001). both mental health and substance use issues (Cropsey, Wexler, Melnick, Taxman, & Young, As previously noted, offenders who have CODs 2007; Hiller et al., 2011; Osher, 2008; Peters et al., are characterized by great diversity in the 2012; Peters et al., 2004). types of disorders experienced, the nature Low detection rates Inaccurate detection of CODs in justice of symptoms, the level of CODs may also settings may result in a wide range of negative of impairment, personal be attributable consequences (Chandler et al., 2004; Hiller et strengths, and risk for al., 2011; Harris & Lurigio, 2007; Lurigio, 2011; to the absence criminal recidivism. of screening Osher et al., 2003; Peters et al., 2008), including In addition to procedures in the following: compiling information ■ Recurrence of symptoms while in secure related to treatment justice settings to settings and case planning, comprehensively ■ Increased risk for recidivism one of the major examine both ■ Missed opportunities to develop intensive benefits of gathering mental health and treatment conditions as part of release or comprehensive substance use supervision arrangements screening and issues ■ Failure to provide treatment or neglect of assessment information appropriate treatment interventions is the ability to match offenders to appropriate services. For example, ■ Overuse of psychotropic medications some jurisdictions operate multiple court-based ■ Inappropriate treatment planning and programs (e.g., drug courts, mental health referral courts, specialized dockets for CODs) that are ■ Poor treatment outcomes differentially appropriate for offenders according to their individual treatment and supervision Once CODs are identified in justice settings, the needs. In custody settings, program options challenge is to provide specialized treatment and may differ by duration, intensity, and degree of transition services. Justice-involved individuals isolation from the general inmate population. In with CODs exhibit more severe psychosocial some justice settings, offenders who have CODs problems, poorer institutional adjustment, and may be routed to different program “tracks” (e.g., greater cognitive and functional deficits than other in a drug court, jail, or prison), depending on the individuals (Lurigio, 2011; Ruiz, Douglas, Edens, severity of CODs and supervision needs/criminal Nikolova, & Lilienfeld, 2012; Sung, Mellow, & risk level. In each of these cases, screening and Mahoney, 2010). Comprehensive treatment assessment should be used to strategically examine practices involve integrating mental health and relevant program eligibility and exclusion criteria, substance use services (Houser, Blasko, & and to gauge the “fit” between key needs of the Belenko, 2014; Lurigio, 2011; NIDA, 2008) and

12 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System offender and available services. Research also treatment programs for CODs. Research indicates indicates the importance of matching offenders that the ASAM PPC are able to triage people who to program services based on an individualized have mental disorders to more intensive treatment profile of “criminogenic needs,” criminal risk programs geared towards CODs (Stallvik & level, and “responsivity” factors (Andrews, Nordahl, 2014) and that people referred to more 2012; Andrews & Bonta, 2010a) that affect intensive treatment services have more severe the ability of offenders to engage in evidence- mental health and substance use problems. based treatment and supervision—areas that are discussed in “Special Clinical Issues in Screening Opportunities for Screening and and Assessment for Co-occurring Disorders in the Assessment Justice System.” Opportunities for screening and assessment are Several approaches for treatment matching of present at all points of contact within the criminal offenders to treatment and supervision services justice system. The Sequential Intercept Model are described in this monograph. One model used (see Figure 1) provides a conceptual framework to identify the severity of substance use and co- for communities to organize targeted strategies for occurring mental disorders and to match people to justice-involved individuals with serious mental treatment services is the Patient Placement Criteria illness. Within the criminal justice system there (PPC), developed by the American Society of are numerous intercept points—opportunities for Addiction Medicine (ASAM). The ASAM PPC linkage to services and for prevention of further are used to match individuals to appropriate levels penetration into the criminal justice system. This and types of treatment and have been effective linear illustration of the model shows the paths an as an assessment approach in the criminal justice individual may take through the criminal justice system for people who have CODs. This model system, where the five intercept points fall, and provides an assessment of six dimensions related areas that communities can target for diversion, to treatment, such as severity, frequency, and engagement, and reentry. duration of substance use, in addition to other factors, including risk of relapse, co-occurring Intercept 0: Community Services mental health symptoms, motivation and readiness At Intercept 0, first responders have several for treatment, and social and occupational opportunities to screen for co-occurring disorders functioning (Mee-Lee, 2013; Stallvik & Nordahl, and conduct assessments (Abreu, Parker, Noether, 2014). These factors are used to match patients Steadman, & Case, 2017). Because Intercept 0 to different levels of services, ranging from early involves short-term responses and care models intervention to medically managed intensive to address acute, crisis level episodes, it is a inpatient services and including specialized brief intervention point where an individual

Figure 1. The Sequential Intercept Model

13 Screening and Assessment of Co-Occurring Disorders in the Justice System

co-located with detoxification facilities. In this setting, the tools listed in a subsequent section of this monograph, “Instruments for Screening and Assessing Co-Occurring Disorders,” will provide for efficient and standardized assessment.

Intercept 1: Law Enforcement In general, opportunities for screening at Intercept 1 are presented to law enforcement; other first responders, such as emergency medical technicians; and to emergency room personnel (see Figure 3). Law enforcement officers have a brief opportunity to flag signs of mental and substance use disorder and hand off individuals experiencing a mental health crisis to appropriate services. With the expansion of Crisis Intervention Teams has come the development of law enforcement- friendly crisis stabilization units as one-stop drop- Figure 2. Intercept 0: Community Services off sites for people experiencing a mental health crisis. experiencing a mental or substance use disorder can be identified and recommended for specialized Law enforcement agencies with limited training care before an arrest occurs (see Figure 2). in mental health and substance use disorders are at a disadvantage in identifying and appropriately Staff within the crisis care continuum who may handling people with mental illness or co- routinely perform screening and assessment occurring disorders. Eight-hour Mental Health include EMS, fire department and law enforcement First Aid training can provide law enforcement first responders, staff of mobile crisis outreach teams, and staff of 23 hour crisis respite centers. Staff of 24-hour crisis phone lines are also part of Intercept 0, and can link individuals to behavioral health providers for screening and assessment.

First responders and mobile crisis-teams can develop uniform guidelines with local hospitals and crisis centers to provide routine on-site screenings. In addition, mobile crisis teams are increasingly able to access current health records of people with co-occurring disorders who are services recipients, thus enhancing the opportunity to expedite screening and assessment and assisting in timely disposition.

Crisis stabilization units providing up to 23-hour care offer a specialized response for people with co-occurring disorders, prompt triage, and referral to appropriate services. Often these services are Figure 3. Intercept 1: Law Enforcement

14 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System officers with basic skills in identifying and Intercept 2: Initial Detention/Initial responding to mental illness and substance use Court Hearings disorders. The most comprehensive responses are by Crisis Intervention Teams, which consist of a Once a person has been arrested, there are two cadre of officers who have completed 40 hours primary opportunities to screen and assess for of training and are responsible for resolving calls co-occurring disorders (see Figure 4). The first involving people experiencing a mental health opportunity is for jail booking personnel and crisis. These officers often have a dedicated health screeners to conduct brief, structured drop-off site, and many use checklists to aid the screens to flag people who may have co-occurring identification of mental illness and substance use. disorders for further clinical assessment. Tracking forms and databases are used for record- Where available, the second opportunity for keeping and identification of repeated contacts. screening is by pretrial service staff. Pretrial First responders, especially law enforcement services may be a function of an independent officers, are expected to resolve calls in as swift agency or probation; either way they have an a manner as possible. Opportunities to train opportunity to briefly screen for co-occurring responders in the identification of the signs and disorders while developing the pretrial release/ symptoms of mental and substance use disorders detention recommendation. In some communities, and to more quickly resolve crisis situations, arrestees are initially detained in a police or whether through training in de-escalation court lockup rather than jail prior to their initial techniques or in the administration of naloxone to appearance. Pretrial services may be the first counter a heroin overdose, have more operational opportunity to screen these individuals since their value than adding extensive screening procedures. being placed under arrest. Nevertheless, law enforcement officers should For courts with a court clinic or embedded document their observations and ensure that clinicians, clinicians may be available to screen information is provided to emergency room, crisis people for co-occurring disorders and to identify stabilization unit, or mobile crisis staff. Where a hand off to a health care practitioner is not possible, information should be communicated to jail booking or lockup officers.

Mental health co-response services have expanded in recent years at Intercept 1 as a specialized response to mental health crises. Mental health clinicians or mobile crisis teams, which co- respond with law enforcement officers, can improve the usefulness of screenings by providing immediate responses on-scene. Increasingly, mobile crisis teams or clinicians employed by law enforcement agencies are providing follow-up services, including further assessments and case management, after an encounter occurs in the community.

Figure 4. Intercept 2: Initial Detention/Initial Court Hearings

15 Screening and Assessment of Co-Occurring Disorders in the Justice System service recipients. Diversion program case eligibility assessments of individuals identified by workers may also conduct screenings prior to the jail or during Intercept 2 (see Figure 5). the first court appearance to determine program eligibility. Jail size and resources may impact the practicality of implementing comprehensive assessment The challenge at this intercept is the short procedures. The holding capacity of jails ranges time frame between initial detention and first from a handful of cells to space for 15,000 appearance. Individuals may be held for only a inmates. Small and even mid-size jails may matter of hours before being released, which can lack the resources to provide basic screening, hamper efforts to screen and prohibits further assessment, and treatment. These jails often clinical assessment. rely on reach-in services by community-based providers. However, jails are required to conduct Intercept 3: Jails/Courts at least basic screening for suicide, mental health, The purpose of brief screening at jail booking and substance use. Larger jails will have in-house is typically to identify people who may have behavioral health professionals to conduct more a mental or substance use disorder for further intensive screening and assessment. The average clinical assessment. The initial screen may be jail stay is fewer than 7 days; screening and conducted by booking officers or jail health staff. assessment information collected during the jail Some jails have their newly booked inmates booking process should be used to refer and link matched with the client databases of state or local inmates to court-based diversion programs and to behavioral health authorities to assist continuity of community-based services upon release. care. Screening and assessment within the jail also At the dispositional court, screening and aids the housing classification and management assessment are important for the purpose of inmates and the connection with available of informing the disposition and sentencing behavioral health services within the jail. Apart decisions. Defense attorneys often gather from the jail, specialty court and other diversion information on a client’s behavioral health programs may conduct clinical and program history, even if it is not presented in court. Public defenders in larger jurisdictions may have a staff social worker to help identify clients’ treatment needs. Defender-based advocacy programs, operated by a nonprofit or a county agency, may review a client’s history (i.e., criminal, familial, educational, occupational, and health) to develop a dispositional recommendation.

Court-based diversion programs, including specialty courts, often have extensive screening and assessment procedures to identify eligible individuals and to formulate treatment plans. Efforts to develop unified screening and assessment procedures across programs greatly benefit the programs by increasing the likelihood that individuals are placed into the most appropriate program.

Probation officers responsible for the presentence Figure 5. Intercept 3: Jails/Courts investigation may conduct screens and

16 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System incorporate treatment history into their sentencing can work with inmates and practitioners to identify recommendations to the judge. The presentence appropriate services and supports, including investigation is notable because it may include access to health coverage, as inmates approach treatment recommendations. Many probation the end of their jail sentence. Transition planners agencies are implementing criminal risk and can also work with probation officers on the hand need assessments to better match individuals off for inmates being released into the custody of to supervision and treatment resources. These probation. assessments should be shared with community- based practitioners to ensure that criminal risk, Prisons have the opportunity during the reception need, and responsivity are addressed through process to screen and assess for co-occurring services. disorders. Prisons are more likely to offer comprehensive mental health and substance Intercept 4: Reentry use programming. Screening and assessment at reception and periodically over the course of For jails, the opportunity for screening presents an inmate’s sentence can guide prison treatment itself at Intercept 2 or Intercept 3. Among the services and transition planning. As with jails, population of sentenced inmates, officers that officers can identify inmates who did not present are trained in the identification of mental health with sufficient acuity at the time of reception to symptoms can generate referrals to health services merit a referral to health services. Ninety days for inmates with a mental illness who did not from release, prison transition planners can work present at booking. Jails with sufficient resources with inmates to identify service needs, connect may offer basic behavioral health programming. to health coverage, and prepare for reintegration Planning for reentry should begin at jail booking into the community. Transition planners who are (see Figure 6). Periodic screening and assessment working with inmates being released to parole should take place over time to determine changes supervision can work with inmates to prepare in inmate needs for institutional programming and for the immediate requirements of parole. Most to inform reentry services. Jail transition planners prisons are remote from the community of return, and the responsibility for identifying appropriate treatment resources often falls on the parole department. Many states and communities have established transitional case management capacity to work with inmates while they are still incarcerated and for a period of time after release. As with probation agencies, prisons and parole departments are implementing risk and need assessment instruments to guide supervision and treatment programming. Information gathered from these instruments should be shared with community practitioners to better inform the treatment process.

Intercept 5: Community Corrections Probation The majority of people under correctional supervision are on probation. Collaboration Figure 6. Intercept 4: Reentry between probation agencies and behavioral health

17 Screening and Assessment of Co-Occurring Disorders in the Justice System

the terms of supervision may need to be screened for co-occurring disorders in order to determine if the noncompliance is a result of symptoms or functional impairment.

Parole As with at-risk probationers, screening and assessment of parolees is crucial as they are transitioning from a long-term stay in an institutional environment. Parolees with substance use disorders may have difficulty managing their abstinence from alcohol and drugs upon release. Mental health problems may arise due to the difficulties of transitioning back into the community, especially if a parolee is experiencing a gap in access to services and medication.

In many states, prison and parole services are two parts of one agency. Information on prison Figure 7. Intercept 5: Community Corrections inmates with mental or substance use disorders programs are essential to reducing recidivism may be available to parole officers in advance of and promoting recovery (see Figure 7). For an inmate’s release into the custody of the parole probation agencies, new probationers can be agency. screened at booking for co-occurring disorders. Officers can also take advantage of information Defining Screening and Assessment on a probationer’s treatment needs that has been gathered during earlier intercepts, such as Individuals in the justice system who have CODs at pretrial or for the presentence investigation. are characterized by diversity in the scope and For probationers who have been diverted to a intensity of mental health, substance use, social, specialized program at Intercept 2 or Intercept medical, and other problems. As a result, no single 3, the information may be available from the clinical approach fits the needs of this population, agency responsible for case management. and effective and comprehensive screening Probation officers can use the information to and assessment procedures are of paramount place probationers into appropriate services, importance in defining the sequence, format, and such as groups, or into specialized, lower ratio nature of needed interventions. Screening and caseloads where officers have received additional assessment of CODs are part of a larger process of training in the supervision of people with mental gathering information that begins at the point of or substance use disorders. Specialized probation contact of the individual with the justice system. caseloads and co-located probation and mental The Center for Substance Abuse Treatment’s health services are some of the strategies being Treatment Improvement Protocol (TIP) Series used to achieve better probation outcomes #42 and other government monographs (Center for individuals with co-occurring disorders. for Substance Abuse Treatment [CSAT], 2005a; Comprehensive screening and assessment can Steadman et al., 2013; NIDA, 2006) outline a match probationers to appropriate services, set of sequential steps that are often followed while criminal risk and need assessments can in gathering information related to CODs. match them to appropriate supervision levels. These steps provide a blueprint for developing Probationers who are struggling to comply with

18 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System a comprehensive system of screening and provide a full psychosocial assessment, and one assessment activities and include the following: or more screens will typically provide sufficient information to inform decisions about referral for ■ Engage the offender services and further assessment. ■ Collect collateral information (e.g., from family, friends, other practitioners) Assessment is implemented when there is a ■ Screen and detect CODs need for more detailed information to help place people in a specific level of care (e.g., outpatient ■ Determine severity of mental health and versus residential treatment) or type of service substance use problems (e.g., COD treatment, intensive community ■ Determine the level of treatment services supervision). Assessment differs from screening needed in that it addresses not only immediate needs for ■ Diagnosis services, but also informs treatment planning ■ Determine the level of disability and or case planning. Thus, assessment examines a functional impairment range of long-term needs and factors that may ■ Describe key areas of psychosocial affect engagement and retention in services, problems such as housing, vocational and educational ■ Identify strengths and supports needs, transportation, family and social supports, motivation for treatment, and history ■ Identify cultural and linguistic needs and supports of involvement in behavioral health services. Several types of assessments are available that ■ Determine an offender’s level of motivation vary according to the scope and depth of coverage and readiness for treatment (i.e., “stage of needed. For example, several sets of instruments change”) that are described in this monograph (e.g., Global ■ Develop an individualized treatment plan Appraisal of Individual Needs [GAIN], Mini Screening for CODs in the justice system is used International Neuropsychiatric Interview [MINI], to identify problems related to mental health, Texas Christian University Drug Screen [TCUDS]) substance use, trauma/PTSD, criminal risk, other provide different options for assessment that may areas that are relevant in determining the need be tailored to a particular justice setting. for specialized services (including treatment, Screening case management, and community supervision), and the need for further assessment. Screening Screening for CODs is a brief, routine process also helps to identify acute issues that require designed to identify indicators, or “red flags,” for immediate attention, such as suicidal thoughts or the presence of mental health, substance use, or behaviors, risk for violence, withdrawal symptoms other issues that reflect an individual’s need for and detoxification needs, and symptoms of serious treatment and for alternative types of supervision mental disorders. Often, multiple screenings are or placement in housing or institutional settings. used simultaneously to identify problem areas that Screening may include a brief interview, use of require referral or additional assessment. This self-report instruments, and a review of archival may be particularly useful at the point of first records. Brief self-report instruments are often appearance hearings/pretrial release or at the time used to document mental health symptoms and of case disposition. Due to the volume of people patterns of substance use and related psychosocial processed at different points in the justice system, problems. Generally, screening instruments do not such as booking in larger jails, intake in prison require that staff members are licensed, certified, reception centers, and first appearance hearings, or otherwise credentialed, and minimal training it is impractical (and unnecessary) to routinely is usually required to administer, score, and

19 Screening and Assessment of Co-Occurring Disorders in the Justice System interpret findings. However, staff training may be to address several different issues. Classification needed to provide effective referral to services if a and risk screening is typically conducted early on screening indicates the presence of problems in a to identify security issues (e.g., history of escape, particular area (e.g., related to trauma history and past aggressive behavior within the institution) and current symptoms of PTSD). to determine level of custody; program needs; and other issues, including history of trauma. Medical In justice settings, screening for CODs should screening identifies health issues, and may address be conducted for all individuals shortly after mental health status and substance use history. the point of arrest and at the time of transfer to Mental health and substance use screenings often subsequent points in the system. While separate are also included within interviews conducted by screening instruments have been developed to pretrial services or other court-related agencies. detect mental health and substance use issues in In community and jail settings, presentence or the justice system, until recently, few instruments postsentence investigations (PSIs) are frequently were available for examining CODs. Optimally, completed to assist in determining the judicial screening tools should be well validated and disposition or case planning. These often involve reliable, with demonstrated properties in both an interview and set of brief screenings to identify justice and non-justice settings (Steadman et al., whether individuals are at high risk for violence 2013). Screening should be conducted early in the or recidivism and to identify problems that may process of compiling information, so that results be addressed through treatment or supervision, can inform the need for assessment and diagnosis including specific mental health problems such (Hiller et al., 2011; NIDA, 2006). as PTSD related to trauma. Brief screening Among the goals of screening for CODs are the may address literacy and educational deficits. following: In related areas of cognitive and behavioral impairment (e.g., interpersonal skills deficits, ■ Detection of current mental health and stress tolerance), there are few well-validated substance use symptoms and behaviors screening tools that gather information relevant ■ Determination as to whether current for placement and disposition. As a result, these symptoms or behaviors are influenced by areas are typically examined through behavioral CODs (e.g., trauma history) observation (Steadman et al., 2013). ■ Examination of cognitive deficits ■ Identification of criminal risk level to Assessment inform the need for placement in more Assessment of CODs is typically conducted or less intensive levels of treatment, through a clinical interview and may include supervision, and custody psychological, laboratory, or other testing and ■ Identification of acute needs (e.g., violent compilation of collateral information from family, behavior, suicidal ideation, severe medical friends, and others who are in close proximity to problems) that may need immediate the individual. Assessment is usually conducted attention by a trained professional who is either licensed or ■ Determination of eligibility and suitability certified to provide mental health and substance for specialized CODs treatment services use treatment services. Those conducting ■ Level of functional impairment (e.g., stress assessments for substance use and mental health tolerance, interpersonal skills) problems would optimally have received advanced graduate-level training and supervised field It is important to consider the multiple types and experience in providing clinical services and have purposes of screening. For example, a series of significant experience assessing and diagnosing screenings may be provided in jails and prisons mental and substance use disorders. Assessment

20 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System

in the criminal justice setting should be conducted ■ History of previous mental health or by individuals who are knowledgeable about substance use treatment(s) and response to the dynamics of criminal behavior and who treatment(s) understand the pathways and interactions between ■ Family history of mental health or criminal behavior and clinical pathology related to substance use disorders substance use and mental disorders. ■ Development of diagnoses according to formal classification systems (e.g., DSM-5) Assessment of CODs provides a comprehensive examination of psychosocial needs and problems, ■ Identification of the full spectrum of including the severity of mental and substance psychosocial problems that may need to be use disorders, conditions associated with the addressed in treatment occurrence and maintenance of these disorders, ■ Determination of the level of service problems affecting treatment, individual needs related to mental and substance use motivation for treatment, and areas for treatment problems interventions. A risk assessment is often provided ■ Identification of the level of motivation and that examines a range of “static” (unchanging) and readiness for treatment “dynamic” (changeable) factors that independently ■ Review of other factors that may inhibit contribute to the likelihood of criminal recidivism, engagement in evidence-based services for violence, institutional misconduct, or other CODs, such as literacy, transportation, and salient behaviors. The risk assessment process is history of trauma/PTSD described in more detail in “Special Clinical Issues ■ Examination of individual strengths, areas in Screening and Assessment for Co-occurring of functional impairment, cultural and Disorders in the Justice System.” As indicated linguistic needs, and other environmental previously, assessment is an ongoing process that and social supports that are needed helps to engage justice-involved individuals in the ■ Evaluation of the risk for behavioral treatment planning process, identify strengths and problems, violence, and criminal recidivism weaknesses, review motivation and readiness for that may affect placement in various change, examine cultural and other environmental institutional or community settings needs, provide diagnoses related to CODs, and ■ Review of criminogenic risk factors (or determine the appropriate setting and intensity “criminogenic needs”), such as antisocial and scope of services necessary to address CODs attitudes and peers, educational deficits, and related needs. Several multistaged models unemployment, lack of social supports, and for assessing CODs are described in monographs absence of prosocial leisure skills that address both offender and non-offender ■ Provide a foundation for treatment planning populations (Mee-Lee, 2013; CSAT, 2005a; 2006a; Steadman et al., 2013). Key Areas to Examine in Assessing Co- occurring Disorders within the Justice System Goals of the CODs assessment process include the The following types of information should be following: examined in assessing CODs within the justice ■ Examine the scope and severity of mental system (Mee-Lee, 2013; CSAT, 2005a; Steadman and substance use disorders, conditions et al., 2013; NADCP, 2014): associated with the occurrence and ■ Juvenile and adult justice system history maintenance of these disorders, and and current status interactions between these disorders (e.g., history of symptoms, psychotropic ■ Mental health history, current symptoms, medication use, collateral information) and level of functioning

21 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ Substance use history, current symptoms, » peers and level of functioning » lack of educational achievement ■ Suicide risk » employment deficits ■ Reasons for living » lack of social support ■ Feelings of belonging to a particular social » lack of prosocial leisure skills group ■ History of violent or aggressive behavior ■ Ability to follow through with intentions of ■ Employment/vocational status and related self-harm skills ■ Detail of plans surrounding suicidal ■ Socioeconomic status ideation ■ Educational history and status ■ Length, recency, and frequency of suicidal thoughts ■ Literacy, IQ, and developmental disabilities ■ Chronological history of the interaction ■ Treatment history related to mental between mental and substance use disorders, substance use disorders, disorders and CODs, and response to and compliance with treatment (including ■ Family history of mental and substance use psychopharmacological interventions) disorders (including birth complications and in utero substance exposure) ■ Prior experience with peer support groups, including specialized groups for CODs ■ Medical status and history of medical (e.g., Double Trouble) and traditional self- disorders help groups for substance use disorders ■ Current medications and treatment and (e.g., Alcoholics Anonymous [AA] and service providers Narcotics Anonymous [NA]) ■ Trauma exposure (including combat, non- ■ Cognitive appraisal of treatment and combat, and general trauma) recovery, including motivation and ■ Social and family relationships readiness for change; motivation to receive ■ Family history of criminal involvement, treatment; self-efficacy; and expectancies substance use, and mental health conditions related to substance use, use of medication, and presence of mental and substance use ■ Interpersonal coping strategies, social skills disorders deficits, problem-solving abilities, and communication skills ■ The offender’s understanding of treatment needs ■ Ingrained patterns of criminal thinking ■ Personal goals (short- and long-term) ■ Risk for criminal recidivism (i.e., rearrest) related to treatment and recovery, and other ■ Each criminal risk factor (also referred to as life goals “criminogenic needs”) that independently ■ Resources and limitations affecting contributes to the likelihood of future the offender’s ability to participate in arrest/recidivism—optimally, assessment treatment (e.g., transportation problems, will include separate risk scores across homelessness, child care needs) each of these domains, so that treatment and supervision strategies can be targeted Areas to Obtain More Detailed Assessment to address areas of most urgent need Information » substance use disorders ■ Symptoms of CODs » antisocial beliefs or attitudes » Specific mental health and substance » personality style use symptoms and severity of the related disorders

22 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System

» Whether symptoms are acute or » If a history of attention deficit/ chronic and how long the individual hyperactivity disorder (ADHD) is has had the symptoms and related suspected, assessment should examine disorders attention and concentration difficulties, » Exaggeration or suppression of hyperactivity and impulsivity, and the symptoms to achieve a purposeful developmental history of childhood goal, such as to avoid placement in an ADHD symptoms intensive treatment program or to gain ■ History of interaction between the CODs access to a more favorable housing unit » It is particularly important to examine ■ Substance use history and recent patterns the chronological history of the two of use disorders, including periods before » Assessment of substance use should the onset of drug and alcohol use and include the primary substances used during periods of abstinence (including over time; other drugs used over enforced abstinence while in jail or time; misuse of prescription drugs; prison). Current mental disorders reasons for substance use; context should be assessed relative to the use of substance use; involvement with of alcohol and other drugs to determine substance-involved peers; periods if the symptoms subside during periods of abstinence; how abstinence was of abstinence obtained; frequency of attempts to cut » In some settings, substance use and down or quit; substance use treatment mental health history information is history (including medication- collected separately. This tends to assisted treatment); age at first use of hinder an understanding of the effects substances; and frequency, amount, of drugs and alcohol on mental health and duration of use, including patterns symptoms, and the extent to which of high and low intensity use and level mental disorders exist independently of cravings from substance use disorders. These ■ Mental health history and current issues are particularly important in psychological functioning providing differential diagnosis and in identifying the specific nature of » Mental health information should CODs. Unfortunately, few assessment include current and past symptoms instruments examine the chronological (e.g., suicidality, depression, anxiety, relationship between CODs and the psychosis, paranoia, stress, self- intertwined nature of these disorders image, inattentiveness, impulsivity, hyperactivity, history of trauma/ ■ Medical/health care history and status PTSD), history of mental health » Key areas to examine include history treatment (including hospitalizations) of injury and trauma, chronic disease, and use of medication, and patterns of physical disabilities, substance toxicity denial and manipulation and withdrawal, impaired cognition » If severe cognitive impairment (e.g., mental status examination (e.g., traumatic brain injury [TBI]) for severe cognitive impairment), is suspected, a Mini Mental Status neurological symptoms, and prior use Examination (MMSE; Folstein, of psychiatric medication. Assessment Folstein, McHugh, 1975) or other should also examine the presence of type of cognitive screen should be chronic health disorders (e.g., diabetes, administered to assess the level of heart conditions) and infectious disease impairment (e.g., HIV/AIDS, TB, Hepatitis C)

23 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ Criminal justice history and status » Stability of the home and social » The complete criminal history should environment, including violence in the be reviewed, including prior arrests home (e.g., intimate partner violence) and reasons for arrests/incarceration, and effects of the home and other in addition to current criminal justice relevant social environments (e.g., status work, school) on abstinence from substance use ■ Cultural and linguistic needs » Social supports (e.g., peers, family) » Cultural beliefs about mental and substance use disorders, treatment ■ Other psychosocial areas of interest services, and the role of treatment » Housing/living arrangements professionals, including potential » Vocational/employment history and feelings of discrimination from training needs treatment and service practitioners and » Financial support willingness to report mental health symptoms » Eligibility for entitlements and health insurance status » Abilities to adapt to the treatment culture and to deal with conflict in these settings Developing a Comprehensive » Reading and writing skills Screening and Assessment » Barriers to providing cultural and Approach linguistic services Integrated (or blended) screening and assessment ■ Individual strengths and environmental approaches should be used to examine CODs in supports the justice system. In the absence of specialized » Ability to manage mental and instruments to address both disorders, an substance use disorders integrated screening approach typically involves » Risk and protective factors in the home use of a combination of mental health and environment (e.g., substance-involved substance use instruments. Integrated screening family members or peers) and the and assessment approaches are associated with potential for relapse to both mental and more favorable outcomes among people in the substance use disorders justice system and in the community (Henderson, » Interests and skills Young, Farrell, & Taxman, 2009; Hiller et al., » Expectancies related to treatment and 2011; Substance Abuse and Mental Health recovery Services Administration [SAMHSA], 2011) and » Motivation for change and incentives help to maximize the use of scarce treatment and goals that are salient for the resources. individual Screening and assessment can help to determine » Vocational skills and educational the relationship between CODs and prior criminal achievements behavior and to identify the need for criminal ■ Social relationships justice supervision. Because of the high rates of » Social interactions and lifestyle, effects CODs in justice settings, detection of one type of of peer pressure to use drugs and disorder (i.e., either mental or substance use) alcohol, family history, and evidence should immediately “trigger” screening for the of current support systems. other type of disorder. In general, the presence of mental health symptoms is more likely to signal a substance use disorder than substance use

24 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System symptoms to signal a mental disorder. However, disorders relative The SBIRT approach due to high base rates of both disorders in the to the general uses evidence- justice system, screening and assessment should population. based screening routinely address both areas. If both mental and Veterans in the instruments to substance use disorders are present, the interaction justice system of these disorders and motivation for treatment may have unique provide early should also be assessed. combat-related identification of experience with drug and alcohol trauma that One approach that integrates screening and problems. assessment is the Screening, Brief Intervention, a screen may and Referral to Treatment model (SBIRT; help to identify. SAMHSA, 2011). The SBIRT approach uses Trauma screening is also complicated due evidence-based screening instruments to to the sensitive nature of the information provide early identification of drug and alcohol obtained. Universal trauma awareness and staff training may help to facilitate more problems. Screening information is then used to detailed assessment of trauma by clinicians determine the risk for substance use relapse and working with justice populations. to identify the necessity for a brief intervention, counseling, or treatment referral. Although ■ Mental health and substance use screening should be completed at the earliest possible SBIRT demonstrates good potential in identifying point after entry to the justice system. For people who are at risk for substance use disorders example, identification of these problems (Madras et al., 2009), there have been equivocal among pretrial defendants will assist findings related to outcomes with different types of the judge in establishing conditions of substance-involved populations (Bernstein et al., release (e.g., drug testing, involvement in 2010; Saitz et al., 2007). Additional research is treatment) that will increase the likelihood needed to examine SBIRT outcomes implemented of stabilization in the community and the in the justice system, and in particular among individual’s return for additional court people who have CODs. The SBIRT approach is hearings. described in more detail in “Screening Instruments ■ Ongoing screening for CODs should be for Substance Use Disorders.” provided at the different stages of criminal justice processing, such as diversion, Recommendations for developing an integrated entry to jail, pretrial and presentence and comprehensive screening and assessment hearings, sentencing, probation, entry to approach for CODs in the justice system include prison, parole or aftercare, and revocation the following: hearings. Ongoing screening will help to identify individuals who are initially ■ All individuals entering the justice system should be screened for mental reluctant to discuss mental health or and substance use disorders. Universal substance use problems but who may screenings are warranted due to the high become more receptive to involvement in rates of CODs among individuals in treatment services over time. For example, the justice system and to the negative some individuals may seek treatment after consequences for non-detection of these learning more about the availability and disorders. quality of correctional program services, while others may experience mental health ■ Universal screening should also be symptoms while incarcerated and elect to conducted for history of trauma and participate in treatment. for PTSD. Although female offenders are disproportionately affected, male ■ Ongoing assessment of CODs and level offenders also have very high rates of these of criminal risk should occur within the

25 Screening and Assessment of Co-Occurring Disorders in the Justice System

justice system, as the level of functional disorders and a range of other “substance- impairment, symptoms of CODs, induced” mental disorders. Each set of CODs motivation to engage in services, and is characterized by differences in prevalence, risk level may change over time in both etiology, and history. The following section community and institutional settings. specifies key information that should be examined Reassessment can lead to important during screening and assessment of CODs in adjustments related to the treatment/ justice settings. case plan, movement to different levels of intensity of treatment and supervision, Risk Factors for Co-occurring Disorders duration of placement in services, and to sanctions and incentives. A number of risk indicators for developing CODs should be considered in screening and assessment ■ Whenever feasible, similar and in the justice system (Brady & Sinha, 2007; Drake standardized screening and assessment instruments for CODs should be used et al., 1996; Drake, Mueser, & Brunette, 2007; across different justice settings, with Gregg et al., 2007; Horsfall, Clearly, Hunt, & information regarding the results shared Walter, 2009; Seal et al., 2011; Seal et al., 2009; among all settings involved. This approach Sung et al., 2010). People who have several of promotes greater awareness of CODs and these characteristics should be carefully screened needed treatment interventions and reduces for CODs. As more of these characteristics are unnecessary repetition of screening and observed, there is a greater likelihood of CODs assessment for individuals identified as and a corresponding need for more detailed having CODs. screening for mental health and substance use ■ Information from previously conducted problems. The following characteristics carry screening and assessment should be elevated risk for CODs: communicated across different points in the criminal justice system. A systemic ■ Male gender approach to information sharing is needed, ■ Youthful offender status including development of memoranda ■ Low educational achievement of understanding or agreement among ■ History of unstable housing or agencies having contact with the offender homelessness at different linkage points. ■ History of legal difficulties or incarceration Key Information To Address in ■ Suicidality Screening and Assessment for Co- ■ History of emergency room or acute care visits occurring Disorders ■ High frequency of relapse to substance use Individuals with CODs are characterized by ■ Antisocial or substance-using peers diversity in the scope, severity, and duration of ■ Poor relationships with family members symptoms; functional abilities; and responses ■ Family history of substance use or mental to treatment interventions (Baillargeon et al., disorders 2009; Clark, Samnaliev, & McGovern, 2007; Lehman, 1996; Mueser et al., 2003; Seal et al., ■ History of mental health and substance use 2011; Van Dorn, Volavka, & Johnson, 2012). treatment, often coupled with patterns of The intertwined nature of mental and substance poor adherence to treatment use disorders is reflected in the latest edition of ■ History of disruptive behavior the American Psychiatric Association’s DSM- 5 (2013), which differentiates between mental

26 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System

Observable Signs and Symptoms of members and community supervision and Co-occurring Disorders correctional officers In addition to the previously listed risk factors for Indicators of Substance Use Disorders CODs, several observable signs and symptoms Similarly, substance use indicators suggest the of mental and substance use disorders should be presence of CODs: reviewed during screening and assessment. These include the following: ■ Evidence of acute drug or alcohol intoxication ■ Unusual affect, appearance, thoughts, or speech (e.g., confusion, disorientation, ■ Signs of withdrawal from drugs or alcohol rapid or slurred speech) ■ Signs of escalating drug or alcohol use (e.g., from drug test results) ■ Suicidal thoughts or behavior ■ Cravings for drugs or alcohol ■ Paranoid ideation ■ Negative psychosocial consequences ■ Impaired judgment and risk-taking behavior associated with substance use ■ Self-reported substance use, including ■ Drug-seeking behaviors » Age at first use ■ Agitation or tremors » History of use ■ Impaired motor skills (e.g., unsteady gait) » Current pattern of use ■ Dilated or constricted pupils » Drug(s) of choice ■ Elevated or diminished vital signs » Motivation for using ■ Hyperarousal or drowsiness ■ Prior substance use treatment history, ■ Muscle rigidity including detoxification, outpatient, and ■ Evidence of current intoxication (e.g., residential treatment services alcohol on breath) ■ Peers and associates who are drug users or ■ Needle track marks or injection sites who have antisocial features Indicators of Mental Disorders ■ Family history of substance use disorders ■ History of overdose Key indicators relevant to mental disorders that should be examined when screening or assessing ■ History of trauma, abuse, and neglect for CODs, include the following: Recommended screening instruments for mental, ■ Acute and observable mental health substance use, and co-occurring mental and symptoms substance use disorders are provided in the section ■ Suicidal thoughts and behavior “Instruments for Screening and Assessing Co- ■ Age of onset of mental health symptoms occurring Disorders.” ■ Mental health treatment history (including Cognitive and Behavioral Impairment hospitalizations), response to treatment, and use of psychotropic medication(s) Screening and assessment can be useful in detecting key cognitive and behavioral features ■ History of trauma, abuse, and neglect related to CODs, which can influence the course ■ Disruptive or aggressive behavior of treatment and may inform the type and format ■ Family history of mental illness of treatment provided. One area that typically ■ Reports of unusual thoughts or behaviors does not receive sufficient attention during from those who have routine contact screening and assessment of CODs is cognitive with the individual, including family

27 Screening and Assessment of Co-Occurring Disorders in the Justice System and behavioral impairment related to psychosocial information), including guidelines and and interpersonal functioning. This functional expectations for treatment and supervision impairment often affects the individual’s ability ■ Lack of recognition of the consequences to engage and effectively participate in treatment related to criminal behavior or violations of (Bellack et al., 2007; Clark, Power, Le Fauve, & community supervision arrangements Lopez, 2008; DiClemente et al., 2008; Drake et ■ Poor judgment (e.g., related to substance al., 2008; Gregg et al., 2007; Horsfall et al., 2009). use, discontinuation of medication) Impairment in interpersonal or social skills is ■ Disorganization in major life activities important to assess, as this influences the ability to (e.g., lack of structure in daily activities, interact with treatment staff, supervision officers, lack of follow through with directives) judges, and other treatment team members. ■ Poor problem-solving skills and planning Related areas of functional ability include reading abilities and writing skills and how the individual responds ■ Short attention span and difficulty to confrontation or stress and manages unusual concentrating for extended periods thoughts and impulses. ■ Poor response to confrontation and stressful These areas of cognitive and behavioral situations impairment are not frequently examined ■ Impairment in social functioning through traditional mental health or substance ■ Low motivation to engage in treatment use assessment instruments and yet are often more important than diagnoses in predicting These cognitive and behavioral deficits are treatment outcome and identifying needed important to consider in the context of screening treatment interventions. Assessment of and assessment for several reasons. First, they functional impairment typically requires extended may influence the accuracy of information observation of the individual’s behavior in settings obtained during screening and assessment. For relevant to the treatment and reentry process. An example, due to diminished attention span, understanding of functional impairment, strengths, agitation, and difficulty in remembering historical supports, skills deficits, and cultural barriers is information, assessments may need to be essential to developing an informed treatment plan administered in several different sessions. Second, and to selecting appropriate levels of treatment these considerations may shape the process of services (Andrews & Bonta, 2010b; Mee-Lee, conducting screening, assessment, treatment, 2013; CSAT, 2005a). and supervision. For example, the format of treatment groups may need to be modified to People in the justice system who have CODs include more experiential work; repetition of often have significant cognitive impairment, material; and extensive modeling, practice, and including deficits related to concentration and feedback related to psychosocial skills. Third, attention, verbal memory, and planning abilities these deficits may affect the outcomes of treatment or “executive functions” (Bellack et al., 2007; and supervision and should be considered in Blume & Marlatt, 2009; Brady & Sinha, 2007; determining the intensity, duration, and scope of Levy & Weiss, 2009; Peters et al., 2012). In treatment and supervision services. Finally, these comparison to other offenders, those with CODs areas may become the focus of some treatment and are characterized by the following cognitive and supervision activities through interventions such behavioral impairments: as cognitive and behavioral skills training and ■ Difficulties in comprehending, motivational enhancement groups. Unfortunately, remembering, and integrating important many of these complex areas of cognitive and information (particularly verbal behavioral functioning are not easily measured or assessed using traditional instruments. Assessment

28 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System of these areas is most effectively accomplished skills, training needs, financial support, and over a period of time and through an approach that eligibility for entitlements. Many of these incorporates observation, interview of collateral psychosocial factors accounted for in mental sources, review of records, and use of specialized disorder and substance use assessments are also assessment instruments. important for criminal risk and needs assessments. Finally, assessment should explore advantages Other Psychosocial Areas of Interest (and disadvantages) of reducing substance use Assessing individual strengths and environmental and becoming abstinent, and should identify supports can help to provide optimism for various types of “competing responses” to use of successful recovery, establish strategies for substances (e.g., prosocial leisure activities and managing mental and substance use disorders, peers). identify key interests and skills, and determine expectancies related to treatment (CSAT, 2005a; Criminal Justice Information Drake et al., 2007; Drake et al., 2008; Horsfall Assessment of CODs in the justice system should et al., 2009). Treatment goals and interventions carefully examine the criminal history and developed for justice-involved people who have current criminal justice status. The pattern of CODs should capitalize on existing skills and prior offenses may reveal important information strengths. Cultural and linguistic issues are also regarding how mental health and substance use important in designing treatment interventions problems have affected criminal behavior. The for CODs (CSAT, 2005a; Alegria, Carson, criminal justice history may also help to identify Goncalves, & Keefe, 2011; Hatzenbuehler, Keyes, the need for supervised reentry, case management Narrow, Grant, & Hasin, 2008). Cultural beliefs, services, placement in structured residential for example, may influence about programs following release from custody, and mental and substance use disorders, engagement relapse prevention strategies. Information in treatment services, and the role of treatment regarding current criminal justice status will assist professionals. They may also influence the ability in coordinating treatment and management issues or willingness to adapt to the treatment culture and with courts and community supervision staff. to handle conflict. In recent years, a number of key “criminal justice Several demographic and psychosocial indicators characteristics” have been identified among should also be reviewed when examining CODs. individuals in the justice system who have CODs. Assessment should examine educational history, These individuals tend to be younger at the time reading and writing capabilities, housing and of their first offense and often have a history of living arrangements, social interactions and aggressive or violent behavior. They also tend to lifestyle, peer influences on use of drugs and have histories of multiple incarcerations and are alcohol, family history, and current support often unable to function independently in criminal systems. Deficiencies in reading and writing justice settings (Baillargeon et al., 2010; Castillo skills may also influence the ability to successfully & Alarid, 2011; Kubiak, Essenmacher, Hanna, & engage in treatment planning and other key Zeoli, 2011; McCabe et al., 2012; Mueser, 2005; activities. The stability of the home and social Sindicich et al., 2014). environment should be assessed, to include the occurrence of violence and effects of the home Criminal risk should also be carefully examined, and other relevant social environments (e.g., as described in more detail in “Special Clinical work, school) on substance use and psychological Issues in Screening and Assessment for Co- functioning. Assessment should also consider the occurring Disorders in the Justice System.” The vocational and employment history, psychosocial most salient area of risk is for criminal recidivism, although assessment is sometimes conducted to

29 Screening and Assessment of Co-Occurring Disorders in the Justice System

identify risk for institutional violence, technical ■ Current court orders requiring assessment violations while on community supervision, and and involvement in treatment, including for committing sexual offenses. People in the the length of involvement in treatment (if justice system who have CODs are generally at specified) higher risk for recidivism than other offenders ■ Duration and conditions of current justice (Skeem, Nicholson, & Kregg, 2008). As described system supervision later in this monograph, key areas to include in ■ Current supervision arrangements (e.g., risk screening and assessment include “static” whether the person is supervised as part risk factors (e.g., history of prior felony arrests/ of a specialized caseload, the supervising convictions, and age at first arrest); “dynamic” probation or parole officer, frequency of risk factors related to antisocial beliefs, attitudes, court or supervision appointments, and fees behaviors, and peers; substance use problems; and reporting requirements) educational deficits; unemployment/vocational ■ Currently mandated consequences deficits; social and family problems; and lack for noncompliance with conditions of of prosocial leisure skills. Parental history of supervision, including any conditions involvement in the justice system may give related to treatment follow up information about the development of antisocial personality characteristics and issues related Drug Testing to child development and early attachment and There is a long-recognized relationship between loss. Assessment of criminal risk can identify chronic drug use and crime (Bennett, Holloway, the severity of problems in each of these areas & Farrington, 2008; Hser, Longshore, & Anglin, and the most important targets for intervention 2007; Paparozzi & Guy, 2011; Schroeder, during treatment and supervision. A range of Giordano, & Cernkovich, 2007; Stevens, 2010; risk assessment instruments are available that can Warren, 2008). National studies conducted by be administered at several different points in the the Arrestee Drug Abuse Monitoring (ADAM) justice system (e.g., pretrial, incarceration, reentry, program indicate that over 60 percent of community supervision). individuals charged with a criminal offense test positive for drug use at the time of arrest (National The following criminal justice information can Institute of Justice [NIJ], 2003; Valdez, Kaplan, assist in shaping treatment, supervision, and case/ & Curtis, 2007). Heavier drug users demonstrate treatment planning services for justice-involved more frequent and more severe criminal behavior individuals who have CODs: that fluctuates with their drug use (Anglin et al., ■ Risk for criminal recidivism 1996; Bennett et al., 2008; Carpenter, 2007). ■ History of felony arrests (including age at Decreasing substance use among justice-involved first arrest, type of arrest) individuals through treatment and monitoring ■ Juvenile arrest history can ultimately reduce the frequency of crimes (particularly violent crimes) committed by this ■ Alcohol and drug-related offenses (e.g., driving under the influence (DUI) or population. Drug testing is often used to identify driving while intoxicated (DWI), drug and monitor substance use, abstinence, relapse, possession or sales, reckless driving) and overall treatment progress in the justice system due to limitations of self-report data ■ Number of prior jail and prison admissions and duration of incarceration (Dupont & Selavka, 2008; Kleinpeter, Brocato & Koob, 2010; Large, Smith, Sara, Paton, Kedzior, ■ Disciplinary incidents in jail and prison & Nielssen, 2012; Martin, 2010; Peters, Kremling, ■ History of probation and parole violations & Hunt, 2015; Rosay et al., 2007). Drug testing is preferred over other means of detecting use,

30 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System such as self-report or observation of symptoms, is relatively easy to obtain (Heltsley et al., 2012; because it increases the likelihood of detection and Sample et al., 2010). Refusal to submit to drug reduces the lag time between relapse and detection testing and tainted samples should be regarded (Dupont & Selavka, 2008; Large et al., 2012; as positive test results. However, positive test Martin, 2010). results must be confirmed by use of additional “gold standard” testing procedures (e.g., gas Drug testing can be conducted at all stages of chromatography/mass spectrometry–GC/MS) the justice system, including after arrest; before using the original specimen provided (Mee-Lee, trial; and during incarceration, probation, and 2013; Cary, 2011; Meyer, 2011; NADCP, 2014; parole (Friedmann, Taxman, & Henderson, 2007; Paparozzi & Guy, 2011). Kleinpeter et al., 2010; Paparozzi & Guy, 2011). Drug testing can inform judges whether conditions Research examining the effectiveness of regarding substance use should be included in bail drug testing and supervision in reducing setting and sentencing. It can be used to ensure relapse, rearrest, failure to appear in court, and that an individual is meeting such requirements; unsuccessful termination from probation and for example, testing can provide information parole has demonstrated mixed results (Cissner about abstinence during probation and parole et al., 2013; Gottfredson Kearley, Najaka, & supervision. Use of drug testing is particularly Rocha, 2007; Hawken & Kleiman, 2009; Kinlock, important in drug courts, mental health courts, Gordon, Schwartz, & O’Grady, 2013; Kleinpeter and in other diversion programs that provide et al., 2010; Zweig, Lindquist, Downey, Roman, supervised treatment and case management & Rossman, 2012). For example, when assessing services in lieu of prosecution or incarceration whether pretrial drug testing reduced individual (Marlowe, 2003; NADCP, 2014; Paparozzi & Guy, misconduct during pretrial release, drug testing 2011). For example, within drug courts, routine was related to lower rearrest rates but not lower monitoring of substance use is often linked to failure-to-appear rates at one site, and lower sanctions that are established in advance and that failure-to-appear rates but not lower rearrest escalate. Examples of sanctions include verbal rates at another site (Rhodes, Hyatt, & Scheiman, reprimands by the judge, writing assignments, 1996). Variability in drug testing procedures (e.g., community service, and increasing intervals of frequency, responses to positive drug tests) has detention. been cited as a possible cause of these differences (Carey, Finigan, & Pukstas, 2008; Kleiman, 2011; When used in combination with treatment, routine NADCP, 2014; Zweig et al., 2012). drug testing can encourage treatment retention, compliance, and program completion. Positive Drug testing has different legal implications drug tests, failure to submit to drug testing, based on the stage of justice processing at which or adulterated samples should lead to routine it is used (NADCP, 2014; Cary, 2011; Carey, notification of judges, supervision officers, and Mackin, & Finigan, 2012; Harrell & Kleiman, others who provide oversight of the individual 2001; Marlowe, 2011; Marlowe, 2012b). When within the justice system. In order to reduce the drug testing is performed at the pretrial stage, prevalence of adulterated samples, individuals it typically cannot be used as evidence or should be supervised by a gender-matched considered in case outcomes, unless the arrestee individual while providing the sample, and a enters a preplea diversion program. Under these confirmatory sample should be provided as soon conditions, prosecution is deferred pending as possible if adulteration is suspected (Mee-Lee, successful completion of a substance use treatment 2013; Cary, 2011; NADCP, 2014). Saliva testing or other intervention program. Drug testing is can be used as a confirmatory sample because often used in conjunction with treatment and saliva collection is less easily tampered with and sanctions after a guilty plea has been submitted

31 Screening and Assessment of Co-Occurring Disorders in the Justice System and prior to sentencing. Individuals unable to Drug testing can present some interesting remain abstinent or to otherwise abide by program challenges when working with justice-involved requirements and guidelines in diversionary or individuals who have CODs. For example, among postsentence treatment settings are often sentenced people with mental disorders, drug testing can lead and processed through traditional criminal justice to distrust of treatment and service practitioners channels (NADCP, 2014; Carey et al., 2012). and reluctance to actively engage in treatment. It is important to carefully discuss drug-testing All justice-involved individuals who have CODs, expectations, parameters, and consequences and to including those in jail and prison, should be drug adhere consistently to drug-testing guidelines and tested (Carey et al., 2008; Carey et al., 2012; to reconfirm these on a regular basis. Individuals Gotffredson et al., 2007; Hawken & Kleiman, who are aware of these expectations and 2009; Kinlock et al., 2013; NADCP, 2014). parameters at the onset of substance use treatment More frequent drug testing should be provided are more likely to comply with these guidelines for individuals who are at high risk for relapse, (Burke & Leben, 2007; NADCP, 2014; Tyler, including people who have CODs, difficulties 2007). in achieving sustained abstinence, a history of frequent hospitalization, unstable housing Another challenge is coordination of drug testing arrangements, and who have been recently among several different treatment and service released from custody or are returning from practitioners. Often times, drug testing and community furloughs/visits. In general, drug treatment planning are not properly coordinated testing should begin immediately after an arrest between community treatment and service or other triggering event that brings the individual practitioners (e.g., primary care physicians) into contact with the justice system, and should be and staff working in criminal justice settings. administered randomly but at consistent intervals For example, physicians in the community during the course of treatment, supervision, and may prescribe anti-anxiety medications (e.g., incarceration. benzodiazepines) that may interfere with or undermine substance use treatment, and this For offenders with CODs, drug testing should information may not be communicated with be provided at least weekly, and optimally twice community supervision staff or other justice- weekly during the first few months of community related personnel. In some cases, medications treatment and supervision (Carey et al., 2008; prescribed for alcohol or opioid addiction (e.g., Carey et al., 2012; NADCP, 2014). The frequency methadone, naltrexone, buprenorphine) may be of drug testing may be tapered off as the individual misused by offenders and may actually undermine demonstrates the ability to remain abstinent. substance use treatment if drug testing and careful However, risk of relapse is an ongoing issue, monitoring are not provided. In other cases, particularly when the frequency and intensity drug testing may be ordered by several different of services are reduced as participants move treatment and service practitioners, and this successfully through program stages. Thus, it information needs to be shared with staff who is important to continue drug testing over time are providing criminal justice supervision and to confirm gains made during treatment, and as treatment services. Thus, it is important for staff people progress through treatment in the justice in criminal justice settings to involve community system (Cary, 2011; Marlowe, 2011, 2012; health care practitioners in treatment planning NADCP, 2014). It is equally important to develop and in ongoing discussions about medication models of intervention that recognize that relapse use, including sharing of information regarding is part of the recovery process. drug testing and prescription medication. This approach will assist in preventing relapse, crafting appropriate sanctions, and reinforcing the

32 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System importance of drug testing as an integral part of & Wong, 2008). Random drug testing is the most the overall treatment plan. effective in deterring substance use because the likelihood of detection is very high (Mee-Lee, Frequency of Drug Testing 2013; American Society of Addiction Medicine, Two types of testing schedules are typically 2010; Auerbach, 2007; Cary, 2011, McIntire et al., used once it is determined that drug testing is 2007). appropriate for a particular individual (Robinson & Jones, 2000). “Spot testing” is usually performed Regardless of the drug testing schedule, any on- if it is suspected that an individual is currently site testing should be sent to a lab for confirmation intoxicated and if a certain event occurs, such of a positive result to ensure the results are legally as a suspected resumption of criminal activity. admissible. This is particularly important for Spot testing can also be useful for detecting drug alternative drug testing methods, such as hair, or alcohol use during high-risk periods, such as sweat, or saliva testing. Confirmatory lab testing weekends or holidays (NADCP, 2014). These are is rarely performed, however, due to the expense unscheduled and use drug-testing methods that can of such testing. However, it is important to be be administered easily and inexpensively on site. able to confirm drug test results, as it may become Research indicates that during the initial phases necessary to produce this as evidence in court. of treatment, conducting drug tests at least twice Types of Drug Testing weekly are most effective because drug detection windows are 2–4 days for most types of drugs Several different types of drug tests are available (Carey et al., 2008; Carey et al., 2012). Blood that vary according to the level of accuracy and and saliva testing are the most accurate methods intrusiveness but are generally quite reliable. Six types of testing, as these are difficult to adulterate of drug testing are commonly used in justice settings, (Paparozzi & Guy, 2011). The utilization of including those that examine urine, blood, hair, saliva, breathalyzers is also useful during early stages of sweat, and breath. Improvements in urine testing treatment, as well as examination for physical and across classes of drugs include the use of portable behavioral signs of drug effects, such as cognitive urine technology (PUTT), which provides several symptoms or hand-eye coordination. advantages over larger but outdated approaches (e.g., Enzyme Multiple Immunoassay Technique Random drug testing allows programs to –EMIT). PUTT can be provided at a relatively discourage use while minimizing the cost of low cost, provides fast and efficient results, and frequent testing. Individuals do not know when offers ease of testing and interpretation. Examples they will be called in for testing and as a result are of PUTT are test strips, test cups, and hand-held less likely to use substances or to tamper with the cassettes, which allow for frequent and random drug testing process. Offenders in the community drug testing (Paparozzi & Guy, 2011). Another are often required to phone in to a central location detection device that has gained recent attention each morning to learn if they have to submit to a for improving compliance among alcohol users is drug test that day. If they are given such a notice, the Secure Continuous Remote Alcohol Monitor they are required to report for drug testing within (SCRAM). The SCRAM device is worn on the 10–12 hours. Although it is common practice to ankle, and is able to detect alcohol vapor in sweat schedule testing in weekly blocks, individuals and to wirelessly transmit this data. should be tested multiple times a week, so that offenders can’t anticipate what day of the week Hair testing provides an option for long-term they will be tested. Testing in weekly blocks detection of drug use, and has advantages in that increases the chances that offenders will engage it is difficult to adulterate hair samples. However, in short-term drug use, in which the drugs may be as noted in Table 1, caution should be used when out of their system by the next drug test (Marlowe conducting hair testing because of the risk for

33 Screening and Assessment of Co-Occurring Disorders in the Justice System external environmental contaminants and for methanol should not be used because these can racial bias (Cooper, Kronstrand, & Kintz, 2012; remove traces of the ingested drug(s). Vignali, Stramesi, Vecchio, & Groppi, 2012). In order to decrease the probability of external Hair samples should be collected within 4–6 contamination, it is recommended that hair weeks after drug ingestion to increase chances samples be taken from the scalp, as this hair has of detection. A positive hair sample should be the least variability in growth, and increases the confirmed with a separate second hair sample test. probability of detecting the ingested drug(s). Hair Hair samples should be dried upon collection, as samples should be approximately 0.5–1 inch in wet samples can alter analysis results (Cooper length. Moreover, it is recommended that hair et al., 2012). Finally, it is important to consider samples be washed prior to testing because this racial bias, as it is unclear whether hair testing removes not only environmental contaminants, but is equally effective in identifying cocaine use also contaminants from skin cells, bodily fluids, among ethnic or racial minorities. For example, and hair products. Although there are no standard studies indicate that there may be low agreement procedures for washing hair samples, solvents in frequency of consumption and concentration like acetone should be used because this removes levels found in hair samples, particularly among external contaminants but does not remove traces African Americans, for whom concentrations may of the ingested drug(s). Other solvents with be higher than indicated by self-reported substance use (Vignali et al., 2012).

Table 1. Comparison of Alternate Drug Testing Methodologies

Invasiveness Detection Cutoff Sample of Sample Advantages Disadvantages Cost Time Levels Collection Urine Intrusion of Hours to Yes High drug Cannot indicate Low to privacy days concentrations; blood levels; easy to moderate established adulterate methodologies; quality control and certification Blood Highly invasive Hours to Variable Correlates with Limited sample Medium to days limits of impairment availability; high detection infectious agent Hair Noninvasive Weeks to Variable Permits long-term Potential racial Moderate months limits of detection of drug bias and external to high detection exposure; difficult contamination to adulterate Sweat Noninvasive Days to Screening Longer time frame High inter-individual Moderate weeks cutoffs for detection than differences in to high urine; difficult to sweating adulterate Saliva Noninvasive Hours to Variable Results correlate Contamination from Moderate days limits of with impairment: smoke; pH changes to high detection provides estimates may alter sample of blood levels Breath Noninvasive Hours No, except Ethanol Very short time Low to for ethanol concentrations frame for detection; moderate correlate with only detects volatile impairment compounds

34 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System

Other forms of urine testing are available that Standardization of drug testing procedures increase the window of detection for up to occurred while NIDA was responsible for several days for specific metabolites of alcohol, overseeing the National Laboratory Certification ethyl glucuronide (EtG) and ethyl sulfate (EtS) Program (NLCP), which certifies all nationally (Cary, 2011). Procedures are also available recognized drug-testing laboratories. The NLCP to detect adulteration of drug test samples, is now operated by SAMHSA. The NIDA 8-10 including measurement of the temperature of panels are not typically conducted on site, and are samples (temperatures should range between sent to SAMHSA-certified labs for analysis. 90 and 100° F), where lower temperatures may indicate tampering. Creatinine levels can also In general, it is important to note the rapid be measured, for which lower concentrations development of alternative drugs that are not (below 20 mL) may indicate adulteration of test identified through these standard drug-testing samples (Mee-Lee, 2013; Katz, Katz, Mandel, procedures, such as “Spice” and “K2.” Offenders & Lessenger, 2007). Detailed information about may elect to use these during periods of drug each type of drug testing is included in Table testing (e.g., while involved in treatment) to avoid 1, which also provides a comparison of key detection of cannabinoids. Thus, random testing features, as well as advantages and disadvantages of a wide variety of standard and alternative drugs of the different types of drug testing. Standard is advised (Mee-Lee, 2013; Cary, 2011; Perrone, procedures used by most drug-testing companies Helgesen, & Fischer, 2013). include the SAMHSA 5 (previously known as the Chain of Custody Process NIDA 5), and the NIDA 7, NIDA 8, and NIDA 10, To ensure that a drug test sample is admissible in which provide testing for commonly used illegal court, documented procedures must be in place for drugs whose detection has been standardized by collection, testing, and storage. Clear procedures the National Institute on Drug Abuse (NIDA) should be established that delineate the chain of due to the frequency of their use (Clark & Henry, custody from the time of sample collection to the 2003). The NIDA 7, 8, and 10 test for additional time of official reporting of drug test results within drugs not covered by the SAMHSA 5 panel. For the justice system. All professionals involved example, the NIDA 8 test panel examines the in this process are ultimately held accountable following drugs: for their role in maintaining standards for drug ■ cannabinoids (marijuana, hash) testing (Mee-Lee, 2013; Cary, 2011; Meyer, ■ cocaine (cocaine, crack) 2011; NADCP, 2014). All laboratory tests ■ amphetamines (amphetamines, should examine the likelihood of tampering or methamphetamines, speed) adulteration. Specimens should be stored in a ■ opiates (heroin, opium, codeine, morphine) locked, temperature-controlled space and remain there until the possibility of a challenge or court ■ phencyclidine (PCP) hearing has passed. Records should be kept ■ MDMA (ecstasy) that document the chain of custody regarding ■ barbiturates responsibility for oversight of the specimen at each ■ benzodiazepines point in the drug testing process, as well as the time and date that any particular activity occurred. The NIDA 10-panel screen tests for hydrocodone Key drug testing activities include the following and oxycodone in addition to the drugs in the (NADCP, 2014): NIDA 8 panel, while the NIDA 7 screens for ■ The individual reporting for testing or MDMA in addition to the standard SAMHSA 5 check-in drugs and distinguishes between amphetamines and methamphetamines. ■ Sample collection

35 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ Storage procedures of functioning, symptoms, and level of ■ Examination of the sample for adulteration criminal risk ■ Transportation to the laboratory Another complicating factor is that individuals ■ Sample testing vary greatly in their expression of CODs. Mental ■ Follow-up tests and substance use disorders have a waxing and waning course and may manifest differently at ■ Review of the results different points in time. Individuals who have ■ Recording of the results mental disorders may be particularly vulnerable to the effects of substance use, even in relatively Enhancing the Accuracy of small amounts. For example, small amounts Information in Screening and of alcohol or drug use can heighten symptoms Assessment of mental disorders. Symptoms of severe substance use disorders may vary depending on There are numerous challenges in gathering the substances used and accompanying mental accurate screening and assessment information disorders. The chronic nature of substance regarding people who have CODs in the justice use also makes it difficult to date the onset and system (Fletcher et al., 2009; Lehman et al., 2009; duration of CODs and periods of abstinence. Taxman et al., 2009). Accuracy of information Cognitive impairment and other mental health obtained during screening and assessment can be symptoms may lead to inaccurate recall of compromised by many factors (Cropsey et al., information. Undiagnosed TBI (e.g., as a result of 2007; Hiller et al., 2011; Osher, 2008; Peters et al., frequent fights, injuries from falling, or of combat 2012; Zweig et al., 2012), including the following: among veterans) may also influence the level of cognitive impairment. Finally, the consequences ■ Inadequate staff training and poor familiarity with mental and substance use of substance use among justice-involved people disorders who have CODs may be quite different than among other populations, including revocation of ■ Time constraints in conducting screening probation or parole, and incarceration in jail or and assessment prison. ■ Previous results of screening and assessment, which have been conducted Symptom Interaction between Co- under suboptimal conditions or by occurring Disorders untrained staff who may not be aware of unique issues related to CODs Screening and assessment of CODs are often rendered more difficult by symptom interactions, ■ Incomplete, mislabeled, or misleading clinical or criminal justice records including symptom mimicking, masking, precipitation, and exacerbation (Brady & Sinha, ■ The transparent nature of screening and 2007; Horsfall et al., 2009; Schladweiler, assessment instruments may lead to individuals providing false information Alexandre, & Steinwachs, 2009; Tsuang, Fong, & Lesser, 2006). Understanding these interactions is ■ Offenders may anticipate negative important in identifying issues that may contribute consequences related to disclosure of to substance use relapse, recurrence of mental mental health or substance use symptoms health symptoms, or both (Donovan, 2005; Gil- ■ Symptoms may be feigned or exaggerated Rivas, Prause, & Grella, 2009; Mazza et al., 2009; if an offender believes this will lead to Schladweiler et al., 2009). Ongoing observation more favorable placement or disposition of symptom interaction is often needed to provide ■ Results of previous screening or assessment may be invalid due to changes in the level

36 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System differential diagnosis of various mental and symptoms to receive medication, housing in substance use disorders. medical units, or contact with medical staff.

Several important types of symptom interaction Accuracy of Self-report Information should be noted: Screening and assessment of mental and substance ■ Use of alcohol and drugs can create mental use disorders in the justice system is most often health symptoms based on self-report information. In general, ■ Alcohol and drug use may precipitate or self-report information has been found to have elicit symptoms of some mental disorders fair to good reliability and specificity but does ■ Mental disorders can precipitate substance not always identify the full range of symptoms of use disorders. Most individuals who CODs (Drake, Rosenberg, & Mueser, 1996; Peters have CODs indicate that mental health et al., 2015; Hjorthoj, Hjorthoj, & Nordentoft, symptoms preceded their substance use 2012; Schuler, Lechner, Carter, & Malcolm, ■ Mental health symptoms may be worsened 2009; Wood, 2008). Furthermore, self-report by alcohol and other drugs information obtained from justice-involved ■ Mental health symptoms or disorders are individuals has been found to be valid and useful sometimes mimicked by the effects of for treatment planning (Landry, Brochu, & substance use (e.g., cocaine intoxication Bergeron, 2003; Schuler et al., 2009; Peters, et al., can cause auditory or visual hallucinations) 2015; Wood, 2008). In post-adjudicatory settings, ■ Alcohol and other drug use may mask or self-reported criminal history information tends to hide mental health symptoms or disorders be more comprehensive than information obtained (e.g., alcohol intoxication may mask solely from archival records, and self-reported underlying symptoms of depression) demographic information is quite consistent with archival records. The considerable symptom interaction between CODs often leads to difficulty in interpreting Accuracy of self-reported substance use can whether symptoms are related to a mental disorder be influenced by several factors. Self-reported or to a substance use disorder (Steadman et substance use information provided by justice- al., 2013). Justice-involved individuals who involved individuals has been found to be have CODs may have difficulty providing an generally less accurate than that provided by accurate history of symptom interaction due clients enrolled in substance use treatment and to cognitive impairment, active mental health patients interviewed in emergency rooms (Magura symptoms, confusion regarding the effects of & Kang, 1996; McCutcheon et al., 2009; Sloan, their substance use, and to the chronic nature Bodapati, & Tucker, 2004). The validity of of their alcohol and drug use (Bradburn, 2000; self-report information in the justice system is Langenbucher & Merrill, 2001; Sacks, 2008). also influenced by the type of substances used Justice-involved individuals may also anticipate (Mieczkowski, 1990; Peters et al., 2015; Hjorthoj negative consequences related to self-disclosure et al., 2012; Rosay et al., 2007). For example, of mental health or substance use symptoms, such individuals are more likely to admit to marijuana as placement under more restrictive conditions use rather than opiate or cocaine use, and are of supervision or placement in more intensive least likely to admit to cocaine use, followed by treatment. Alternatively, symptoms may be amphetamines, opiates, and marijuana (Knight, feigned or exaggerated if an individual believes Hiller, Simpson & Broome, 1998; Lu, Taylor, this will lead to more favorable placement or & Riley, 2001; Peters et al., 2015; Hjorthoj et disposition. For example, individuals who are al., 2012; Rosay et al., 2007). Accuracy of self- incarcerated may falsely report mental health reported substance use is less accurate for patterns

37 Screening and Assessment of Co-Occurring Disorders in the Justice System of recent use (De Jong & Wish, 2000; Large et al., and substance use problems (Del Boca et al., 2013; 2012; Lu, Taylor, & Riley, 2001; Magura & Kang, Sacks, 2008). Specifying a time frame related 1996; Yacoubian,VanderWall, Johnson, Urbach, & to past substance use rather than asking about Peters, 2003). In one study (Harrison, 1997), only “typical” or “usual” substance use patterns also half of arrestees who tested positive for drug use enhances the reliability of self-report information reported recent use. (Del Boca & Darkes, 2003; Del Boca et al, 2013).

Other important factors influencing accuracy of Use of Collateral Information self-reported substance use are discrimination and Whenever possible, results from interviews and perceived consequences related to detection of use, instruments used to examine CODs should be including enhanced severity of criminal sentences, supplemented by collateral information obtained more stringent conditions of supervision, more from family members, friends, house mates, and intensive treatment, and incarceration. Some other informants who have close contact with the offenders may try to influence others’ individual (DeMarce, Burden, Lash, Stephens, of their drug use to avoid social exclusion (i.e., & Grambow, 2007; Stasiewicz et al., 2008). In positive impression management) by minimizing addition, observations of symptoms and behaviors reported substance use. Demographic and by arresting officers, booking officers, correctional background variables may affect the accuracy staff, probation and parole officers, treatment staff, of reporting. Youthful and African American case managers, and other staff can provide relevant offenders tend to underreport crack/cocaine use in collateral information. Nonclinical staff who comparison to other offenders. Female offenders interact with the justice-involved individual may are more likely than males to provide accurate be particularly helpful in describing withdrawal self-reporting of substance use (Peters et al., 2015; symptoms; relapse indicators; mental health Rosay et al., 2007; Schuler et al., 2009). The symptoms; and other significant psychosocial presence of mental disorders and physical and problems, such as self-destructive behaviors or cognitive impairment may also affect the accuracy interpersonal difficulties. of self-disclosed substance use, in addition to cultural issues and credibility of the interviewer Observation by family members, friends, or (Blume, Morera, & García de la Cruz, 2005; Del direct care staff can provide information that is Boca, Darkes, & McRee, 2013; Kuendig et al., as accurate as data compiled from interviews 2008; Peters et al., 2015). Given the potentially or standardized instruments (Comtois, Ries, significant consequences for detection of alcohol & Armstrong, 1994; DeMarce et al., 2007; and other drug use in justice settings, it is widely Stasiewicz et al., 2008). For example, in accepted that self-report information should be community settings, the combination of ongoing supplemented by collateral information and drug observation, collateral reports, and interviews has testing when available. produced the most accurate information regarding current alcohol use among individuals with Strategies for maximizing the accuracy of schizophrenia (Drake et al., 1990). Substance- self-report information include providing using associates often provide more accurate clear instructions regarding the screening and information than non-using family members assessment process, engaging justice-involved regarding patterns of substance use (Hagman, individuals in a dialogue about the purpose of Cohn, Noel, & Clifford, 2010; Kosten & Kleber, screening and assessment, establishing rapport 1988). Unfortunately, individuals who have CODs through use of motivational interviewing and often have constricted social networks and live in other related techniques, and carefully explaining isolated settings, thus limiting the use of collateral the scope of and limits to confidentiality and the informants (Drake, Alterman, & Rosenberg et al., potential consequence for reporting mental health

38 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System

1993; Hawkins & Abrams, 2007; Min, Whitecraft, When using an extended assessment period, Rothbard, & Salzer, 2007; Stasiewicz et al., 2008). addressing acute symptoms and safety issues (e.g., suicidal behavior) should take precedence Use of an Extended Assessment Period over the development of diagnoses. With careful Many individuals who are screened or assessed medical assessment, psychotropic medication can for CODs in justice settings may be under the be provided to treat acute mental health symptoms influence of alcohol or other drugs. In order to among individuals with CODs who are suspected accurately examine CODs and related issues, of recent drug or alcohol use. Given the variability these individuals need to be provided a period of of symptoms over time among justice-involved detoxification. Even for those in jail or prison, individuals with CODs, diagnostic indicators residual effects of substance use may cloud should be continually reexamined by staff who the symptom picture for several months after are knowledgeable about patterns of symptom incarceration. interaction. As discussed previously, it is also important to reassess risk for criminal recidivism, If there is uncertainty regarding recent substance as the specific factors that contribute to recidivism use, an extended assessment period or “baseline” risk (e.g., criminal peers, employment, family is recommended to help determine whether mental supports) can change over time, leading to lower health symptoms are likely to resolve, persist, or or higher risk levels. In many justice settings, worsen. While the DSM-IV-TR and DSM-5 criminal risk is reassessed via standardized risk (APA, 2000; APA, 2013) indicate that individuals assessment instruments approximately every 6 should be abstinent for approximately 4 weeks months, as this provides a sufficient window to before an accurate mental health diagnosis can be allow relevant changes to occur. provided, the precise ...it is...important length of the extended Several steps are often taken during an extended to reassess risk baseline for screening assessment period to determine the presence, and assessment should scope, and severity of CODs: for criminal be determined by the ■ Assess the significance of the substance use recidivism, as the severity of the disorder specific factors symptoms and the » Obtain a longitudinal history of mental that contribute to general health status. health and substance use symptom recidivism risk (e.g., The utility of screening onset criminal peers, and assessment in » Analyze whether mental health employment, family detecting mental health symptoms occur only in the context supports) can or substance use needs of substance use and identify specific may be limited among change over time, types of mental health symptoms and justice-involved related behavioral problems that have leading to lower or individuals whose been elicited by prior substance use. higher risk levels symptoms are in For justice-involved individuals, it temporary remission, is particularly important to identify especially if the in advance the types of sanctionable instruments utilized focus primarily on current behaviors that have occurred in the symptoms. It may be more relevant to examine past during periods of relapse. It and incorporate the history and level of is also useful to ascertain whether psychosocial functioning during the past year in criminal justice sanctions and rewards making determinations related to service and have influenced the degree and intensity of substance use treatment needs.

39 Screening and Assessment of Co-Occurring Disorders in the Justice System

» Determine whether sustained take place in lock-ups and other more abstinence leads to rapid and full restrictive settings, and the lack of privacy, remission of mental health symptoms external noise, and other factors may need ■ Determine the length of current abstinence to be taken into account when examining responses) » If 4 weeks of abstinence has not been achieved, diagnosis and full ■ The interview should be prefaced by a clear interpretation of the interactive articulation of the limits of confidentiality, effects of CODs may be delayed until and the justice entities involved in abstinence has been achieved receiving information ■ Reassess mental health symptoms after a ■ Examine nonintrusive information first period of sustained abstinence (e.g., background information), during the assessment interview. After rapport ■ As mental health symptoms resolve, has been established, proceed to address traditional substance use treatment services substance use issues and other domains may be appropriate (e.g., drug courts, (e.g., living situation, educational and intensive outpatient programs); if not, the vocational history). Sometimes gathering individual may require specialized mental mental health information near the end of health or CODs treatment services the assessment interview offers a chance ■ Periodically reevaluate criminal risk and to develop rapport before asking about the symptoms of mental and substance information that may be more prejudicial use disorders to determine the level of and difficult to disclose; at the same time, treatment, ancillary services, housing engaging with the person requires that the assignments (if in correctional settings), interviewer meet the person where they and supervision that are needed are, and if they choose to begin with their mental health history, the interviewer needs Other Strategies To Enhance the to flexibly adapt to this new interview Accuracy of Screening and Assessment sequence Information ■ Use motivational interviewing techniques ■ Use archival records to examine the to enhance accurate self-reporting. onset, course, diagnoses, and response Key techniques include expressing to treatment of mental and substance use empathy, fostering an understanding disorders, and other relevant history of the discrepancy between a person’s stated life goals and current behaviors ■ Wait to use self-report instruments until (e.g., substance use), avoiding arguing, it is determined that an individual is not addressing resistance by offering new intoxicated or in withdrawal options, encouraging behavior change, and ■ Re-evaluate using self-report instruments if supporting self-efficacy and self-confidence initial assessments were conducted during a ■ Depending on the context, use of a period when mental health symptoms were structured interview approach may be more prominent preferable. This may include (1) screening ■ Provide repeated screening and assessment for consequences of substance use, (2) over time a lifetime history related to CODs, (3) a ■ Utilize interview settings, to the extent calendar method to document patterns of possible in justice settings, to promote substance use in recent months (e.g., use of disclosure of sensitive clinical information timeline follow-back procedure), and (4) ■ Compile self-report information in a assessment of current and past substance nonjudgmental manner and in a relaxing use setting when possible (some screenings

40 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System

■ Review the psychometric properties reserved for higher risk offenders (Andrews & of available screening and assessment Bonta, 2010; Bonta & Andrews, 2007). instruments. Research indicates that these instruments have different levels of Research has identified a common set of specificity, sensitivity, and overall accuracy “criminogenic needs” that should be addressed in in justice settings and may also vary in offender treatment programs, including specialized their effectiveness with different ethnic and CODs programs (Andrews et al., 2006). Attention racial groups to these needs can have a cumulative effect in reducing recidivism (Andrews & Bonta, 2010a; Special Clinical Issues in Screening Carey & Waller, 2011). Thus, offender programs and Assessment for Co-occurring should focus on multiple needs that are linked to recidivism (Bonta & Andrews, 2010). These Disorders in the Justice System criminogenic needs are dynamic, and can be Risk Assessment changed through interventions such as those provided in specialized and highly structured Identifying “High Risk” and “High Need” CODs treatment programs. Offender programs Offenders that focus on criminogenic needs result in average There is abundant evidence indicating that reductions in recidivism of 19 percent (Bonta & programs for offenders with CODs, where there Andrews, 2007). The major criminogenic needs are limited resources and where the goal is to include the following: reduce recidivism, should target those who are ■ Antisocial attitudes at “high risk” for recidivism (Andrews, 2012; ■ Antisocial personality features Andrews & Bonta, 2010a; Kushner, Peters, & Cooper, 2014). Criminal risk is typically ■ Antisocial friends and peers determined by examining a combination of ■ Substance misuse “static” or unchanging factors (e.g., age at first ■ Family and social/relationship problems arrest, number of prior arrests/convictions) and ■ Education deficits “dynamic” or changeable factors, otherwise ■ Poor employment skills known as “criminogenic needs” (see description to follow), which independently contribute to the ■ Lack of prosocial leisure activities risk for recidivism. Programs that target high- Programs for offenders with CODs should also risk offenders reduce recidivism by an average of avoid targeting areas that have been found to be 10 percent (Bonta & Andrews, 2007), and yield unrelated to the risk for recidivism, such as self- approximately double the economic benefits esteem and emotional discomfort, and structured (Bhati, Roman, & Chalfin, 2008; Lowenkamp, disciplinary programs, such as “boot camps” Holsinger, & Latessa, 2005; Lowenkamp, Latessa, (Andrews & Bonta, 2010b). & Holsinger, 2006). Targeting “high risk” and “high need” offenders is consistent with principles Although mental disorders are not independently of the widely accepted Risk-Need-Responsivity linked with recidivism (Fisher et al., 2014; (RNR) model, which is described later in this Junginger, Claypoole, Laygo, & Crisanti, 2006), monograph (Andrews, Bonta, & Wormith, 2006; offenders who have mental disorders are at Bonta & Andrews, 2007; McMurran, 2009). The high risk for recidivism due to elevated levels “Risk Principle” from this model indicates that the of criminogenic needs, including substance use intensity of services provided by CODs programs disorders, lack of education, unemployment, should be proportional to the risk of recidivism, and lack of social support (Skeem, Nicholson, and that the most intensive services should be & Kregg, 2008). Thus, while treating mental

41 Screening and Assessment of Co-Occurring Disorders in the Justice System disorders alone does not reduce risk for 2007). This can also reduce “protective factors” recidivism among offenders with CODs, it is for criminal behavior among lower risk offenders, vitally important to involve these people in such as involvement in school, employment, and comprehensive treatment that addresses a range family, and can provide exposure to more severe of criminogenic needs. Enhanced mental health antisocial behaviors and peer groups that are more functioning can contribute to the responsivity of likely to reinforce and support criminal activity other interventions that reduce recidivism (e.g., (Lowenkamp & Latessa, 2004). However, CODs substance use treatment); thus, mental health treatment, in general, can serve low risk offenders treatment is considered an important area to target who may be at risk of increased substance use among offenders. For example, if an individual without treatment. is too depressed to get out of bed, he or she may miss a probation appointment or a mandated Matching offenders who have CODs to different drug screen, potentially resulting in a violation levels of supervision is also important (Kushner of conditions of probation and arrest. This does et al., 2014). For example, offenders have better not mean the mental disorder increases criminal outcomes when the frequency of court status conduct, but it can contribute to further penetration hearings is matched to their risk level (Listwan, within the justice system, especially related to Sundt, Holsinger, & Latessa, 2003). High-risk technical violations. Also, the ability for probation offenders experience better outcomes when to supervise effectively can be impacted by mental attending frequent status hearings, while low- disorders. While there are legal mandates for risk offenders have worse outcomes (Marlowe, providing mental health services in correctional Festinger, Lee, Dugosh, & Benasutti, 2006). The settings, these services also help to ameliorate purpose of matching offenders to different levels behavioral problems and human suffering. In of supervision is based on an understanding of addition, treatment of mental health problems is the offenders’ needs and how meeting these needs of critical importance in engaging offenders who will enhance outcomes. For instance, high-risk have CODs in other evidence-based services, such offenders have multiple criminogenic needs as substance use treatment, vocational training, (e.g., substance use, antisocial beliefs and values, educational services, and family counseling, again education, employment) that require frequent fostering their responsivity to these interventions. and ongoing supervision specifically tailored to these needs, to the risk for relapse, and to the Criminal justice programs should not focus level of social and occupational functioning. intensive oversight and services on offenders who In addition to involvement in mental health have low levels of risk and criminogenic needs, treatment and specialized dual disorders treatment, as this approach is likely to ineffectively allocate high-risk offenders who have CODs should be intensive resources for individuals who do not encouraged to engage in prosocial activities, require them (DeMatteo, 2010; Lowenkamp & cognitive restructuring related to criminal Latessa, 2005). Placement of low risk/low need thinking, educational and vocational training offenders in intensive treatment services can programs, and family and social support services. increase the probability of substance use and Other key areas include relapse prevention crime (Lowenkamp & Latessa, 2005), as these and case management to assist with housing, offenders do not require intensive treatment or transportation, and enrollment in benefits. On supervision, and reductions in recidivism are likely the other hand, low risk offenders tend to have to be quite small. Also, mixing low risk/low need higher functioning related to the criminogenic offenders with people who have more pronounced need areas and therefore may not require the and ingrained antisocial characteristics can be same level of intensive treatment services and counterproductive and lead to poor outcomes community supervision (Steadman et al., 2013). (Andrews & Dowden, 2006; Bonta & Andrews, In fact, evidence shows that placing people who

42 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System are at low risk in highly intensive services can (e.g., arrest history) and other archival lead to increases in recidivism and other adverse information is routinely included in the outcomes (Andrews, 2012; Lowenkamp & risk assessment process. Staff training is Latessa, 2004). required for administration and scoring of risk assessment instruments. Most Implications for Screening and Assessment of risk assessment instruments include brief CODs in the Justice System screening versions that vary in the time Screening and assessment of offenders who have required for administration CODs should include identification of risk for ■ Risk assessment instruments vary in their recidivism, including specific “criminogenic need” predictive validity with different gender factors. This information is most effectively and race/ethnicity groups (Desmarais & compiled through administration of a formal risk Singh, 2013). Third and fourth generation assessment instrument, which addresses both risk assessment instruments that include static and dynamic factors that influence the structured professional judgment tend to have better predictive ability than likelihood for recidivism. Both CODs treatment second generation instruments, which rely and supervision may be structured quite differently on actuarial approaches (Singh, Fazel, for people who have different levels of risk and Gueorguieva, & Buchanan, 2014) criminogenic needs (Marlowe, 2012a). Several ■ Several monographs provide detailed key issues in conducting risk assessment are descriptions of available risk assessment highlighted below: instruments, including those developed ■ Eligibility screening processes for by the Council of State Governments offender CODs programs should prioritize Justice Center (Desmarais & Singh, 2013) admission for people who have high risk and the National Center for State Courts and high levels of criminogenic needs, such (Casey, Warren, & Elek, 2011). Although as people who have a significant criminal a comprehensive description of risk history and a severe substance use disorder assessment instruments is beyond the scope ■ Risk level should be identified at the of this monograph, several commonly used earliest possible point prior to disposition instruments include the following: (e.g., sentencing) of offenders who have » Level of Service Inventory–Revised CODs. In many criminal justice settings, (LSI-R; Andrews, & Bonta, 1995) a two-tiered process is used for risk » Ohio Risk Assessment System (ORAS; identification. This includes an initial Latessa, Smith, Lemke, Markarios, & brief risk screening to identify and sort out Lowencamp, 2009) low-risk offenders, who can benefit from low-intensity programs (e.g., diversion), » Correctional Offender Management and a comprehensive risk assessment to Profiling for Alternative Sanctions more precisely identify the risk level and (COMPAS; Brennan & Oliver, 2000) to identify specific criminogenic needs that » Wisconsin Risk/Needs (WRN; should be targeted in CODs programs Henderson, 2007) scales and the Client ■ A variety of standardized and validated risk Management Classification (CMC; assessment instruments are available for Arling & Lerner, 1980) offenders with CODs. These instruments » Risk and Needs Triage (RANT; generally address similar sets of static Marlowe et al., 2011) and dynamic risk factors, and are quite » Historical-Clinical-Risk effective in the initial sorting of offenders Management-20 (HCR-20; Webster, to low, medium, and high risk categories. Douglas, Eaves, & Hart, 1997) Review of criminal justice records

43 Screening and Assessment of Co-Occurring Disorders in the Justice System

» Short-Term Assessment of Risk and tailored for participants with varying Treatability (START; Webster, Martin, levels of criminal risk and criminogenic Brink, Nicholls, & Middleton, 2004) needs (Marlowe, 2012a). For participants » Risk-Needs-Responsivity Simulation with higher levels of risk and need, these Tool (Crites & Taxman, 2013) tracks may be longer in duration; include more intensive treatment and supervision ■ Risk assessments should be periodically services; and provide services to address readministered to offenders with CODs, specific criminogenic needs, such as as risk level and criminogenic needs cognitive interventions to modify criminal change over time. Changes detected in attitudes and beliefs the overall risk level and in the pattern of criminogenic needs will help inform ■ Clinical judgment and input from treatment placement in treatment and supervision and service practitioners should be services and may signal the need for further included when determining level of risk psychosocial assessment. The frequency and matching offenders to varying levels of of reassessing risk assessments should be treatment and supervision determined by the justice setting and the ■ The validity of risk assessment instruments likelihood for change among the dynamic may vary according to characteristics of risk factors assessed. For example, people different justice-involved populations; who are placed on community supervision conditions present within the jurisdiction/ will ordinarily have greater potential for setting (e.g., law enforcement and change in dynamic risk factors related to prosecutorial practices, community employment, family and social supports, supervision resources); and the population and substance use in comparison to people base rates of arrest, crime, and violence. who are in custody settings As a result, risk assessment instruments ■ As mentioned previously, major deficits should be validated within the specific related to criminogenic needs that are jurisdiction and justice setting for which identified during risk assessment should they are intended to be used. Validation be addressed in CODs treatment programs should examine the ability of a particular and in community supervision, with instrument to accurately classify justice- specific goals, objectives, and interventions involved populations into categories of risk articulated for each area of criminogenic (e.g., low, medium, and high) according need to outcomes of interest, such as arrest or ■ Information regarding criminal risk and return to custody. This analysis determines types of criminogenic needs should be the “positive predictive value” of the risk considered in placing offenders with assessment instrument. CODs in treatment and supervision. For example, within court-based programs, Evaluating Suicide Risk criminal risk level may be particularly More than 90 percent of people who commit useful in determining the frequency of suicide in the United States have a history of status hearings. Other formal placement mental disorder(s), particularly depression and criteria (e.g., American Society of substance use (U.S. Department of Health & Addiction Medicine Patient Placement Human Services, 2003; Nock et al., 2008; Nock Criteria; ASAM PPC; Mee-Lee, 2013) may et al., 2009; Rush, Dennis, Scott, Castel & Funk, also be very helpful in triaging offenders 2008). Within justice settings, suicide attempts with CODs to different levels and types of treatment are five times more likely among people who have mental disorders (Goss, Peterson, Smith, ■ CODs programs for offenders may benefit Kalb, & Brodey, 2002; Hayes, 2010), perhaps due from including special “tracks” that are

44 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System to increased stress related to incarceration and Most suicidal behavior is preventable through community supervision and to the disproportionate implementation of comprehensive screening, numbers of those who have CODs. Ongoing triage, supervision procedures, and changes to the suicide screening is particularly important for immediate residential environment (e.g., removal offenders who have CODs, as the combination of of items from the jail or prison cell, increasing serious mental illness, such as severe depression, the frequency of staff monitoring). The goals bipolar disorder, and schizophrenia, and substance of screening for suicide risk are to identify risk use or withdrawal has been found to significantly and protective factors and to implement a plan elevate the risk for suicide (Hawkins, 2009; Hayes, of preventive action, as needed. It is useful to 2010; Nock et al., 2009; Ruiz, Douglas, Edens, gather suicide screening information from multiple Nikolova, & Lilienfeld, 2012). Given the high sources, including interviews with the offender, proportion of people with CODs in the justice objective/self-report instruments, collateral reports system, it is essential that suicide screening be from those who have ongoing contact with the conducted in a comprehensive and systematic person, and medical/treatment records and other manner. Screening should be conducted at the archival information. Direct questioning of the time of entry into justice settings and at transfer offender is needed to examine suicidal intentions, to different settings, including correctional lethality of potential behavior, probability of the institutions. A number of well-validated suicide behavior (e.g., specific plans), and means available screening and assessment instruments are to accomplish suicide. described later in this monograph. The Suicide Risk Decision Tree framework Screening for suicide risk in the justice system is provides a comprehensive approach in assessing important for both legal and ethical/professional suicide risk (Cukrowicz, Wingate, Driscoll, & reasons. Much of the litigation involving Joiner, 2004; Joiner, Walker, Rudd, & Jobes, correctional mental health services has focused 1999; Joiner, Van Orden, Witte, & Rudd, 2009). on inadequate suicide screening and prevention This interview assessment tool addresses two procedures. Screening for suicide risk should important factors in determining suicide risk: be conducted at every major transition point (1) desire, and (2) capability to commit suicide. within the criminal justice system, including at Desire is composed of two main components: arrest, booking in jail, enrollment in diversion lack of belonging to important social groups and programs, involvement in community supervision, perceived burdensomeness; for example, the transfer to prison, and release from custody. individual feels like a burden to his or her family Many standardized suicide risk screening tools and friends. The second factor, capability, is the are available that can be administered by either acquired ability to engage in self-harm, which is mental health professionals or other staff working influenced by fearlessness of death, suicidal plans in justice settings. Many of these screens do not and preparations, and duration and intensity of require intensive training to administer, score, and suicidal ideation. interpret, although all staff who administer suicide risk screening should be fully versed in methods The Suicide Risk Decision Tree interview also to refer offenders with elevated suicide risk to examines other risk and protective factors to appropriate resources. For example, if there are determine the overall severity of suicide risk. questions regarding the level of suicide risk or if The Interpersonal Needs Questionnaire (INQ)/ the level of suicide risk is determined to be high, a Acquired Capability for Suicide Scale (ACSS) full assessment should be conducted by a trained is a shorter, two-part self-report suicide screen and licensed or certified mental health clinician. based on the Suicide Risk Decision Tree (Van Orden, Cukrowicz, Witte, & Joiner, 2012). The INQ/ACSS, Suicide Risk Decision Tree, and

45 Screening and Assessment of Co-Occurring Disorders in the Justice System

other screening and assessment instruments for ■ Fearlessness of death (e.g., repeated suicide risk are described later in this monograph. exposure to traumatic events) As mentioned previously, assessments using the ■ Impending court dates Suicide Risk Decision Tree or other approaches ■ Recent incarceration should be conducted by trained and licensed or certified mental health professionals who are Areas for Brief Screening of Suicide Risk familiar with suicide risk and protective factors Brief screening for suicide risk can be conducted and who can provide clinical services or referral to by nonclinical staff, although screening staff these services. should be trained in how to provide immediate responses to promote safety and to prevent suicide, Suicide Risk Factors including referral sources for further assessment. The following suicide risk factors are important Suicide risk screening should address the to examine in the process of screening and following areas: assessment for suicide risk (Centers for ■ Current mental health symptoms Disease Control and Prevention, 2008; Hayes, 2010). Review of these risk and protective ■ Current suicidal thoughts factors can help identify people who need more ■ Previous suicide attempts and their comprehensive assessment, close supervision, and seriousness other precautions to prevent suicide: ■ Whether suicide attempts were intended or ■ Age (escalation of risk with age, accidental particularly over 45; however, suicide rates ■ The relationship between suicidal behavior among young people have been increasing) and mental health symptoms ■ Gender (higher risk of completed suicides ■ Lack of social support or feelings of for males, higher risk of suicide attempts connectedness to important social groups for females) ■ Feelings of burdensomeness to family and ■ Race and ethnicity (highest risk for suicide friends among Whites) ■ Acquired ability to engage in self-harm ■ Previous or current psychiatric diagnosis (e.g., capability, fearlessness of death) ■ Current evidence of depression As mentioned previously, for people with ■ Substance use identified suicide risk, a thorough assessment ■ Poor problem solving or impaired coping should be conducted by a trained and licensed or skills certified mental health professional. Assessment ■ Social isolation and limited social support of suicide risk/potential should include an ■ Previous suicide attempt(s) interview to review thoughts, behaviors, and plans related to suicide. In addition to the screening ■ Family history of suicidal behavior items described previously, the following areas ■ History of physical, sexual, or emotional should be reviewed during the assessment abuse; family violence; and exposure to interview: punitive parenting ■ Thoughts related to suicide (i.e., ■ History of prostitution frequency, intensity, duration, specificity), ■ Current and identifiable stressors, with distinguishing between passive and active a particular focus on recent losses and suicidal thoughts diminished supports (e.g., related to ■ Current plans (specificity, method, time and homelessness, unemployment, loss of a date) loved one)

46 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System

■ Lethality of suicidal plans and availability trauma and PTSD range from 20 to 40 percent of potential instruments (e.g., drugs, (Steadman et al., 2013). In the past two decades, weapons) there has been a significant influx of women to the ■ Preparatory behavior justice system (Greenfeld & Snell, 1999; Mumola ■ Self-control & Karberg, 2006; Shaffer, Hartman, & Listwan, 2009). Rates of mental disorders among justice- ■ Reasons for living involved women are significantly higher than ■ Social support among the general population, and are higher in In summary, suicide screening should be provided comparison to justice-involved men (Mallik-Kane for all justice-involved individuals at the point of & Visher, 2008; Teplin, Abram, & McClelland, arrest, at the time of entry into or transfer from 1996; Veysey, Steadman, Morrissey, & Johnsen, correctional institutions, and at sequential stages 1997; Zlotnick et al., 2008; Steadman et al., during justice system processing (e.g., arrest, 2009). Moreover, women are more likely to have booking, pretrial diversion, probation, parole). a substance-related disorder or offense (Shaffer et Suicide screening is particularly important during al., 2009; Gunter et al., 2008; Federal Bureau of the first month of incarceration or when there is an Investigation, 2007; Couture, Harrison, & Sabol, impending court date (Hayes 2010). While suicide 2007). screening is important for all individuals in the As many as 78 percent of justice-involved women justice system, it is particularly important for those report a history of childhood or adult physical, who have mental disorders and CODs (Baillargeon sexual, or emotional abuse (Goldenson, Geffner, et al., 2010; Ruiz et al., 2012). At highest risk for Foster, & Clipson, 2007; Messina, Grella, Burdon, suicide are people who have severe depression, & Prendergast, 2007; Lynch, DeHart, & Green, schizophrenia, or who are suffering from certain 2013; Moloney, van den Bergh, & Moller, 2009; types of (Hayes, 2010). All Prendergast, 2009). High rates of PTSD are suicidal behavior (including threats and attempts) found among both men and women in the justice should be taken seriously and assessed promptly system. PTSD and other co-occurring drug use to determine the type of immediate intervention and mental disorders are highly prevalent in other that is needed. In some cases, suicide screening special populations such as returning veterans. In is incorporated within health/clinical assessments, addition to having high rates of substance use and such as those routinely conducted for all offenders mental disorders, returning veterans have rates of in institutions. PTSD that range from 50 to 73 percent (Seal et al., 2009; 2011). There is also emerging evidence that Trauma History and Posttraumatic trauma and PTSD among veterans may be related Stress Disorder (PTSD) to combat or pre-military experiences. Veterans Trauma histories are common among justice- often enter the justice system due to behaviors involved people and members of the general related to mental or substance use disorders and population. In 2014, SAMHSA published are sometimes placed in diversion programs such the following concept of trauma: “Individual as Veterans Treatment Courts (Russell, 2009; trauma results from an event, series of events, Christopher, 2010). or set of circumstances that is experienced by an individual as physically or emotionally harmful Given the prevalence of trauma among justice- or life threatening and that has lasting adverse involved individuals, trauma screening and effects on the individual’s functioning and assessment is essential in jails, prisons, and mental, physical, social, emotional, or spiritual community settings. In the past, trauma-related well-being” (SAMHSA, 2014). For offenders issues have not been fully addressed in some who have substance use disorders alone, rates of justice settings due to concerns that staff are not

47 Screening and Assessment of Co-Occurring Disorders in the Justice System adequately trained to provide treatment services or licensed or certified mental health professional. to fears that addressing these issues will disrupt In some cases, trauma screening is incorporated treatment activities or lead to exacerbation of into routine health/clinical assessments that are mental health symptoms. In fact, failure to conducted for all offenders in a particular justice address trauma issues often undermines setting (e.g., jail or prison). engagement in treatment and may result in commonly experienced trauma-related symptoms, Several specific factors should be considered such as depression, agitation, and detachment, in screening and assessment for trauma/PTSD being mistakenly attributed to other causes and related CODs among justice-involved (Steadman et al., 2013). Other consequences of women. Most justice-involved women are not screening for trauma include inappropriate primary caretakers of dependent children and treatment referral, dropout from treatment, and may experience significant anxiety, guilt, low premature termination of treatment (Belknap, self-esteem, and lack of self-efficacy related to 2006; Hills, Siegfried, & Ickowitz, 2004; Mallik- their inability to care for children during periods Kane & Visher, 2008; of incarceration (Chesney-Lind & Pasko, 2012; Douglas, Plugge, & Fitzpatrick, 2009; Grella & Veterans often enter Shaffer et al., 2009; Greenwell, 2006; Mallik-Kane & Visher, 2008; the justice system Steadman et al., 2013). Without screening for Shaffer et al., 2009; Sacks, 2004). Justice- due to behaviors trauma/PTSD in justice involved women who have a history of trauma and related to mental settings, it is unlikely PTSD also frequently have significant medical or substance use that specialized problems, such as HIV/AIDS, other sexually disorders, and are treatment interventions transmitted diseases, or hepatitis, and these sometimes placed in will be provided. conditions should be identified during screening and assessment (Douglas et al., 2009; Mallik- diversion programs Substance use and Kane & Visher, 2008). Given that two-thirds of such as Veterans withdrawal symptoms incarcerated women are from cultural or ethnic Treatment Courts (e.g., increased anxiety, minorities (Greenfeld & Snell, 1999; Rettinger (Russell, 2009; difficulty sleeping, and & Andrews, 2010), screening and assessment Christopher, 2010). increased intrusion of approaches should be selected that are culturally traumatic thoughts) valid and sensitive. can minimize, mask, or mimic symptoms of trauma and PTSD, and A significant amount of research on trauma and therefore screening and assessment of these PTSD has been conducted in recent years, and a issues should be conducted or supplemented number of specialized screening and assessment during periods of abstinence. PTSD is optimally instruments are available for use in justice diagnosed after offenders have moved beyond settings. DSM-5 has introduced a new schema acute stages of withdrawal from alcohol or other for diagnosing PTSD. Important changes to drugs. As with screening for suicide, trauma the diagnosis of PTSD involve more inclusive screening can be conducted by nonclinical definitions of Criterion A (the indexed traumatic staff through use of standardized self-report event) and dividing the old Criterion C into instruments, which require minimal training. two criteria (negative cognitions and mood, However, all staff who administer trauma screens arousal; APA, 2013). A summary of each of should be knowledgeable about appropriate these instruments is provided in “Screening and referral sources and the nature of trauma-related Diagnostic Instruments for Trauma and PTSD.” services. Offenders who are identified with significant symptoms of trauma/PTSD should receive a thorough assessment by a trained and

48 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System

Motivation and Readiness for prison and participation in court-based diversion Treatment programs is often voluntary in nature, coercion is applied from use of behavioral reinforcement As is the case with most behavioral health that includes loss or attainment of privileges and interventions, outcomes related to CODs sanctions and incentives that are systematically treatment are highly dependent upon personal and consistently applied. For example, drug courts relationships established with service practitioners offer an opportunity for offenders to participate during screening and assessment and during in court-supervised substance use treatment in early stages of treatment (CSAT, 2005a, 2006a; exchange for deferred prosecution and dismissal Lurigio, 2011). Justice-involved individuals who of charges. Motivation for treatment in justice have CODs generally do not have a history of settings is affected by successful participation in treatment services, nor … justice-involved perceived sanctions of vocational and educational achievement, and people with low and incentives, such as may have little optimism and few expectations motivation have probation revocation for successful outcomes within justice treatment and “good time” settings (Chandler et al., 2004; Lurigio, 2011). higher rates of treatment for involvement in Moreover, these individuals are often demoralized correctional treatment. by financial, service-related, or other barriers, or dropout (Lurigio, by their own limitations that affect employment, 2011). However, Perceived coercion interpersonal relationships, and emotional well- it is a common (i.e., external being. misperception pressures, including legal sanctions) is that motivation to For these reasons, assessment and treatment an important factor planning for CODs in the justice system should engage in treatment that affects offenders’ address motivation and readiness for treatment. is necessary to motivation to enter and Motivation has been found to be an important provide effective engage in treatment. predictor of treatment compliance, dropout, and services for justice- Offenders who are outcomes (Lurigio, 2011; Olver, Stockdale, & involved individuals court-referred are Wormith, 2011; Peters & Young, 2011). In assumed to have particular, justice-involved people with low been coerced to enter motivation have higher rates of treatment dropout treatment due to legal contingencies related to (Lurigio, 2011). However, it is a common reduced jail or prison time, dismissal of charges, misperception that motivation to engage in or other factors. However, actual level of treatment is necessary to provide effective services engagement in treatment is often determined by an for justice-involved individuals. Rather, targeting offender’s perception of choice in entering these self-efficacy through goal setting and use of treatment programs. Although justice involvement motivational interviewing strategies can encourage is related to perceived coercion, offenders typically successful treatment outcomes (CSAT, 2005b; have a choice to voluntarily enter treatment or be Lurigio, 2011; Olver et al., 2011). processed through normal judicial channels. Many Motivation and Engagement Strategies offenders report that if offered, they would have entered treatment even without legal pressures Motivational interventions for offenders who (Prendergast, Greenwall, Farabee, & Hser, 2009; have CODs should be provided throughout the Farabee, Prendergast, & Anglin, 1998). Offenders’ justice system, including in coerced treatment perception of coercion is often influenced by the settings, such as court-mandated jail treatment consequences of not engaging in treatment, with or treatment programs provided as a condition higher levels of perceived coercion related to more of probation or parole. Although treatment in severe legal consequences. Interestingly, offenders

49 Screening and Assessment of Co-Occurring Disorders in the Justice System who have stronger perceptions of coercion also CODs frequently have low tolerance to stress, report lower motivation to engage in treatment and low cognitive functioning, poor coping skills, readiness to change (Day et al., 2009; Prendergast and poor psychosocial functioning, which often et al., 2009). In summary, it is unclear to what prevent meaningful participation in treatment and extent perceived coercion influences treatment recognition of the need for treatment and behavior completion and recidivism, as treatment outcomes change (DiClemente et al., 2008; Carey, Maisto, are equivalent among coerced and voluntary Carey, & Purnine, 2001; Gregg et al, 2007; participants (Prendergast et al., 2009). The Horsfall et al., 2009). best predictor of treatment outcomes may be the interaction between perceived coercion and Offenders who have CODs may also lack the motivation over the course of treatment (Knight, interpersonal skills necessary to establish a healthy Hiller, Broome, & Simpson, 2000; Prendergast et social support system and to work effectively al., 2009). with others in a structured treatment setting. Without the presence of a strong social support Motivation increases when continued substance system, these individuals may have increased use threatens current housing, involvement in difficulty coping with related stress and changes mental health treatment, vocational rehabilitation, during treatment, which can result in resorting to family and relationships, and when continued substance use as a coping mechanism (Horsfall substance use will lead to incarceration (Peters et al., 2009). Even people who are medically & Young, 2011; Ziedones & Fisher, 1994). Drug managed for their mental health symptoms may courts and other coerced drug treatment programs have difficulty finding energy to participate allow offenders to gain insight into their addiction in treatment, due to the side effects of their and co-occurring disorders and to receive a medications (Gregg et al., 2007; Horsfall et al., comprehensive range of services to address 2009). Moreover, changing motivation among psychosocial problems. Although participants in people who have CODs may be problematic drug courts and other coerced treatment programs during treatment because of the cognitively do not typically have high internal motivation taxing nature of activities such as goal setting, to change their behaviors during early stages of decision-making, and cognitive-behavioral skill treatment, they often develop internal motivation development (DiClemente et al., 2008). Another after engaging in intensive services, observing issue is that people who have CODs may be progress among other participants, and addressing motivated to change their thoughts and behaviors their own ambivalence to make major lifestyle related to substance use but not their mental changes. disorders (DiClemente et al., 2008; Heesch, Velasquez, & von Sternberg, 2005; Freyer et al., People in the justice system who have CODs may 2005). not be as motivated to enter treatment as those who have substance use disorders alone (Horsfall Treatment of CODs in the justice system typically et al., 2009; Drake et al., 2008). Those who have involves constructing several targeted goals CODs often experience a range of problems that relevant to substance use, mental disorders, contribute to low motivation, which can lead and other related issues. Targeting multiple to difficulty engaging in treatment, treatment problems and goals may be confusing and drop-out, relapse, and other adverse outcomes difficult for people who have CODs. Thus, (Barrowclough, Haddock, Fitzsimmons, & multimodal engagement strategies are used Johnson, 2006; Gregg et al., 2007; Horsfall et al., that include motivational interviewing and 2009). For example, the presence of severe mental behavioral reinforcement techniques to facilitate health symptoms can inhibit treatment engagement understanding of the interactive nature of and motivation. Justice-involved people who have CODs and to establish small but achievable

50 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System goals (Bellack, Bennett, Gearon, Brown, & achieve behavior change and recovery (CSAT, Yang, 2006; DiClemente et al., 2008). 2006b; Miller, Rollnick, & Moyers, 1998; Lurigio, 2011; Peters & Young, 2011). Several evidence- Due to the low levels of internal motivation for based treatment curricula (McMurran, 2009) have treatment and recovery among many offenders been developed to operationalize motivational who have CODs, motivational interviewing interviewing approaches, including Project techniques provide a very helpful mechanism MATCH (Matching Alcohol Treatments to Client to address ambivalence towards making major Heterogeneity; Miller, Zweben, DiClemente, & lifestyle changes that include modifying thoughts, Rychtarik, 1999) and Project START (Screening beliefs, and behaviors related to engagement in to Augment Referral and Treatment; Martino, mental health and substance use treatment and to Ondersma, Howell, & Yonkers, 2010). These criminal activities. The purpose of motivational curricula are based on Motivational Enhancement interviewing is not to normalize ambivalence Therapy (MET) and cognitive behavioral therapy towards change, but to develop discrepancy (CBT) approaches. Specific programmatic between the offenders’ current attitudes and interventions that are frequently provided during behaviors and their values and goals. Through early stages of treatment for people with CODs motivational interviewing, offenders are guided to include “engagement” and “persuasion” groups. examine these discrepancies, identify their current These groups target ambivalence in making major problems and areas for change, and determine how lifestyle changes and are designed to enhance treatment and recovery can assist in meeting their internal motivation for change. personal goals. The key is to facilitate self-insight and encourage internal motivation for addressing Identifying Stages of Change changes in attitudes and behaviors. Treatment Motivation for treatment is expected to change staff serve as guides, remaining objective towards over time for justice-involved people with CODs, the offender’s problems, but still questioning who often cycle through several predictable the offender’s opinions regarding their current “stages of change” during the course of treatment lifestyle in order to elicit concern about current and recovery. In the early stages of change, people lifestyle choices. Once the offender identifies who have CODs may not recognize the importance discrepancies between his or her current attitudes of substance use disorders or other psychosocial and behaviors and personal goals, work can begin problems that complicate treatment and are to develop cognitive and behavioral skills to unlikely to commit to changing their substance accomplish lifestyle changes that are congruent use behavior and to the goals of treatment. In with recovery from mental and substance use the justice-involved population, with the chronic disorders. relapsing nature of recovery from substance use Engagement in treatment for justice-involved and mental disorders and the presence of antisocial individuals who have CODs can also be enhanced beliefs, attitudes, and peers, movement through by utilizing other key motivational interviewing stages of change does not typically follow a linear strategies, including providing a welcoming pattern. For example, justice-involved individuals attitude during the screening and assessment who have CODs frequently return to previous process, normalizing ambivalence to making stages of change before achieving sustained lifestyle changes, showing empathy and respect abstinence and recovery. for the challenges inherent to the difficult Several stages of change related to addictive process of treatment and recovery, understanding behaviors are described by the “transtheoretical initial resistance to change, avoiding arguments model,” developed by Prochaska and DiClemente with offenders related to lifestyle change, and (1992), and include the following: maintaining optimism for individuals’ ability to

51 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ Precontemplation (lack of awareness about issues that are most salient to the offender addiction problems) and which the offender is willing to address. ■ Contemplation (awareness of addiction Assessment of motivation and readiness should be problems) conducted routinely for justice-involved people ■ Preparation (decision point about with CODs to match individuals to treatment commitment to change) services (Lurigio, 2011). Several screening and assessment instruments have been developed that ■ Action (active change behaviors related to addiction) address motivation and readiness for treatment, including those that can be administered as ■ Maintenance (ongoing behaviors to prevent repeated measures over time. A detailed review relapse to addiction) of motivational screening instruments is provided Another stages-of-change model has been later in this monograph. crafted to describe motivation and readiness for treatment among people who have CODs (Osher Cultural Issues Related to Screening & Kofoed, 1989) and to design “stage-specific” and Assessment treatment services. This model is premised on the Screening, assessment, and treatment interventions assumption that stage-specific interventions will for CODs in the justice system should carefully enhance treatment adherence and outcomes among consider the influences of ethnicity, social people who have CODs. For example, offenders class, gender, sexual orientation, race, disability who are in early stages of change are unlikely status, socioeconomic level, and religious and to respond to skills-based interventions that are spiritual affiliation, given the large proportion designed to enhance abstinence if ambivalence of ethnic and racial minorities in these settings and resistance to making lifestyle changes are not (Marlowe, 2013; NADCP, 2010, 2014; Pinals first addressed (e.g., through early engagement and et al., 2004). Minority status generally serves motivational interviewing techniques). Similarly, as a barrier to treatment referral and utilization offenders who are in later stages of change but among people who have CODs, and individuals who receive treatment and supervision services of racial or ethnic minorities are consistently that focus primarily on early recovery issues (e.g., less likely than their White counterparts to seek ambivalence) may drop out of treatment. A rating treatment for both substance use and mental scale has been developed to identify the need for disorders (Hatzenbuehler et al., 2008). Ethnic and stage-specific treatment services among people racial minorities also tend to have lower rates of who have CODs, entitled the Substance Abuse successful treatment completion and higher rates Treatment Scale (SATS; McHugo, Drake, Burton, of recidivism (Belenko, 2001; Finigan, 2009; & Ackerson, 1995). The SATS scale evaluates Marlowe, 2013; NADCP, 2014). Individuals who the level of engagement in services according have experienced shame and social exclusion may to the following categories: pre-engagement, have reduced self-efficacy related to recovery, and engagement, early persuasion, late persuasion, may anticipate that treatment staff will judge them early active treatment, late active treatment, negatively, thus affecting treatment outcomes. relapse prevention, and remission or recovery. Experiences of poverty, discrimination, and In summary, stages-of-change models provide a involvement with the criminal justice system valuable framework to guide the screening and may also increase vulnerability and exposure to assessment process and to identify appropriate chronic stress among ethnic and racial minorities interventions for justice-involved individuals (Marlowe, 2013; NADCP, 2014) and shape who have CODs. These models can help design underlying belief systems of individuals regarding treatment services that sequentially address treatment and recovery processes. One apparent

52 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System consequence is that minorities who have CODs by extended family and social networks, which are more likely to report seeking self-help (e.g., may influence beliefs regarding shame, guilt, and AA/NA) services to deal with substance use respect as they relate to CODs. These factors are problems and are less likely to seek mental health particularly important to consider during initial treatment (Hatzenbuehler et al., 2008). Minorities assessment interviews, treatment planning, and in may also experience discrimination in assignment subsequent treatment engagement activities. to different types of treatment and in the type of sanctions provided within the justice system The extent to which justice-involved individuals and are less likely to receive certain types of are assimilated to American culture can also rehabilitative services (Justice Policy Institute, influence their receptiveness to treatment for 2011; Marlowe, 2013; Nicosia, MacDonald, & CODs, particularly Pacula, 2012; NADCP, 2014). In some cases, when an individual’s Minorities may discriminatory policies in justice settings have beliefs are not fully also experience consistent with the led to coercing minorities who have CODs into discrimination in dominant culture substance use treatment rather than specialized assignment to mental health services (Hatzenbuehler et al., 2008). (Brome, Owens, Allen, & Vevaina, 2000; different types Symptoms of mental disorders may be expressed Castro & Alarcon, of treatment and very differently among ethnic and racial 2002; Klonoff & in the type of minorities. Unless cultural norms are well Landrine, 2000; sanctions provided understood and sufficient follow-up time is NADCP, 2014). One within the justice allowed to assess and understand the full meaning apparent example is system, and are of atypical self-reported thoughts, emotions, and that Latinos born in behaviors, these symptoms may be misinterpreted, the United States are less likely to receive leading to misdiagnosis, inappropriate use of more likely to identify certain types medication, and placement in inappropriate levels themselves as having of rehabilitative of care. Some minorities who have CODs may not CODs in comparison services (Justice readily understand that they have mood or anxiety to their foreign-born Policy Institute, disorders, in comparison to the more recognizable counterparts. The 2011) and less prejudicial substance use disorders likely rationale for this (Hatzenbuehler et al., 2008). is not underreporting among foreign-born Latinos but rather the lack of Staff working with justice-involved offenders assimilation to American culture that may serve as should actively explore expectations and beliefs protective factors against developing CODs (Vega, that may have been shaped by experiences of Canino, Cao & Alegria, 2009). racism and discrimination and should consider these factors as they gather and interpret Different beliefs, expectations, and levels of information during screening and assessment. acculturation can influence treatment engagement Important cultural themes to consider during the and outcomes among justice-involved individuals assessment and treatment process include, but who have CODs. Research indicates that are not limited to, religiosity and related beliefs attending to cultural beliefs through appropriate and customs, independent versus interdependent staff training improves outcomes in substance use cultural orientations, trust versus distrust of treatment (Guerrero & Andrews, 2011; Northeast authority figures, disclosure of personal problems, Addiction Technology Transfer Center [ATTC], and gender roles (CSAT, 2006b; Osborne, 2008; NADCP, 2014). Matching ethnic and 2008; NADCP, 2014). Some ethnic and racial racial minorities to integrated treatment services minority groups are more likely to be influenced in the justice system that are culturally sensitive

53 Screening and Assessment of Co-Occurring Disorders in the Justice System can also improve treatment outcomes (Marlowe, staff diversity (e.g., diverse racial and ethnic 2013; Northeast ATTC, 2008). It should be noted, background), multilingual abilities, availability however, that few specialized CODs treatment of cross-cultural screening and assessment tools, interventions have been developed for ethnic and and use of culturally sensitive treatments. Results racial minorities, and there are few evidence-based of this self-assessment can be used to improve protocols to help organize this type of specialized program services by identifying staff training treatment. needs, gaps in services, and minority groups that are underrepresented among program and Some individuals in the justice system who have treatment staff. CODs may not be fully candid during screening and assessment interviews because their cultural Staff Training affiliation does not condone self-disclosure of Those working in justice settings, including problems to those outside of the immediate family. judges, prosecutors, defense counselors, treatment Self-disclosure may also be inhibited among staff, case managers, court personnel, correctional individuals who have experienced discrimination officers, program directors, and community from people who share the culture or ethnicity supervision staff, are often inadequately trained of the staff person conducting screening or in identification, assessment, diagnosis, treatment, assessment interviews. Some minorities may and supervision of individuals with CODs consider themselves undeserving of CODs (Steadman et al., 2013). For example, screenings treatment due to the combined stigma attached to are often conducted by staff who lack training endorsing a co-occurring disorder and minority or experience related to mental or substance use status (Lawrence-Jones, 2010). disorders and who may be unfamiliar with related Language barriers can also influence the outcome treatment services for these disorders in the justice of screening and assessment interviews among system. In recent years, a specialized base of justice-involved individuals who have CODs. knowledge and set of skills have been developed Alternative strategies should be explored for for working with justice-involved individuals individuals who do not read or comprehend who have CODs. Training in these areas should English effectively. Whenever possible, screening be provided for all staff who are involved in and assessment should be conducted in the screening and assessing CODs in the justice individual’s language of choice and by staff from system. a similar cultural background. Many screening One of the challenges inherent to training is instruments are available in Spanish or other that there are often parallel sets of staff who languages, and whenever possible, bilingual are providing treatment, supervision, and legal staff should conduct screening and assessment monitoring of offenders who have CODs. The interviews. training needs of these staff will differ, but share Maintaining a staff of diverse ethnic or cultural commonalities related to understanding the backgrounds is highly important in promoting dynamics of addiction, mental disorders, and effective participation in screening, assessment, CODs; screening approaches, risk assessment, and other treatment activities. Given that case management and monitoring approaches this can be challenging, it is also helpful to that address major criminogenic needs; and periodically assess the cultural competencies of therapeutic use of sanctions and incentives. The justice programs that serve offenders who have intersection of staff roles is also important to CODs. One approach is to use a semi-structured emphasize through multidisciplinary cross-training self-assessment protocol (Osborne, 2008) to to help define each person’s responsibilities review data collection procedures, staff training, relative to sharing information related to treatment

54 Key Issues in Screening and Assessment of Co-occurring Disorders in the Justice System and supervision and providing screening and assessment, case management, and other activities and to ensure effective collaboration in working with offenders who have CODs (Steadman et al., 2013).

Specialized multidisciplinary training in criminal justice settings should be considered in the following areas: ■ Prevalence, course, and signs and symptoms of CODs ■ Interaction of symptoms of mental and substance use disorders and how this can inform diagnosis and differential diagnosis of CODs ■ Strategies for enhancing accuracy of screening and assessment information among offenders who have CODs ■ Training in use of specialized screening, assessment, and diagnostic instruments ■ Integrated treatment approaches (e.g., Integrated Dual Disorder Treatment [IDDT]) and other evidence-based practices ■ Adapting court/community supervision, and use of sanctions and incentives for individuals who have CODs ■ Motivational interviewing techniques for use with justice-involved individuals who have CODs ■ Cultural diversity and cultural sensitivity (NADCP, 2014) ■ Identification of unique training needs for justice personnel and clinical personnel

55 Screening and Assessment of Co-Occurring Disorders in the Justice System

56 Instruments for Screening and Assessing Co-occurring Disorders

Screening and assessment of CODs in the justice Key Issues in Selecting Screening system should incorporate use of standardized and Assessment Instruments instruments that have been validated with offender populations. Use of standardized instruments There are several key issues in selecting screening will enhance the consistency of information and assessment instruments related to CODs: gathered during this process and will promote a shared understanding of important domains to ■ Reliability. The reliability of a screening instrument refers to the ability to obtain be reviewed in addressing CODs. Standardized similar scores after readministering instruments that yield summary scores and scores the same instrument over time or after across different domains provide a common administering the instrument by different vocabulary for staff to communicate needs for people. Reliability can be difficult to treatment, supervision, and monitoring (Fletcher achieve when screening justice-involved et al., 2009; Taxman, Cropsey et al., 2007) individuals who have CODs due to the across different justice settings, such as courts, changing symptom picture that may be probation, and reentry from custody. However, affected by recent alcohol or other drug many criminal justice programs do not administer use, withdrawal from substances, use of standardized instruments (Cropsey et al., 2007; psychotropic medications, or intentional Friedmann et al., 2007) and instead use improvised malingering or dissimulation. Screening screening and assessment techniques that have may need to be readministered if there are questionable validity and that may lead to poor concerns about the accuracy of information outcomes among offenders who have CODs. obtained, and at minimum, interpretation of screening should include caveats Given the absence of specialized screening about potential adverse influences on the instruments that address the multiple relevant accuracy of information. components of CODs, several instruments (e.g., ■ Validity. Many standardized mental health mental health, substance use, trauma/PTSD, and substance use instruments are not motivation) are often combined to provide a sensitive to or specific in identifying CODs. comprehensive screening. These screening Sensitivity refers to an ability to identify instruments are sometimes included in a battery individuals with mental or substance use to provide focused information regarding acute disorders, or both, while specificity refers mental health and substance use needs and to an ability to identify individuals without suitability for placement in various settings. such disorders. Screening instruments Screening instruments for CODs should be that examine the same area (e.g., presence administered concurrently with drug testing and of a mental disorder) often have varying levels of sensitivity and specificity. These examination of collateral information. properties should be carefully examined, as the need for higher sensitivity or higher specificity will depend upon the particular

57 Screening and Assessment of Co-Occurring Disorders in the Justice System

justice setting and the purpose of screening. MHSF-III and the GAIN-SS had somewhat higher For example, when using a mental health overall accuracy than the MINI and had higher screen in a large prison system, it is sensitivity than the MINI in detecting mental very important to use an instrument with disorders (Sacks et al., 2007b). However, each of high sensitivity, so that mental disorders the mental health screens performed adequately are not underidentified. In contrast, to in detecting severe mental disorders (i.e., identify substance use disorders in a large bipolar disorder, major depressive disorder, and prison system for purposes of placement schizophrenia). These mental health-screening in residential treatment programs (e.g., instruments were found to have somewhat higher Therapeutic Communities [TCs]), it is overall accuracy among male offenders. perhaps more important to use a screen with high specificity, so that inmates One study examined the effectiveness of substance are not mistakenly placed in intensive use screening instruments among prisoners (Peters treatment services. et al., 2000). Three instruments were found to be ■ Use in Criminal Justice Settings. Not the most effective in identifying individuals with all screening and assessment instruments substance use disorders, as determined by the related to CODs have been validated SCID diagnostic interview: the Simple Screening for use within justice settings, although Instrument (SSI), the Texas Christian University a growing number of studies have been Drug Dependence Screen V (TCUDS V), and a conducted in these settings. Instruments combined measure that consisted of the Alcohol that have not been validated in justice Dependence Scale (ADS) and Addiction Severity settings may still be used; however, caution is urged in interpreting results and research Index (ASI)–Drug Use section. These instruments is needed to examine the accuracy of the outperformed several other substance use screens, particular instrument (e.g., in reference including the Michigan Screening to similar instruments that have known Test (MAST)–Short version, the ASI–Alcohol Use psychometric properties). section, the Drug Abuse Screening Test (DAST- 20), and the Substance Abuse Subtle Screening Comparing Screening Instruments Inventory (SASSI-2) on key measures of positive predictive value, sensitivity, and overall accuracy. Only a few studies have compared the effectiveness of mental health or substance use Subsequent sections describe a range of available screening instruments in detecting the respective mental health and substance screening instruments, disorders (Peters et al., 2000; Sacks et al., 2007b). as well as those examining both mental and As part of the NIDA Criminal Justice–Drug substance use disorders. Abuse Treatment Studies (CJ-DATS) network, a multisite study was conducted to identify Recommended Screening effective screening instruments for CODs among Instruments individuals enrolled in prison-based addiction treatment (Sacks et al., 2007b). The effectiveness A set of recommended screening instruments in of the Global Appraisal of Individual Needs–Short the justice system is provided below and in Figure Screener (GAIN-SS), the Mental Health Screening 8: Form-III (MHSF-III), and the Mini International ■ Recommended screening instruments for Neuropsychiatric Interview–Modified (MINI-M) mental disorders * Instrument available at no cost were compared by examining results from the » Brief Jail Mental Health Screen SCID, a comprehensive diagnostic interview, (BJMHS) Figure 8. Recommended Screening Instruments which served as the criterion measure. The

58 Instruments for Screening and Assessing Co-Occurring Disorders

MHSF-III and the GAIN-SS had somewhat higher overall accuracy than the MINI and had higher sensitivity than the MINI in detecting mental disorders (Sacks et al., 2007b). However, each of the mental health screens performed adequately in detecting severe mental disorders (i.e., bipolar disorder, major depressive disorder, and schizophrenia). These mental health-screening instruments were found to have somewhat higher overall accuracy among male offenders.

One study examined the effectiveness of substance use screening instruments among prisoners (Peters et al., 2000). Three instruments were found to be the most effective in identifying individuals with substance use disorders, as determined by the SCID diagnostic interview: the Simple Screening Instrument (SSI), the Texas Christian University Drug Dependence Screen V (TCUDS V), and a combined measure that consisted of the Scale (ADS) and Addiction Severity Index (ASI)–Drug Use section. These instruments outperformed several other substance use screens, including the Michigan Alcoholism Screening Test (MAST)–Short version, the ASI–Alcohol Use section, the Drug Abuse Screening Test (DAST- 20), and the Substance Abuse Subtle Screening Inventory (SASSI-2) on key measures of positive predictive value, sensitivity, and overall accuracy.

Subsequent sections describe a range of available mental health and substance screening instruments, as well as those examining both mental and substance use disorders.

Recommended Screening Instruments A set of recommended screening instruments in the justice system is provided below and in Figure 8: ■■ Recommended screening instruments for mental disorders * Instrument available at no cost »» Brief Jail Mental Health Screen (BJMHS) Figure 8. Recommended Screening Instruments

59 Screening and Assessment of Co-Occurring Disorders in the Justice System

» Correctional Mental Health Screen » Posttraumatic Stress Disorder (CMHS-F/ CMHS-M) Checklist for DSM-5 (PCL-5) » Mental Health Screening Form-III ■ Recommended screening instruments for (MHSF-III) suicide risk ■ Recommended screening instruments for » Interpersonal Needs Questionnaire substance use disorders (INQ), combined with the Acquired » Texas Christian University Drug Capability Suicide Scale (ACSS) Screen V (TCUDS V) (Note: To » Beck Scale for Suicide Ideation (BSS) conduct a screening that includes more » Adult Suicidal Ideation Questionnaire detail about alcohol use, the AUDIT (ASIQ) can be combined with the TCUDS V or the SSI instrument. ) Specific instruments are recommended for » Simple Screening Instrument (SSI) screening of mental disorders, substance use » Alcohol, Smoking, and Substance disorders, co-occurring mental and substance use Involvement Screening Test (ASSIST) disorders, motivation and readiness for treatment, trauma/PTSD, and suicide risk. These screening » TCU Drug Screen V (TCUDS V) instruments can generally be administered by » Alcohol Use Disorders Identification nonclinicians and without extensive specialized Test (AUDIT)* training, although staff need to be knowledgeable » Simple Screening Instrument (SSI) about how to refer offenders who are positively » Alcohol Use Disorders Identification identified by screens to appropriate services. Test (AUDIT) Recommendations are based on a critical review ■ Recommended screening instruments for of the research literature examining each area of co-occurring disorders screening. A comprehensive review of screening » Mini International Neuropsychiatric instruments in each of these areas is provided in Interview-Screen (MINI-Screen) subsequent sections and includes a discussion of positive features, concerns, and availability » Brief Jail Mental Health Screen and pricing. In addition to the areas identified in (BJMHS) and TCU Drug Screen V (TCUDS V) Figure 8, screening of CODs in the justice system should also include examination of criminal risk. » Correctional Mental Health Form A wide variety of criminal risk screening and (CMHS-F/CMHS-M) and TCU Drug assessment instruments are available (Desmarais Screen V (TCUDS V) & Singh, 2013), although it is beyond the scope of ■ Recommended screening instruments for this monograph to review these instruments. motivation and readiness » Texas Christian University Motivation As per the recommendations in Figure 8 to Form (TCU MOTForm) conduct a comprehensive screening that includes » University of Rhode Island Change more detail about alcohol use, the AUDIT can Assessment Scale-M (URICA-M) be combined with the TCUDS V or the SSI instrument. When screening for trauma/PTSD, ■ Recommended screening instruments for the THS, the LSC-R, and the LEC-5 instruments trauma history and PTSD provide checklists for examining traumatic The Trauma History Screen (THS), or » life events, and it is recommended that one of » Life Stressor-Checklist (LSC-R), or these instruments be used in combination with » Life Events Checklist for DSM-5 the PCL-5 screen, which identifies symptoms (LEC-5), and related to trauma/PTSD. Use of two separate

60 Instruments for Screening and Assessing Co-Occurring Disorders screening instruments to examine mental disorders family members) and from archival records (e.g., and substance use disorders would require criminal history). approximately 10–25 minutes to administer and score. Providing additional screening for An important component of assessment in the trauma/PTSD, suicide risk, and motivation justice system is formal diagnoses of mental and would increase the total amount of time required substance use disorders. Among individuals to approximately 25–35 minutes. Each of the who have CODs, this process often involves recommended screening instruments in Figure differentiating between several types of disorders 8 can be administered as repeated measures to (e.g., depression, anxiety, PTSD, borderline examine changes over time. This information can disorders) that share common symptoms and be very useful in identifying the need for changes examining the potential effects of substance use to treatment/case plans, the level of treatment and on symptoms of various mental disorders. In supervision services, and for further assessment. addition to providing descriptive and prognostic information, diagnostic classification (e.g., through Issues in Conducting Assessment and use of the DSM-IV-TR/DSM-5; APA, 2000, 2013) Diagnosis with justice-involved individuals who have CODs assists in identifying key areas to be addressed As described previously, assessment of CODs during psychosocial assessment and in developing is usually conducted after completing an initial an individualized treatment/case plan (ASAM, screening and following referral to treatment 2013; Stallvik, & Nordahl, 2014). Important services. If symptoms of both mental and revisions have been made to the DSM-5 criteria substance use disorders are detected during for both mental and substance use disorders, screening, the assessment should examine the and these should be carefully reviewed before potential interactive effects of these disorders. providing diagnoses. Criminal risk factors should also be assessed, particularly the set of “criminogenic needs” or A range of diagnostic instruments are available “dynamic” risk factors that can change over time to examine symptoms of mental and substance and that should be the targets of justice-system use disorders within the DSM-5 classification interventions. Assessment provides the basis for framework. Instruments may be fully structured developing an individualized treatment/case plan, (e.g., AUDADIS-IV), thereby requiring minimal and depending upon the setting, a community training to administer, or may be semistructured reentry plan. Key elements of CODs assessment (e.g., SCID-IV), requiring training and application include examination of skill deficits, the need for of clinical judgment. For a detailed review of psychotropic medications, and types of treatment available diagnostic instruments for examining and ancillary services that are needed. Sufficient CODs in the justice system, refer to the section time should be allowed prior to assessment to “Assessment and Diagnostic Instruments for Co- ensure that an individual is detoxified and to occurring Mental and Substance Use Disorders.” ascertain whether any mental health symptoms exhibited are related to recent substance use (e.g., The following considerations should be reviewed withdrawal symptoms). Standardized assessment in selecting and administering diagnostic methods should be implemented at early stages instruments: of involvement in the justice system and at key ■ Structured interview instruments (e.g., transition points during subsequent involvement in SCID-IV; AUDADIS-IV) are useful in the justice system. Use of formal assessment and providing reliable and accurate diagnosis diagnostic instruments should be supplemented of CODs, although these instruments often by information from collateral sources (e.g., from require considerable time to administer and may not be practical in all justice settings

61 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ Diagnostic instruments should have good by one of the screening tools described in Figure interrater reliability and validity 7. The PSS-I or PDS should also be administered ■ Diagnosis should be based on observation if an individual endorses “high risk” on screens of mental health and substance use used to identify trauma/PTSD. These instruments symptoms over time, and diagnostic can assist in differential diagnosis of PTSD and interviews should be supplemented by other mental disorders. review of collateral sources of information and by drug testing, whenever feasible Recommendations assessment instruments are provided below and in Figure 9: ■ Diagnoses of individuals with CODs should be reviewed periodically, given that ■ Recommended instruments for mental key symptoms often change over time (e.g., disorders following periods of prolonged abstinence) » Personality Assessment Inventory (PAI) Recommended Instruments for ■ Recommended instruments for substance Assessment and Diagnosis of Co- use disorders and treatment matching occurring Disorders » TCU Drug Screen V (TCUDS V) » TCU Client Evaluation of Self and Few instruments have been validated for use in Treatment (TCU CEST) assessing individuals with CODs. Moreover, few TCU Mental Trauma and PTSD Screen studies have attempted to validate different types » (TCU TRMA) of assessment instruments in criminal justice settings. Given the heterogeneity of symptoms » TCU Physical and Mental Health presented by individuals with CODs, it is unlikely Status Screen (TCU HLTH) that a single instrument will be sufficient to » TCU Criminal Justice Comprehensive assess the full range of co-occurring problems or Intake (TCU CJ CI) to distinguish individuals who have CODs from ■ Recommended assessment and diagnostic those who have either a mental or a substance instruments for co-occurring disorders use disorder. Therefore, when identifying CODs » Alcohol Use Disorders and Associated in the justice system, it is important to combine Disabilities Interview Schedule-IV different types of screening and assessment (AUDADIS-IV) instruments to gain a comprehensive picture of » Mini International Neuropsychiatric psychosocial functioning and potential treatment Interview (MINI) and supervision needs (Steadman et al., 2013). » Structured Clinical Interview for DSM An integrated approach for assessing CODs in the ■ Recommended assessment instruments for justice system should include a comprehensive trauma history and PTSD review of mental and substance use disorders, an » The Posttraumatic Symptom Scale examination of criminal justice history and status, (PSS-I) and assessment of criminal risk (Steadman et al., » The Posttraumatic Diagnostic Scale 2013; Kubiak et al., 2011). Assessment should (PDS) also review the interactive effects of mental and » Clinician Assisted PTSD Scale for substance use disorders. Several previously DSM-5 (CAPS-5) described screening instruments may be used ■ Recommended assessment and diagnostic as part of an assessment battery to examine instruments for suicide risk specialized areas (e.g., trauma history/PTSD) related to CODs. The Suicide Risk Decision Tree » Suicide Risk Decision Tree should be administered if suicide risk is indicated

62 Instruments for Screening and Assessing Co-Occurring Disorders

These instruments are based on a critical of diagnostic instruments can require up to two review of the research literature examining both hours. Selection of assessment and diagnostic assessment and diagnostic instruments for use with instruments should consider the level of staff CODs. A comprehensive review of assessment training, certification, and expertise required. and diagnostic instruments (“Assessment and Diagnostic Instruments for Co-occurring Mental Screening Instruments for and Substance Use Disorders”) is provided in Substance Use Disorders subsequent sections and includes a discussion of positive features, concerns, and availability A wide range of substance use screening and pricing. Assessment instruments differ instruments are available, including both significantly in their coverage of areas related to public domain and proprietary products. mental and substance use disorders, validation for These instruments vary considerably in their use in community and criminal justice settings, effectiveness, cost, and ease of administration cost, scoring procedures, and training required for and scoring (Hiller et al., 2011). As with other administration. screening instruments, substance use screens are somewhat vulnerable to manipulation by those Assessment instruments generally require from seeking to conceal substance use problems, and 45–90 minutes to administer. Depending on the concurrent use of drug testing is recommended to individual symptom presentation, administration generate the most accurate screening information

*Instrument available at no cost

Figure 9. Recommended Assessment Instruments

63 Screening and Assessment of Co-Occurring Disorders in the Justice System

(Richards & Pai, 2003). A range of substance use use disorders have not apparently affected screening instruments are reviewed in this section the prevalence of alcohol or drug use that can assist in detecting co-occurring disorders diagnoses in offender populations (Kopak, (CODs), with information provided about positive Proctor, & Hoffman, 2014) features and concerns related to each instrument. ■ Gambling disorder is an addictive disorder resembling substance use disorders from Changes to the DSM-5 Diagnostic the biopsychosocial perspective Classification System ■ Caffeine disorder is no longer considered Several substance use disorders are described in an addictive disorder the section of the DSM-5 (APA, 2013) entitled “Substance-Related and Addictive Disorders.” Screening Instruments Substance use and are no longer considered separate disorders as they Alcohol Dependence Scale (ADS) were in DSM-IV, and have been combined into The ADS (Skinner & Horn, 1984) is a widely a single disorder (“substance use disorder”) that used 25-item instrument developed to screen measures severity of symptoms on a continuous for symptoms of alcohol use disorders. This scale from mild to severe. The new DSM-5 measure assesses withdrawal symptoms, increased resolves a problem with the DSM-IV approach, alcohol tolerance, awareness of compulsive and which classified “substance abuse” as a milder excessive drinking, salience of drink-seeking form of “substance dependence” when in fact the behaviors, and impaired control over drinking. symptoms of substance misuse can be quite severe The instrument was developed through factor in clinical practice. On the other hand, “substance analysis of the original 147-item Alcohol Use dependence” can imply that the individual is Inventory (AUI) and is published by the Addiction psychologically addicted to the substance when in Research Foundation. Questions on the ADS are fact the individual may be physically dependent specific to the last 12 months and can be given on the substance, which is a normal physiological as a clinical interview or self-report assessment response to certain drugs. (Chantarujikapong, Smith, & Fox, 1997). A cut- off score of ≥ 8 has been used in clinical samples Major highlighted changes to the DSM-5 to identify those with alcohol use diagnoses classification system for substance use disorders (Chantarujikapong et al., 1997; Ross, Gavin, & are as follows: Skinner, 1990). Only 9 of the 25 ADS items may ■ There are a total of 11 symptoms of be needed to make a reliable classification in high- substance use disorders that combine risk alcohol drinkers, and ADS items addressing elements of DSM-IV “abuse” and excessive drinking are the most useful in making “dependence” diagnostic criteria this classification (Kahler, Strong, Stuart,Moore, & ■ “Mild” substance use disorder requires Ramsey, 2003; Kahler, Strong, Hayaki, Ramsey, & endorsement of 2–3 symptoms out of a Brown, 2003). total of 11 symptoms ■ “Moderate” substance use disorders Positive Features require the presence of 4-5 symptoms, ■ The ADS is brief, inexpensive, easily while “severe” disorders require 6 or more scored, and does not require specialized symptoms training to administer ■ Changes from the DSM-IV classification ■ The ADS has been found to perform of substance “abuse” and “dependence” adequately in community settings (Ross et disorders to the DSM-5 classification of al., 1990) “mild,” “moderate,” and “severe” substance

64 Instruments for Screening and Assessing Co-Occurring Disorders

■ The ADS is unidimensional, as intended, ■ The ADS has been found to have test-retest and has good internal consistency (alpha = reliability of .92–.98 over a 1-week period .90; Kahler, Strong, Stuart et al., 2003) (Addiction Research Foundation, 1993; ■ ADS scores are significantly correlated Peters et al., 2000) with objective measures of alcohol use ■ Computerized versions of the ADS are severity among incarcerated men (Hodgins available through the Computerized & Lightfoot, 1989) Lifestyle Assessment. Miller and others ■ The ADS is most effective in detecting (2002) report high test-retest reliability moderate to severe levels of alcohol use of this version (r score = .84–.93) over a (Chantarujikapong et al., 1997) 1-week period ■ The ADS in combination with the Concerns Addiction Severity Index (ASI)–Drug ■ The ADS does not examine quantity or Use section was one of three screening frequency of recent and past alcohol use instruments found to be the most effective in identifying substance use among ■ The ADS is limited to screening for alcohol prisoners (Peters & Greenbaum, 1996) use problems ■ The ADS was the most accurate of ■ The superficial nature of ADS items may several screening instruments in detecting result in underreporting of symptoms alcohol disorders among justice-involved ■ Additional validation in subpopulations individuals (Peters et al., 2000) may be necessary (e.g., pregnant women) ■ In determining substance use disorders ■ The ADS does not always exhibit among offenders, the ADS exhibited substantial agreement across types of adequate sensitivity (74 percent, 66 reporting (e.g., self-report, report by percent), specificity (92 percent, 97 service/agency staff), with one study percent), positive predictive value indicating only a 15 percent rate of (89 percent, 98 percent), and negative agreement in a treatment-seeking predictive value (80 percent, 69 percent) population respectively (Peters et al., 2000) ■ The ADS is a commercial product, ■ The ADS performed as well as the although the cost is quite modest Michigan Alcoholism Screening Test (MAST) in detecting alcohol use disorders Availability and Cost (Ross et al., 1990) The ADS is a copyrighted document that can ■ In an addictions setting, at a cut-off score be obtained from its author. The price of $15 of 8 or 9, the ADS has good sensitivity (91 includes a user’s guide and 25 questionnaires. percent), specificity (82 percent), positive Additional packets of 25 questionnaires cost predictive value (93 percent), and negative $6.25. Requests for the kits can be made to predictive value (76 percent; Ross et al., Harvey Skinner Ph.D., Department of Public 1990) Health Sciences, McMurrich Building, University ■ A 12-item version of the ADS can reliably of Toronto, Toronto, Ontario, Canada M5S 1A8. discriminate between levels of alcohol E-mail requests can be sent to harvey.skinner@ severity in treatment-seeking populations utoronto.ca (Kahler, Strong, Hayaki et al., 2003) The ADS can be downloaded at no cost at the ■ The ADS provides both cut-off scores that indicate the presence of an alcohol use following site: http://www.emcdda.europa.eu/html. disorder and treatment cfm/index3583EN.html

65 Screening and Assessment of Co-Occurring Disorders in the Justice System

Computerized versions of the ADS can be scores. The risk levels are also intended to obtained by contacting the Multi-Health Systems distinguish between low, medium, and high risk. regarding and requesting the Computerized An integrated set of brief interventions provides Lifestyle Assessment: 1-800-456-3003 (U.S.); feedback regarding health risks for each substance 1-800-268-6011 (Canada). class.

Modifications to the instrument (ASSIST 2.0) Alcohol, Smoking and Substance reduced the number of items to eight, and Involvement Screening Test (ASSIST) improved the psychometric properties. The most The ASSIST (World Health Organization [WHO] recent version (ASSIST 3.0) provides standardized ASSIST Working Group, 2002) was developed cut-off scores across different types of substances. for the WHO by an international group of The NIDA has modified this measure to include substance use researchers to address the need two parts: (1) the “NIDA Quick Screen,” and (2) for a comprehensive screening instrument in the “NIDA Modified ASSIST,” which provides a primary health care settings. The original 12-item more comprehensive assessment for individuals instrument was developed through identifying who surpass the cut-off score on the Quick Screen. psychometrically sound items from other The Quick Screen inquires only about past year substance use screens, based on a comprehensive use of alcohol, tobacco, and drugs. The ASSIST review of the literature (Babor, 2002). The has been widely adapted for use in different ASSIST measures frequency of substance use; cultures and has been translated into several current symptoms (i.e., in the past 3 months); and languages. This instrument can be administered as problems related to alcohol, tobacco, and other an interview or by self-report. drugs. The ASSIST includes a brief introduction Positive Features describing the purpose of the measure, and items ■ The ASSIST is available at no cost, is quite are grouped by type of substance (e.g., alcohol, brief to administer, and includes scoring cannabis, opioids, stimulants, tobacco). Item 1 and interpretation of scores (e.g., level of provides a brief screen for lifetime use of each treatment needs) according to risk level type of substance. ■ The ASSIST evaluates lifetime substance The remaining items on the ASSIST examine use, current substance use, severity of current frequency of substance use by type of substance use, and risk related to IV drug substance, and frequency of related symptoms use during the past 3 months. For example, item 2 ■ The ASSIST 3.0 includes weighting and inquires about current frequency of use (“how recoding analyses that provide a consistent often have you used the substance in the past 3 cut-off score for substance use months?”). Subscales of the ASSIST include ■ The ASSIST uses an approach that is Specific Substance Involvement (SSI; sum of consistent with the federally funded items 2–7 for each type of substance) and Total Screening, Brief Intervention, and Referral Substance Involvement (TSI; sum of items 1–8 to Treatment (SBIRT) initiative in that across each type of substance). Item 8 inquires accompanying materials are provided about intravenous (IV) drug use in the past 3 to implement brief interventions and months. The ASSIST provides feedback to referral to treatment, based on ASSIST respondents indicating the level of their SSI score findings related to risk level and type of substance(s) used by severity of risk for substance use problems according to designated cut-off scores (low risk ■ The ASSIST includes cut-off scores for = 0–3, moderate = 4–26, high ≥ 27) and physical differentiating between severity of use and mental health risks associated with these (low risk: ≤ 3; moderate risk: ≤ 26; and

66 Instruments for Screening and Assessing Co-Occurring Disorders

high risk: ≥ 27), and is able to adequately individuals with substance use disorders. distinguish between these risk categories These results are comparable to those across different types of substances obtained from the Drug Abuse Screening (Humeniuk et al., 2008) Test, DAST-10 (Smith, Schmidt, ■ The ASSIST 2.0 (Humeniuk et al., 2008) Allensworth-Davies & Saitz, 2010) has been validated in several countries, Concerns using samples that are balanced across age and gender ■ The ASSIST has not been widely studied in offender populations ■ The ASSIST 2.0 demonstrates good overall psychometric properties (Humeniuk et al., ■ Caution should be exercised when 2008). In terms of concurrent validity, interpreting the different ASSIST risk the frequency of current use for each type levels for substance use problems, as the of substance (item 2) is highly correlated instrument appears to more effectively with the Addiction Severity Index (ASI; distinguish between low and moderate r scores range .76–.88), and the total risk than between moderate and high risk substance involvement scores (TSI) are for each type of substance, as measured highly correlated with total MINI (Mini by SSI scores and by the Total Substance Neuropsychiatric Interview) substance Involvement scores (TSI). Additional use disorder diagnoses (r score =.76) studies are needed to examine the ability and with scores on the SDS (Severity of the ASSIST to discriminate between the of Dependence), the RTQ (Revised different risk levels (Humeniuk et al., 2008) Fagerstrom Tolerance Questionnaire), and ■ The cut-off score for alcohol risk levels the Alcohol Use Disorders Identification (≤ 10, low risk; ≤ 26, moderate risk; ≥ 27, Test (AUDIT) high risk) is different from the scores for ■ The ASSIST scores are associated with other substances (Humeniuk et al., 2008) physical and mental health problems, as ■ Validation results for the ASSIST may well as IV drug use (Humeniuk et al., 2008) be inflated by reliance on self-report ■ The ASSIST 2.0 TSI and SSI scores information demonstrate adequate to good sensitivity ■ Further studies of the ASSIST are needed and specificity in distinguishing between to determine the instrument’s validity differently levels of use. Finally, the by gender, culture, race/ethnicity, and ASSIST scores showed strong correlations language with the MINI diagnoses (Humeniuk et al., ■ Further work is also needed to examine the 2008) utility of the ASSIST in providing triage to ■ Kappa reliabilities for agreement between therapeutic interventions in primary care test administrations in the original settings validation study of the ASSIST 1.0 (WHO ■ Studies have not investigated the Group, 2002) were adequate (kappas range differential effects on validity of the .58–90) interview and self-report versions of the ■ The ASSIST 2.0 demonstrates good ASSIST internal consistency (alphas range .77–.94) ■ The NIDA-modified ASSIST does not across different types of substances provide detailed risk assessment feedback, (Humeniuk et al., 2008) as does the original ASSIST ■ The single item Quick Screen from the ■ A one-item screen for drug use in the past NIDA-modified ASSIST provides good year (such as the NIDA Quick Screen) may sensitivity (100 percent) and adequate be less accurate in determining current specificity (74 percent) in classifying

67 Screening and Assessment of Co-Occurring Disorders in the Justice System

substance use among men and Hispanics, use. Several brief forms of the AUDIT include relative to other groups (Smith et al., 2010) the three-item AUDIT-C screen (Bush, Kivlahan, McDonell, Fihn & Bradley, 1998), the FAST, a Availability and Cost four-item screening form (Hodgson, Alwyn, John, The most recent version of the ASSIST (3.0) is Thom & Smith, 2002), and the five-item AUDIT-5 available at no charge via electronic download and (Kim et al., 2013). includes the screening tool, user’s manual, patient feedback card, as well as self-help strategies for The recommended cut-off score on the AUDIT managing substance use. The instrument can be for identifying hazardous drinking or alcohol obtained at the following site: http://www.who.int/ use disorders is ≥ 8, and cut-off scores on the substance_abuse/activities/assist/en/index.html AUDIT-C are ≥ 4 with men and ≥ 3 with women (Babor, Higgins-Biddle, Saunders & Monteiro, The NIDA-modified ASSIST is available at no 2001; Bush et al., 1998). The AUDIT can be charge via electronic download at the following administered as an interview or as a self-report site, which includes detailed instructions for instrument. Both computerized and paper and administration and scoring: http://www.drugabuse. pencil versions of the AUDIT are available, and gov/sites/default/files/pdf/nmassist.pdf there do not appear to be significant differences in the accuracy of information produced by these Alcohol Use Disorders Identification different versions (Lieberman, 2003, 2005; Saitz Test (AUDIT) et al., 2004; Chan-Pensley, 1999). Many foreign language versions of the AUDIT have been The AUDIT is a two-part screening instrument that developed. Although the psychometric properties was developed by the World Health Organization of these versions have improved over time, they (WHO). The AUDIT is based on the International are still somewhat uneven across versions of the Classification of Disease-10 (ICD-10) criteria instrument (Reinart & Allen, 2007). and is intended to identify individuals who have harmful levels of drinking in order to prevent Positive Features harmful consequences. The instrument was ■ The AUDIT is quite brief to administer and initially developed for screening in primary health easy to read, requiring only a seventh grade care settings and was designed for use in multiple reading level cultures and settings to assess harmful and ■ Items were carefully selected based on hazardous alcohol use in the past year. Studies factor analytic procedures (Bohn, Babor, & indicate that the AUDIT examines three major Kranzler, 1995) factors: (1) alcohol consumption, (2) drinking ■ The AUDIT appears to have two distinct behaviors, and (3) consequences of drinking. factors across adult and adolescent populations, including consequences of The first part of the instrument (AUDIT Core) is drinking and alcohol consumption (Carey, a brief, 10-item questionnaire created to measure Carey & Chandra, 2003; Doyle, Donovan, alcohol consumption, symptoms, and alcohol- & Kivlahan, 2007; Karno, Granholm & related consequences. The second part of the Lin, 2000; Maisto, Conigliaro, McNeil, instrument (AUDIT-CSI, Clinical Screening Kraemer & Kelly, 2000; von der Pahlen et Instrument) is a supplement to the Core and al., 2008; Rist, Glöckner-Rist, & Demmel, assesses physiological consequences of alcohol 2009; Shevlin & Smith, 2007; Shields, use. The CSI consists of three sections: (1) trauma Guttmannova, & Caruso, 2004) history, (2) abnormal physical exam findings, ■ The AUDIT has been shown to predict and (3) serum gamma-glutamyl transpeptidase alcohol withdrawal syndrome (Dolman level, which identifies harmful effects of alcohol

68 Instruments for Screening and Assessing Co-Occurring Disorders

& Hawkes, 2005; Reinert & Allen, 2007; range .70–.89) in classifying alcohol use Reoux, Malte, Kivlahan & Saxon, 2002) disorders (e.g. positive or negative AUDIT ■ The AUDIT provides cut-off scores that score) at a cut-off score of 8 (Dybek et al, indicate alcohol severity and risk level, 2006; Reinert & Allen, 2007; Rubin et al., interpretation of these cut-off scores, and 2006; Selin, 2003) treatment recommendations (Babor et al., ■ The sensitivity of the AUDIT is quite high 2001) in comparison to the Michigan Alcoholism ■ The AUDIT has adequate sensitivity and Screening Test (MAST) and the CAGE specificity using the standard cut-off score (Cherpitel, 1998). The AUDIT appears to of 8 (Shields & Caruso, 2003). This cut-off be one of the most sensitive instruments score is most useful in detecting alcohol in detecting current alcohol use disorders use disorders, while lower cut-off scores across different populations and is quite are advisable for detecting hazardous effective in identifying low-level hazardous drinking (Maisto & Saitz, 2003) drinking ■ The AUDIT is a reliable and valid indicator ■ The AUDIT has good sensitivity (81–85 of problem drinking among people who percent), specificity (86–89 percent) and have serious mental illness (Cassidy, adequate positive predictive value (65 Schmitz, & Malla, 2008; Maisto, Carey, percent; Skipsey, Burleson, & Kranzler, Carey, Gordon, & Gleason, 2000; Maisto, 1997) for alcohol use disorders among Conigliaro et al., 2000; O’Hare, Sherrer, substance-involved treatment populations LaButti, & Emrick, 2004; Carey et al., (Pal, Jena, & Yadav, 2004; Skipsey et al., 2003; Reinert & Allen, 2002) and has high 1997) sensitivity and specificity for alcohol use ■ The AUDIT is more accurate than the disorders among this population (Cassidy CAGE or the Short Michigan Alcoholism et al., 2008; Dawe, Seinen, & Kavanaugh, Screening Test (SMAST-G) in identifying 2000; O’Hare et al., 2004; Maisto, Carey et problematic alcohol use among the elderly al., 2000, Maisto, Conigliaro et al., 2000) (Moore, Seeman, Morgenstern, Beck & ■ The AUDIT demonstrates good Reuben, 2002) and has good psychometric convergence with the SCID among properties with middle-aged men and psychiatric populations (Cassidy et al., elderly psychiatric patients (Philpot et al., 2008; Maisto, Carey et al., 2000; Maisto, 2003; Tuunanen, Aalto, & Seppä, 2007) Conigliaro et al., 2000). The optimal ■ The AUDIT is equally reliable across cut-off score for the AUDIT is 10 with gender, ethnic/racial, and age groups psychiatric populations, which provides (Cherpitel, 1997; Kokotailo et al., 2004; sensitivity of 85 percent, specificity of 91 McCloud, Barnaby, Omu, Drummond, percent, positive predictive value of 65 & Aboud, 2004; Selin, 2003; Shields & percent, and negative predictive value of 97 Caruso, 2003; Steinbauer, Cantor, Holzer percent (Cassidy et al., 2008) & Volk, 1998; Volk, Steinbauer, Cantor, & ■ The AUDIT has generally performed well Holzer, 1997) across a variety of settings and populations. ■ The AUDIT has good test-retest reliability The instrument’s internal consistency is (.84–.95) over a 30-day interval (Dybek et good, with a median alpha of .83 (alphas al., 2006; Kim, Gulick, Nam & Kim, 2008; range .75–.97; Lima et al., 2005; Reinert Reinert & Allen, 2007; Selin, 2003) & Allen, 2007; Selin, 2003; Shields et al., ■ The AUDIT has good psychometric 2004) properties (particularly sensitivity and ■ Among community samples, the AUDIT specificity) across a variety of ethnic demonstrates good accuracy (kappas groups, including White non-Hispanic,

69 Screening and Assessment of Co-Occurring Disorders in the Justice System

Hispanic, Asian, and African American men sensitivity (91 percent) and specificity (93 and women (Adewuya, 2005; Cherpitel, percent) in detecting alcohol use disorders 1998; Meneses-Gaya et al., 2010; DeSilva, and demonstrates better psychometric Jayawardana, & Pathmeswaran, 2008; properties than the CAGE and PAT Gomez et al., 2006; Giang et al., 2005; Wu (Hodgson et al., 2002) et al., 2008), and is effective in identifying ■ Among adolescents, the AUDIT has greater risky drinking and alcohol use disorders sensitivity than the CAGE in detecting among a variety of populations (Cassidy et alcohol use disorders of varying severity al., 2008; Caviness et al., 2009; DeSilva et (Knight, Sherritt, Harris, Gates, & Chang, al., 2008; Doyle et al., 2007; Meneses-Gaya 2003) and has been shown to have good et al., 2010; Tuunanen, et al, 2007) concurrent and criterion validity (Kelly, ■ The AUDIT has good sensitivity and Donovan, Kinnane, & Taylor, 2002; Knight adequate specificity in identifying risky et al., 2003) and reliability (Kelly et al., drinking and alcohol use disorders among 2002). No gender differences were found college students (Kokotailo et al., 2004) in using the AUDIT among adolescent ■ Non-English versions of the AUDIT inpatients (Kelly et al., 2002). At a cut- provide adequate internal consistency off score of 2 for identifying problematic (Reinhert & Allen, 2007). Test-retest alcohol use among adolescents, the reliability of these versions are also AUDIT’s sensitivity was 88 percent and the acceptable (kappas range .69–.86; Dybek et specificity was 81 percent (Knight et al., al., 2006; Selin, 2003) 2003) ■ The AUDIT-C demonstrates good Concerns sensitivity and specificity (81–95 percent ■ The AUDIT does not examine substance and 73–91 percent, respectively) for use problems occurring prior to the last identifying harmful drinking patterns and year, and is more effective in detecting current alcohol use disorders at varying cut- current rather than previous alcohol off scores (ranging 2–7) across groups that problems (McCann, Simpson, Ries, & Roy- differ by gender, population, and culture Byrne, 2000) (Bradley et al.,2007; Bradley et al., 2003; Caviness et al., 2009; Dawson, Grant, ■ There is considerable variability in the Stinson & Zhou, 2005; Frank et al., 2008; AUDIT-C cut-off scores by gender, culture, Gual, Segura, Contel, Heather, & Colom, and population (Seale et al., 2006; Bradley 2002; Seale et al., 2006) et al., 2003; Dawson, Grant & Stinson, 2005; Dawson, Grant, Stinson, & Zhou, ■ The AUDIT-C demonstrates good internal 2005; Gual et al., 2002) consistency in both clinical and college samples (.74 and .81 respectively; Shields ■ The instrument has only moderate et al., 2004) and high test-retest reliability specificity (74 percent for the “Core” and (r score = .98; Bergman and Kallman, 40 percent for the “Clinical” component 2002) [Bohn et al., 1995]) ■ The FAST has been validated in ■ There has been little research examining several settings and demonstrates good the temporal stability of the AUDIT in psychometric properties (Hodgson et different populations al., 2002). The FAST is correlated with ■ Within a DUI sample, the AUDIT was other well-validated screening measures found to be less effective in detecting of alcohol use disorders, including the substance use disorders than the MAST AUDIT, PAT (Paddington Alcohol Test), (Conley, 2001) and the CAGE. The FAST has good

70 Instruments for Screening and Assessing Co-Occurring Disorders

■ The AUDIT has lower reliability in alcohol ■ The AUDIT may perform more poorly drinkers with low levels of consumption among African Americans in comparison to ■ The AUDIT may be more effective in Whites (Cherpitel & Bazargan, 2003) identifying needs for assessment and ■ The AUDIT does not perform consistently treatment for justice-involved individuals well across all domains in identifying when conducted several weeks after entry alcohol use disorders among adolescents to prison (Maggia et al., 2004), as shown and may need items that are better tailored by the weak agreement in classification for this age group (Chung et al., 2002) between initial screening and later ■ More research is needed to determine screening (kappa = .27) acceptable cut-off scores for the AUDIT ■ The AUDIT-CSI is somewhat invasive and among non-English speaking populations must be conducted by a trained clinician and in international settings (Cherpitel, Ye, ■ The AUDIT-C may be better at identifying Moskalewicz & Swiatkiewicz, 2005; Pal et alcohol use disorders in women than men al., 2004; Rumpf, Hapke, Meyer & John, (Dawson, Grant, Stinson, & Zhou, 2005) 2002; Tsai, Tsai, Chen & Liu, 2005) ■ The AUDIT and the AUDIT-C are less Availability and Cost sensitive and more specific with females The AUDIT: Guidelines for Use in Primary (Reinert & Allen, 2002; Bradley et al., 2003) and are generally more effective Care Settings-Second Edition is available free screens for alcohol use disorders among of charge from the WHO at the following site: women (Dawson, Grant, Stinson, & Zhou, http://whqlibdoc.who.int/hq/2001/WHO_MSD_ 2005) MSB_01.6a.pdf ■ Some have recommended that cut-off The interview and self-report versions of the scores should be lowered when the AUDIT AUDIT, with scoring rules, are available at the and AUDIT-C are used with women, and following site: http://www.drugabuse.gov/sites/ these scores have varied across female default/files/files/AUDIT.pdf samples (Bradley et al., 2007; Bradley et al., 2003; Chung, Colby, Barnett, & Monti, Comprehensive guidelines for use of the 2002; Gache et al., 2005; Gual et al., 2002; instrument are available from the WHO at the Neumann et al., 2004), although there is following site: http://whqlibdoc.who.int/hq/2001/ little research to validate the use of specific WHO_MSD_MSB_01.6a.pdf cut-off scores for this purpose ■ AUDIT-C item 3 may contribute to the The AUDIT-C is available at no cost and is sensitivity and specificity differences available with information describing scoring and (Bradley et al., 2003) among female interpretation at the following site: http://www. respondents integration.samhsa.gov/images/res/tool_auditc.pdf ■ The AUDIT has not been found to be highly accurate with the elderly in different CAGE populations (Philpot et al., 2003; Moore, Beck, Babor, Hays, & Reuben, 2002; The CAGE is a brief four-item screen to identify Reinert & Allen, 2002) and has low alcohol use problems (Mayfield, McCleod, & Hall, sensitivity but good specificity with this 1974). The CAGE is among the most widely used population (O’Connell et al., 2004) brief alcohol screening instruments with adults ■ The AUDIT-C may have lower sensitivity (Bastiaens, Riccardi, & Sakhrani, 2002). The four (43-46 percent) in primary health care questions corresponding to the acronym CAGE settings (Seale et al., 2006) consist of the following: (1) Have you felt you ought to Cut down on your drinking?, (2) Have

71 Screening and Assessment of Co-Occurring Disorders in the Justice System people Annoyed you by criticizing your drinking?, problems with the CAGE-AID is ≥ 2 positive (3) Have you ever felt bad or Guilty about your responses (Brown & Rounds, 1995). drinking?, and (4) Have you had a drink first thing in the morning to steady your nerves or to get Positive Features rid of a hangover (Eye-opener)? A total score is ■ The CAGE does not require specific obtained to reflect the level of alcohol use severity. training and can be administered by a nonclinician Although the CAGE reviews lifetime alcohol ■ The CAGE is quite brief to administer problems, the National Institute on Alcohol ■ At a cut-off score of 1 or 2, the CAGE Abuse and Alcoholism (NIAAA) has developed exhibits good sensitivity (82–91 percent), a version of the CAGE that examines problems specificity (83–94 percent), and positive during the past year. This past year version of predictive value (74–85 percent) in the CAGE is more specific but less sensitive classifying alcohol use disorders among than the traditional CAGE (Bradley, Kivlahan, patients who have schizophrenia (Dervaux Bush, McDonnell, & Fihn, 2001). The CAGE et al., 2006) can be administered via self-report or interview, ■ The CAGE has moderately good sensitivity and similar outcomes are obtained using both (74 percent) and very good specificity approaches (Aertgeerts, Buntix, Fevery, & (97 percent) in diagnosing substance Ansoms, 2000). A computerized version of the use disorders among individuals with CAGE/CAGE-Adapted to Include Drugs (CAGE- schizophrenia (McHugo, Paskus, & Drake, AID; see "Positive Features" below) is also 1993) and generally has been shown to available, and this method has yielded higher rates have good sensitivity and specificity among of illegal drug use and substance use problems clinical populations (Bastiaens et al., 2002) than administration through interview (Turner et ■ Among inpatient populations, the CAGE al., 2005). There are alternative versions to the exhibits adequate sensitivity (87 percent) CAGE that include other items from the AUDIT and specificity (77 percent) at a cut-off and the MAST, such as the Augmented CAGE score of 2 for alcohol use disorders (Bradley, Bush, McDonnell, Malone, & Fihn, ■ The CAGE has higher sensitivity in 1998), the “5-shot” (Seppä, Lepistö, Sillanaukee diagnosing alcohol use disorders in 1998) and the Leubeck Alcohol Dependence and inpatient populations than in other settings Abuse Screening Test (LAST) Questionnaire (Aertgeerts, Buntinx, & Kester, 2004) (Rumpf, Hapke, Hill, & John, 1997). ■ In a primary care population, the CAGE exhibits adequate sensitivity (85 percent) The CAGE-AID is a four-item instrument that and specificity (78 percent) at a cut- screens for both alcohol and other drug use off score of 1 for alcohol use disorders disorders (Brown & Rounds, 1995). More in (Aertgeerts et al., 2004) depth screens are also available that combine ■ The CAGE exhibits adequate sensitivity the CAGE-AID with other drug use questions (62–89 percent) and specificity (79–93 (e.g., TICS or CRAFFT instruments). The percent) among different racial/ethnic recommended cut-off score for identifying groups at a cut-off score of 2 (Buchbaum, possible alcohol problems in the CAGE is ≥ 2 Buchanan, Centor, Schnoll, & Lawton, positive responses (Cherpitel, 1997), in the 5-shot 1991; Dhalla & Kopec, 2007; Saremi et al., is ≥ 3 positive responses (Seppä et al., 1998), in 2001; Saitz, Lepore, Sullivan, Amaro & the Augmented CAGE is ≥ 2 positive responses Samet, 1999) (Bradley, Bush et al., 1998), and in the LAST is ≥ ■ Diagnostic agreement between written and 2 (Rumpf et al., 1997). The recommended cut- interview versions of the CAGE is quite off score in identifying probable alcohol or drug good (k = .83; Aertgeerts et al., 2000), as

72 Instruments for Screening and Assessing Co-Occurring Disorders

is agreement between computerized and ■ The reliability of the CAGE ranges greatly in-person interviews (.77; Bernadt, Daniels, (.52–.90) across different samples (Shields Blizard & Murray, 1989) & Coruso, 2004) ■ Internal consistency of the CAGE across ■ Interrater reliability of the CAGE for clinical and nonclinical samples averages diagnosis of substance use disorders is .74 (Shields & Caruso, 2004) quite low (kappa = .15; Indran, 1995) ■ The CAGE is highly correlated with ■ The CAGE does not effectively other validated measures of alcohol use discriminate between heavy and non-heavy disorders, such as the SMAST (Hays & drinking in the general population (Bisson, Merz, 1995), and the CAGE-AID is highly Nadeau, & Demers, 1999). Due to the correlated with the AUDIT (Leonardson focus on lifetime problems, the CAGE et al., 2005), supporting the convergent does not differentiate between people with validity of these instruments chronic alcohol problems and those who ■ The test-retest reliability of the CAGE have not experienced problems in many was found to be .80 among psychiatric years (Bradley et al., 2001) outpatients, and .95 in a community sample ■ Within general population samples, no (Teitelbaum & Carey, 2000) CAGE cut-off score provides concurrently ■ The CAGE more effectively classifies high specificity, sensitivity, and positive college students than the SASSI-3 predictive value (Bisson et al., 1999) (Clements, 2002). The CAGE has also ■ The CAGE sometimes provides low been found to effectively distinguish sensitivity in classifying alcohol use between adolescents who have alcohol use disorders (Maisto, & Saitz, 2003), and disorders and those who do not have these there is wide variability in the instrument’s disorders (Hays & Ellickson, 2001) sensitivity (43–94 percent) ■ The CAGE-AID has greater sensitivity ■ Higher CAGE cut-off scores provide better and lower specificity for substance use specificity and sensitivity in primary care disorders in comparison to the CAGE. The settings than in other settings (Aertgeerts et CAGE-AID has greater sensitivity than the al., 2004) CAGE across gender, income, education, ■ The CAGE is more accurate in classifying and different types of substance use males than females (McHugo et al., 1993). disorders (Brown & Rounds, 1995) The instrument underestimates alcohol ■ The CAGE-AID shows high internal problems among females (Bisson et al., consistency (r score= .92; Leonardson et 1999; Cherpitel, 2002; Matano, Wanat, al., 2005) Westrup, Koopman & Whitsell, 2002; Moore, Beck et al., 2002). The CAGE also Concerns has lower sensitivity among White females ■ The CAGE does not examine quantity or than African American females (Bradley, frequency of recent and past substance use Boyd-Wickizer, Powell, & Burman, 1998) and examines a narrow range of diagnostic ■ The CAGE has higher sensitivity among symptoms related to alcohol use disorders African Americans than Whites (Cherpitel ■ The CAGE has not been widely validated 2002) for use in justice settings ■ Translation and cultural differences may ■ The CAGE may have lower test-retest affect responses on the CAGE (Steinbauer reliability among psychiatric patients than et al., 1998) in other populations (r score = .67; Dyson ■ The CAGE has low sensitivity among et al., 1998) elderly psychiatric samples (O’Connell et al., 2004)

73 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ The CAGE is not recommended for use Positive Features with adolescents (Hays & Ellickson, 2001; ■ The DALI requires approximately 6 Knight et al., 2003) and has performed minutes to administer and is easy to score poorly in college samples (Aertgeerts et al., 2000; Bisson et al., 1999) ■ The instrument has good specificity (80 percent) and sensitivity (100 percent) in ■ Several alternate versions (LAST, identifying substance use among people 5-shot, Augmented CAGE) have better with mental disorders (Rosenberg et al., psychometric properties than the CAGE 1998) in detecting alcohol use problems and disorders (Bradley, Bush et al., 1998; ■ The DALI alcohol scale has good specificity (98 percent) and overall Rumpf et al., 1997; Seppä et al., 1998) accuracy of 73 percent in diagnosing Availability and Cost alcohol use disorders. The DALI drug scale has good specificity (97 percent) The CAGE is available free of charge, and the and average sensitivity (50 percent), instrument and scoring information can be found with overall accuracy of 83 percent in at either of the following sites: diagnosing drug use disorders among ■ http://bit.ly/CAGE_inst psychiatric inpatients (Ford, 2003) ■ http://www.projectcork.org/clinical_tools/ ■ The DALI may be good at minimizing html/CAGE.html “false positive” classifications (Ford, 2003)

The CAGE can also be obtained in the document: ■ Interrater reliability ranges .86–.98 (Rosenberg et al., 1998). The DALI has Ewing, J. A. (1984). Detecting alcoholism: the been shown to have test-retest reliability of CAGE questionnaire. Journal of the American .90 (Rosenberg et al., 1998) Medical Association, 252 (14), 1905–1907. Concerns The Dartmouth Assessment of Lifestyle ■ The DALI was developed and validated on Instrument (DALI) newly admitted psychiatric inpatients in a predominantly White and rural population The DALI is an 18-item, interview-administered ■ Future research is needed to validate its scale that examines lifetime alcohol, cannabis, use in ethnically and culturally diverse and cocaine use disorders among people with populations, and in justice and substance severe mental illness. The DALI is a composite of use treatment settings several different instruments and includes 3 items ■ The instrument only examines alcohol, from the Life-Style Risk Assessment Interview and cannabis, and cocaine use disorders the remaining 15 items from the Reasons for Drug Use Screening Test, the TWEAK, the CAGE, the ■ The DALI alcohol screen may have low specificity among psychiatric inpatients Drug Abuse Screening Test (DAST), and the ASI. (Ford, 2003) The DALI contains two scales that assess risk for alcohol use disorders and drug use disorders. Availability and Cost It is designed for people who have more severe The DALI, scoring instructions, cut-off scores, and psychopathology (Rosenberg et al., 1998). This reference materials can be obtained at no cost from instrument has not been studied extensively among the University of Washington Alcohol and Drug broad sets of clinical populations. Information Abuse Library website: http://bit.ly/DALI_inst about recommended cut-off scores can be obtained from the authors, as described in the following The instrument and scoring instructions can also section regarding availability and cost. be obtained at the following site: http://www.dhs. state.mn.us/dhs16_141793.pdf

74 Instruments for Screening and Assessing Co-Occurring Disorders

■ The DAST can distinguish between Drug Abuse Screening Test (DAST) individuals with primary alcohol problems, The DAST (Skinner, 1982) is a brief screening those with primary drug problems, and instrument that examines symptoms of substance those with both sets of problems (Cocco & use disorders. Several versions of the DAST Carey, 1998; Martino et al., 2000; Staley & El-Guebaly, 1990; Yudko et al., 2007) are available, including the original DAST-28, DAST-20, DAST-10, and DAST for Adolescents ■ The DAST-10, DAST-20, and DAST-A can (DAST-A). The DAST reviews drug and alcohol discriminate between people with current problems occurring in the past 12 months. Items substance use disorders, people with past from the DAST were developed to align with those substance use disorders, and people who have never had substance use disorders developed for the Michigan Alcoholism Screening (Cocco & Carey, 1998; Martino et al., Test (MAST). The recommended cut-off score for 2000; Yudko et al., 2007) identifying drug use disorders with the DAST and DAST-20 is ≥ 6 (Gavin, Ross & Skinner, 1989; ■ The DAST, The DAST-10, DAST-20, and DAST-A have high internal consistency Skinner & Goldberg, 1986), ≥ 3 in the DAST-10 (alphas range .74–.95) and good test-retest (Skinner, 1982), and either 6 or 7 in the DAST-A reliability (r scores range .71–.89). These (Martino, Grilo & Fehon, 2000). The DAST instruments also have good sensitivity, can be administered through paper and pencil or specificity, and positive predictive value computerized versions (Martino et al., 2000). in detecting drug use disorders across different groups (including offenders) that Positive Features differ by age, gender, and culture (Carey et ■ The DAST is brief to administer and is al., 2003; Cocco & Carey, 1998; El-Bassel easily scored. A general cut-off score of 6 et al., 1997; Maisto, Carey et al., 2000; is used with the DAST. Other versions of Maisto, Conigliaro et al., 2000; Martino et the DAST employ cut-off scores varying al., 2000; McCann et al., 2000; Peters et al., 3–7 and allow for clinical judgment in 2000; Yudko et al., 2007) determining appropriate cut-offs (Staley & ■ The DAST has been found to have a El-Guebaly, 1990; Yudko, Lozhkina, Fouts, single underlying factor, supporting the 2007) unidimensionality of the measure (Yudko, ■ The DAST has been found to be more Lozkhina, Fouts, 2007; Skinner, 1982; effective than several other drug screening Staley & El-Guebaly, 1990). The DAST-A instruments in identifying drug use and DAST-10 have also been found to be disorders among offenders (Peters et al., unidimensional measures (Carey et al., 2000) 2003; Martino et al., 2000) ■ The DAST-10 has good convergent ■ The DAST-20 correlates well with validity with the SCID in detecting alcohol the original DAST-28 (Coco & Carey, problems and shows incremental validity 1998) and other measures of substance over the SCID alone (Maisto, Carey et al., use (MAST, AUDIT, ASI, Children of 2000; Maisto, Conigliaro et al., 2000) Alcoholics Screening Test) across different ■ The DAST-10 and DAST-20 are related to populations and gender and age groups alcohol, drug, and psychiatric measures, (Cocco & Carey, 1998; El-Bassel et al., supporting its concurrent validity 1997; McCann et al., 2000; Saltstone, across different populations and age Halliwell, & Hayslip, 1994; Staley & groups (Yudko et al., 2007; Achenbach, El-Guebaly, 1990; Yudko et al., 2007), Krukowski, Dumenci, & Ivanova, 2005; supporting the convergent validity of the Cocco & Carey, 1998; Gavin et al., 1989; measure Martino et al., 2000)

75 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ The DAST-A has been found to be a ■ The DAST is a commercial product, reliable and valid screening device for use although the cost is quite modest with adolescents in psychiatric settings and includes wording tailored for adolescents Availability and Cost (Martino et al., 2000). The DAST-A The Drug Abuse Screening Test (DAST) is more likely to underestimate than instrument can be obtained by contacting The overestimate substance use problems Addiction Research Foundation, Marketing Department, 33 Russell Street, Toronto, Ontario, Concerns Canada M5S-2S1 at (416) 595-6000. Additional ■ The DAST does not examine the quantity information regarding the DAST can be obtained or frequency of recent or past substance at the following site: http://bit.ly/DAST_inst use and is limited to screening for drug problems The DAST can also be downloaded, with ■ The validity of the DAST has not been information regarding scoring and interpretation widely examined among individuals with of test scores, at the following site: http://www. CODs projectcork.org/clinical_tools/html/DAST.html ■ There is some evidence that the DAST may consist of five factors, departing from other Michigan Alcoholism Screening Test findings of the unidimensional nature of the (MAST) instrument (El-Bassel et al., 1997; Yudko et al., 2007). Several studies also indicate The MAST (Selzer, 1971) is a self-administered that the DAST-20 and DAST-10 have a screening instrument that consists of 25 items multidimensional factor structure (Cocco & related to drinking behavior, symptoms, and Carey, 1998; Saltstone et al., 1994; Skinner consequences of use. The MAST is a public & Goldberg, 1986; Yudko et al., 2007) domain instrument that was developed through ■ Research indicates that the DAST-10 may funding by the NIAAA. The screen uses a yes/no yield a high number of “false negatives” format to inquire about problematic alcohol use (McCann et al., 2000) and addiction throughout the lifetime (Toland & ■ Studies of the DAST-A have not Moss, 1989). A total score is used to determine extensively examined criterion validity alcohol use severity. The MAST is among the (Martino et al., 2000) most frequently studied substance use screening ■ The DAST-28 has several potentially instruments in clinical settings (Teitelbaum & problematic items (items 7 and 20) that Mullen, 2000). are not highly correlated with the overall DAST score (El-Bassel et al., 1997; The MAST-short version (SMAST; Selzer, Skinner, 1982; Staley & El-Guebaly, 1990; Vinokur, & VanRooijen, 1975) is a widely used Yudko et al., 2007). Similarly, items 4 and 13-item screening instrument that examines 5 of the DAST-20, DAST-10, and item symptoms of alcohol use disorders. A brief 20 of DAST-A are not highly correlated 10-item version, the bMAST is also available to with the total score (Cocco & Carey, 1998; examine lifetime severity of problematic drinking Martino et al., 2000; Yudko et al., 2007) (Pokorny, Miller, & Kaplan, 1972). This version ■ The DAST may result in underreporting includes items from the original MAST that were or denial of symptoms due to the face highly discriminative for alcohol use disorders. validity of test items (El-Bassel et al., 1997; A computer-administered version of the MAST Skinner, 1982; Yudkho et al., 2007). The is also available, as is a version for the elderly DAST-A is susceptible to faking good in (MAST-G; SMAST-G; Blow, Gillespie, Barry, adolescent populations (Yudko et al., 2007) Mudd, & Hill, 1998; Morton, Jones & Manganaro,

76 Instruments for Screening and Assessing Co-Occurring Disorders

1996). The recommended cut-off score for ■ Among elderly male outpatients, the MAST identifying problem drinking with the MAST is ≥ demonstrates good sensitivity (91 percent), 5 (Selzer, 1971), with the SMAST is ≥ 3, (Selzer specificity (84 percent), adequate positive et al., 1975), with the bMAST is ≥ 6, (Pokorny et predictive value (70 percent), and good al., 1972), with the MAST-G is ≥5 (Morton et al., negative predictive value (96 percent; 1996), and with the SMAST-G is ≥ 3 (Blow et al., Hirata, Almeida, Funari, & Klein, 2002) 1998). ■ The MAST has an average test-retest reliability of .81 across groups that differ Positive Features by age, gender, race/ethnicity; across ■ The MAST is available in the public different versions of the instrument; and domain, is brief to administer, and requires across study samples (Shields, Howell, no training Potter, & Weiss 2007) ■ The MAST has good sensitivity in justice ■ Conley (2001) found the MAST to be a settings and effectively identifies most more valid indicator of addiction than the incarcerated individuals who have severe AUDIT alcohol use disorders (Peters et al., 2000). ■ The MAST and SMAST have equivalent The test-retest reliability of the MAST internal consistency across age, gender, among offenders is .86–.88 (Conley, 2001; race/ethnicity; different study populations; Peters et al., 2000) and translated versions of the instrument ■ MAST scores are associated with risk for (Shields et al., 2007) recidivism among male and female DWI ■ The SMAST-G has good sensitivity (85 offenders (Lapham, Skipper, Hunt, & percent) and specificity (97 percent; Moore, Chang, 2000) Seeman et al., 2002) ■ The MAST demonstrates good validity ■ Using DSM-III criteria, the SMAST was and sensitivity to detecting alcohol use found to have higher sensitivity than the disorders among people in psychiatric CAGE or of clinician reports (Breakey, settings (Teitelbaum & Mullen, 2000). Calabrese, Rosenblatt, & Crum, 1998) For example, the MAST has good ■ Accuracy for the SMAST tends to improve sensitivity (88 percent) and moderately when individuals are queried about alcohol good specificity (69 percent) in identifying use problems within the past year rather severe alcohol use disorders among than over the lifetime (Zung, 1984) individuals who have schizophrenia (Searles, Alterman, & Purtill, 1990; Toland ■ The SMAST-G has moderate sensitivity (71 & Moss, 1989). The MAST is more percent) and good specificity (81 percent) accurate in identifying alcohol problems among the elderly (Moore, Seeman et al., among males with schizophrenia than 2002), and an optimal cut-off score of 6 has with females (McHugo et al., 1993). The been identified for use with this population 1-week test-retest reliability of the MAST (Beullens & Aertgeerts, 2004) in a psychiatric sample is .98 (Teitelbaum ■ The bMAST has been validated in two & Carey, 2000) treatment-seeking samples of alcohol users ■ The MAST has been found to be reliable, to and contains two factors (perception of effectively discriminate between problem drinking and consequences of drinking). and non-problem drinkers (Mischke & The bMAST is moderately correlated Venneri, 1987), and to identify alcohol use with the AUDIT and is as effective as the disorders and excessive drinking problems AUDIT in identifying alcohol use severity (Bernadt, Mumford, & Murray, 1984) (Connor, Grier, Feeney & Young, 2007) ■ The bMAST has high specificity and positive predictive value among people

77 Screening and Assessment of Co-Occurring Disorders in the Justice System

who have alcohol use disorders (Soderstrom who have a tendency to answer positively et al., 1997) and in hospital samples when asked about hallucinations associated (Hearne, Connolly & Sheehan, 2002) with heavy drinking, even when such phenomena are unrelated to alcohol Concerns consumption (Toland & Moss, 1989) ■ The MAST is limited to screening for ■ The MAST has wide variability in internal alcohol problems and does not examine the consistency (.43–.93). Fourteen studies quantity or frequency of alcohol use report internal consistencies of less than ■ The MAST lacks a time frame for .80, and there is significant heterogeneity responses. As a result, positive scores do in these estimates (Shields et al., 2007). not necessarily indicate a current alcohol The MAST may produce higher internal problem consistency estimates in males than females ■ The MAST was not one of the most (Shields et al., 2007). Internal consistency effective screening instruments in of the MAST may be higher among clinical identifying severe substance use disorders versus nonclinical samples (Shields et al., among prisoners (Peters et al., 2000) 2007) ■ Both the MAST and SMAST tend to have ■ The bMAST may not be effective in greater sensitivity than specificity and thus assessing current alcohol consumption, misidentify individuals as having substance withdrawal symptoms or tremors (Connor use disorders (Conley, 2001) et al., 2007) ■ The MAST has only moderate specificity in Availability and Cost psychiatric settings (Teitelbaum & Mullen, The MAST can be downloaded at no cost at 2000) and has low specificity in justice the following site, which includes additional settings (Peters et al., 2000) information about the tool: http://bit.ly/MAST_inst ■ Weights for MAST items were not empirically derived, and items related to drug arrests and liver problems detract Screening, Brief Intervention, Referral from the unidimensionality of the measure to Treatment–SBIRT (Thurber, Snow, Lewis & Hodgson, 2001) The Screening, Brief Intervention, and Referral to ■ Among DUI offenders, MAST scores are Treatment (SBIRT) process is not an individual only moderately correlated with substance screening tool but involves an integrative approach use disorders (Conley, 2001) towards screening, intervention, and referral ■ The MAST is not as effective in detecting to treatment services that was designed for use alcohol problems among men (Teitelbaum in primary health care settings and funded by & Mullen, 2000) SAMHSA. The SBIRT approach recommends ■ In psychiatric and treatment settings, the use of an evidence-based substance use screening SMAST underestimates alcohol problems instrument, and SAMHSA grantees that have among women (Breakey et al., 1998) implemented this approach have been required to ■ The SMAST is less sensitive in community use the ASSIST screening instrument. However, treatment samples relative to primary care in general, the SBIRT approach does not specify samples (Chan, Pristach, & Welte, 1994). a particular substance use screening instrument, The bMAST also has low sensitivity in a and a number of instruments reviewed in this hospital admissions sample (Hearne et al., section could be potentially used for this purpose. 2002) Although designed for use in health care settings, ■ Use of the MAST may be problematic the SBIRT approach can be readily adapted for use for people who have schizophrenia and in justice settings in which there is a high volume

78 Instruments for Screening and Assessing Co-Occurring Disorders of offenders screened who are in potential need of determined by substance use severity. treatment services. The SBIRT approach has been The approach uses an integrated model widely implemented across the United States and to provide graduated levels of services is now a reimbursable service through Medicaid for people who have varying needs for and Medicare in many states. substance use treatment (Babor et al., 2007) ■ SBIRT effectively identifies those who The SBIRT approach was intended to reduce are at risk for substance use problems in risk for substance use disorders through early primary care settings. People may not be identification, early intervention, and triage to seeking help for substance use problems in treatment. The approach involves a brief (5–10 these settings, and thus, SBIRT provides minutes) universal screening for indicators of a unique set of early intervention and substance use disorders; a seamless transition prevention services (SAMHSA, 2011) between screening, brief interventions, and brief ■ SBIRT provides significant public health substance use treatment; and triage to more savings ($3.81 for every $1 spent; Fleming intensive and specialized treatment services, et al., 2002; Gentilello, Ebel, Wickizer, if needed. The four steps of SBIRT include Salkever & Rivara, 2005) (1) screening, (2) brief intervention, (3) brief ■ SBIRT has been adapted in justice settings, treatment, and (4) referral to a range of more using TICs (Targeted Interventions for intensive treatment services (SAMHSA, 2011). Corrections; Joe et al., 2012; Knight, Simpson, & Flynn, 2012), which integrate The SBIRT model endorses use of evidence-based screening tools such as the TCU scales substance use screening instruments that can be and the ASI for use in referral to treatment used across a broad range of populations and and treatment planning. The TIC system settings (e.g., primary care, trauma centers) and implements a battery of instruments that can identify risk levels (e.g., low, moderate, that are tailored for offenders, including high) related to substance use severity. These risk measures of substance use, criminal levels can be used to identify those in need of a thinking, motivation and treatment brief intervention, brief treatment, and referral to readiness, and psychological functioning. more intensive services. SAMHSA recommends Results are then used to place offenders that people identified as being of moderate to high into brief interventions that focus on risk for substance use disorders may need brief anger management, HIV/sexual health, interventions, brief treatment, and referral for motivation, and developing positive social intensive services. Commonly, SBIRT screening networks. The TIC system also includes referral to more intensive substance use tools include the ASSIST, the AUDIT, the CAGE, treatment (Joe et al., 2012; Knight et al., and the DAST. Prescreening instruments such as 2012) the NIDA Quick Screen or the AUDIT-C are often used to identify people who may have significant ■ Across settings (i.e., primary care, substance use problems, prior to administration of hospitals, public and rural health care offices, inpatient, and outpatient clinics) a more in-depth screening instrument to determine and use of different universal screening the need for a comprehensive assessment related to tools (i.e., AUDIT, CAGE, DAST), the substance use disorders. SBIRT approach has effectively referred those who screen positive for substance Positive Features use problems at baseline (17–40 percent) to ■ SBIRT combines screening for alcohol either a brief intervention (13–70 percent), and other drugs, and those screened as brief treatment (2–14 percent), or to positive are referred for brief intervention more intensive treatment (4–16 percent), or treatment, based on the risk level as

79 Screening and Assessment of Co-Occurring Disorders in the Justice System

resulting in over 63 percent receiving some ■ SBIRT is reimbursable through Medicaid, type of treatment (Madras et al., 2009) Medicare, and third party insurers in many ■ SBIRT interventions that involve referral states (Madras et al., 2009; ONDCP & to diverse service settings (e.g., trauma SAMHSA, 2012) centers, emergency rooms, primary care ■ SBIRT may also be effective for clinics) and that use a range of different adolescents who are at risk for substance screening instruments have yielded use disorders (Bernstein et al., 2009; significant reductions in substance use D’Amico, Miles, Stern & Meredity, 2008; over a 6-month follow-up period. These Spirito et al., 2004) results are consistent across different levels ■ The SBIRT system has produced effective of substance use severity and across age, outcomes related to physical and mental gender, and race/ethnicity groups (Madras health, employment, housing, and IV drug et al., 2009) use (ONDCP & SAMHSA, 2012; Madras ■ Other studies have shown similarly positive et al., 2009) results for screening and brief interventions ■ Use of the SBIRT approach has led to a for individuals who use different types reduced number of arrests within a 30-day of substances (Bernstein et al., 2005; period (ONDCP & SAMHSA, 2012) Copeland, Swift, Roffman & Stephens, 2001; McCambridge and Strang, 2004; Concerns Humeniuk et al., 2008; Madras et al., 2009; ■ SBIRT services have been studied most Schermer, Moyers, Miller, & Bloomfield, extensively in primary care and hospital 2006; Soderstrom et al., 2007) settings, and have not been as carefully ■ In a study of people screened as having examined within justice populations moderate risk for substance use disorders ■ Those who receive brief interventions for by the ASSIST, people randomly opioid use disorders based on the ASSIST assigned to receive a brief intervention screening do not always experience had significantly lower substance use significant reductions in substance (60 percent reduction) in contrast to a use or have lower scores on substance comparison group. These effects did not use screening instruments over time vary by age or education level (Humeniuk (Humeniuk et al., 2008). Other studies et al., 2008) have not detected changes in substance use ■ The ASSIST appears to be one of the among those receiving the SBIRT brief most comprehensive substance use interventions (Marsden et al., 2006). Some screens that is used in the SBIRT system, reductions in substance use have been as the instrument addresses different identified among comparison groups who types of substances and different levels received no intervention of substance use. The ASSIST and ■ SBIRT may provide different outcomes subsequent brief interventions are relatively for those with alcohol problems, as studies easy to administer (SAMHSA, 2011). have found inconsistencies in response Additionally, national and international rates, severity of use, and intervention organizations have recommended using outcomes (Babor, Steinberg, Anton & the ASSIST (and the AUDIT), including Del Boca, 2000; Madras et al., 2009; NIDA, SAMHSA, and WHO Saitz et al., 2007). For example, Saitz ■ SBIRT has good potential for identifying and others (2007) report that people with people who misuse prescription drugs and severe alcohol use disorders who received in promoting abstinence over a 6-month brief SBIRT interventions did not show a follow-up period (Office of National Drug significant reduction in alcohol use relative Control Policy & SAMHSA, 2012) to a comparison group

80 Instruments for Screening and Assessing Co-Occurring Disorders

■ Substance use screening generally for Substance Abuse Treatment (CSAT) through employs self-report screening instruments, selection of items from eight existing screening which may not be as accurate as clinical instruments and from the DSM-III-R. The SSI interviews or the use of self-report examines five domains related to severe substance instruments in combination with drug testing (Vitale, van de Mheen, van de Wiel, use disorders: (1) alcohol and drug consumption, & Garretsen, 2006) (2) preoccupation and loss of control, (3) adverse consequences, (4) problem recognition, and (5) ■ Additional research is needed to examine tolerance and withdrawal. The SSI can be self- the stability of SBIRT-related reductions in substance use over time during follow-up administered or provided through an interview. periods of greater than 6 months (Madras et The recommended cut-off score for identifying al., 2009) alcohol or other drug (AOD) disorders is ≥ 4 (CSAT, 1994). ■ SBIRT studies with adolescents have yielded inconsistent results in reducing Positive Features substance use and are compromised ■ The SSI is brief to administer and can by several methodological problems be easily administered and scored by (Bernstein et al., 2010; Spirito et al., 2011) nonclinicians, without the need for training SBIRT Resources ■ The SSI is available at no cost Several resources for developing and ■ The SSI is one of the most frequently implementing an SBIRT approach for screening, used substance use screening instruments brief interventions, and referral to treatment are within state correctional systems (Moore & provided at the following sites: Mears, 2003) and is widely used in other justice settings (DeMatteo, 2010; Knight, http://www.samhsa.gov/sbirt Simpson, & Hiller, 2002; Moore & Mears, 2003; Peters et al., 2004; Taxman, Young et http://www.drugabuse.gov/publications/resource- al., 2007) guide ■ In a study comparing the psychometric http://www.samhsa.gov/sbirt properties of several screening instruments in correctional settings, the SSI was found http://www.cdc.gov/ncbddd/fasd/documents/ to be one of the most effective instruments alcoholsbiimplementationguide.pdf in identifying severe substance use disorders (Peters et al., 2000) Billing codes for SBIRT service are available at ■ The SSI had the highest sensitivity (87 the following sites: percent) and overall accuracy (84 percent) http://www.wiphl.org/uploads/media/SBIRT_ of the several substance use screening Manual.pdf instruments examined in a prison-based study and also has good specificity (80 percent; Peters et al., 2000) Simple Screening Instrument for ■ The SSI functions as intended as a Substance Abuse (SSI) unidimensional measure (Boothroyd, The Simple Screening Instrument for Substance Peters, Armstrong, Rynearson-Moody & Abuse (SSI; CSAT, 1994) is a 16-item screening Caudy, 2013) instrument that examines symptoms of severe ■ The SSI has good convergent validity alcohol and drug use disorders that have been with other substance use measures among experienced during the past 6 months. The justice-involved individuals (O’Keefe, instrument was developed by SAMHSA's Center Klebe & Timken, 1999)

81 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ The SSI has good convergent validity, and Availability and Cost at a cut-off score of 4, has moderate to The SSI is available free of charge and is large effect sizes in identifying people who described in the following monograph: The Center need substance use treatment, those who for Substance Abuse Treatment. (1994). Simple have used substances in the past month, screening instruments for outreach for alcohol those reporting functional deficits, and those who have lower levels of “quality of and other drug abuse and infectious diseases. life” (Boothroyd et al., 2013) Treatment Improvement Protocol (TIP), Series 11. Rockville, MD: U.S. Department of Health ■ The SSI exhibits good sensitivity (82 and Human Services. This publication may be percent), specificity (90 percent), positive predictive value (99 percent), and negative downloaded at http://store.samhsa.gov. Or, call predictive value (37 percent) in a Medicaid SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) population. These psychometric properties (English and Español). are not influenced by ethnicity or gender The self-report instrument and scoring instructions (Boothroyd et al., 2013) are available free of charge at the following site: ■ The SSI has good sensitivity at a cut- http://www.ncbi.nlm.nih.gov/books/NBK64629/ off score of 1 in detecting substance use disorders among college students (Kills Small, Simons & Stricherz, 2007) Substance Abuse Subtle Screening and was correlated with several other Inventory (SASSI-3) validated measures of substance use The SASSI-3 (Miller, 1985) examines symptoms disorders (i.e., the AUDIT, Rutgers Alcohol Problem Index-RAPI, and Daily Drinking and other indicators of alcohol and drug use Questionnaire-DDQ) disorders and was designed to identify individuals who may need further assessment and diagnosis ■ The test-retest reliability of the SSI among of these disorders (Lazowski, Miller, Boye, & justice-involved individuals is quite good Miller, 1998). The SASSI-3 includes an initial (.83–.97; O’Keefe et al., 1999; Peters et al., 2000) section consisting of 67 true/false items and 8 subscales that are described as “subtle” indicators ■ The internal consistency of the SSI is of substance use disorders. Although described quite good among adolescents (alpha as “subtle,” many of the items refer directly to = .83; Knight, Goodman, Pulerwitz, & DuRant, 2000), adult offenders (alpha = substance use. A second section of 12 items .91; O’Keefe et al., 1999), and Medicaid examines alcohol use, and a third section examines enrollees (alpha = .85; Boothroyd et other drug use for a total of 93 items. Five of al., 2013). Good internal consistency is the subscales from the first (“subtle”) section provided across race/ethnicity and gender of the instrument and the two subscales derived groups (alphas = 82–.86; Boothroyd et al., from the remaining (“face valid”) sections are 2013) used in determining a yes/no decision regarding the probability of a substance use disorder. The Concerns decision rules in making this determination are ■ The validity of the SSI has not been somewhat different for males and females. examined among individuals with CODs The instrument may be administered via paper ■ The SSI may not be as effective in identifying alcohol use disorders as the and pencil or by computer (Swartz, 1998). The AUDIT (Kills Small et al., 2007) SASSI-A has been developed for use with adolescents. The recommended cut-off score ■ The SSI does not examine the quantity or as indicated by the SASSI-3 user’s guide for frequency of recent and past substance use identifying severe substance use disorders among

82 Instruments for Screening and Assessing Co-Occurring Disorders adults is ≥ 17 with males and ≥ 19 with females Diltz, Smirnoff, & Salyers, 2005; Laux, (Miller, Roberts, Brooks & Lazowski, 1997). Salyers et al., 2005; Lazowski et al., 1998)

Positive Features Concerns ■ Researchers at the SASSI Institute report ■ The SASSI is a commercial product and that the SASSI, SASSI-2 and SASSI-3 is quite expensive in comparison to other (Miller & Lazowski, 1999) have high substance use screening instruments sensitivity, specificity, and positive ■ The SASSI was found to be the least predictive value (Lazowski et al., 1998) effective of eight screening instruments in across a range of settings identifying severe substance use disorders ■ The SASSI adult manual indicates adequate among incarcerated offenders (Peters et al., classification rates of substance use 2000). The SASSI had among the lowest disorders (62 percent; Bauman Merta & overall accuracy (60 percent) of the eight Steiner, 1999) substance use screens examined in the ■ Several studies examining the SASSI-3 study and had the lowest specificity (52 (Arenth, Bogner, Corrigan, & Schmidt, percent) of the five screening instruments 2001; Ashman, Schwartz, Cantor, Hibbard, that specifically examined drug use & Gordon., 2004) indicate adequate disorders, including the Simple Screening sensitivity (72–85 percent), specificity Instrument (SSI) and Texas Christian (63–82 percent), positive predictive value University Drug Screen (TCUDS) that are (68–76 percent), and negative predictive described in this monograph value (74–84 percent) ■ The SASSI does not address a unitary ■ The SASSI demonstrates adequate construct and instead examines several agreement with the CAGE and the MAST underlying factors, in contrast to the intent (Laux, Salyers, & Kotova, 2005; Myerholtz of the instrument (Gray, 2001; Rogers & Rosenberg, 1998) et al., 1997; Stein et al., 2005; Sweet & Saules, 2003). The SASSI appears to have ■ The SASSI “direct” scales perform low internal consistency, reinforcing the relatively well in classifying substance concern that it may be measuring several use disorders (84–89 percent) and perform constructs (Myerholtz & Rosenberg, better than the total SASSI score in this 1998). Several of the SASSI scales appear regard (Ashman et al., 2004; Clements, to measure emotional problems and not 2002; Gray, 2001; Swartz, 1998) substance use (Stein et al., 2005; Sweet & ■ The SASSI-A scales have demonstrated Saules, 2003). In general, it is unclear what good construct validity (Stein et al., 2005), the SASSI indirect scales are measuring and adequate internal consistency (alphas (Gray, 2001). Confirmatory factor analysis range .66–.74) is reported with the direct indicates that the SASSI scales and related scales (Makini et al., 1996; Nishimura et scoring keys are inconsistent with the factor al., 2001) structure that was obtained using a large ■ In one study, the SASSI-A accurately offender population (Gray, 2001) classified 76 percent of people who did not ■ The SASSI-3 provides 10 subscales; admit to alcohol and drug use problems however, research indicates that a (Rogers, Cashel, Johansen, Sewell, & 10-factor structure has a poor fit (Gray, Gonzalez, 1997) 2001). Similarly the SASSI-A provides a ■ Studies indicated good 1- and 2-week test- 5-factor structure, yet research indicates retest reliability and internal consistency several differing factor structures for the for the SASSI’s “face valid” subscales instrument, with a relatively low amount (Clements, 2002; Gray, 2001; Laux, Perera- of variance (33 percent) accounted for by

83 Screening and Assessment of Co-Occurring Disorders in the Justice System

any of these structures (Feldstein & Miller, relatively low validity, with alphas ranging 2007; Rogers et al.,1997; Sweet & Saules, .03–.72 2003) ■ The 1-month test-retest reliability (r score ■ The SASSI produces a high proportion of = .36) and 1-week stability (phi = .63) of “false positives” among juvenile offenders the SASSI in determining the presence (68 percent; Rogers et al., 1997) and adult of a substance use disorder is quite low offenders (51 percent; Swartz, 1998), (Myerholtz & Rosenberg, 1998) which may be due in part to identification ■ Direct questions related to substance of lifetime substance use disorders use symptoms are more effective than ■ The SASSI does not examine the quantity subtle or indirect approaches used by or frequency of recent and past substance the SASSI (Gray, 2001; Myerholtz & use Rosenberg, 1998; Svanum & McGrew, ■ Scores on the SASSI appear to be 1995). The SASSI-3 “subtle” subscales significantly affected by gender, education do not correlate well with criterion level, or minority status, and there is variables (Clements, 2002) and provide no considerable inconsistency in these scores improvement in classification over direct across different studies (Coll, Juhnke, questions (Clements, 2002; Myerholtz & Thobro, & Haas, 2003; Bauman et al., Rosenberg, 1997; Swartz, 1998). In one 1999; Karacostas & Fisher, 1993; Makini study examining the SASSI-A, the “subtle” et al., 1996; Risberg, Stevens, & Graybill, subscales identified less than half of 1995; Yuen, Nahulu, Hishinuma, & individuals who openly admitted substance Miyamoto, 2000) use (Sweet & Saules, 2003) ■ Racial/cultural minorities may be more ■ The SASSI “subtle” subscales are likely to be classified by the SASSI as susceptible to dissimulation, leading to having substance use disorders than other misclassification (Myerholtz & Rosenberg, groups (Bauman et al., 1999; Karacostas & 1997). They also demonstrate low test- Fisher, 1993; Yuen et al., 2000) retest reliability (.25–.45; Gray, 2001; Myerholtz & Rosenberg, 1997) and internal ■ Results of the SASSI may be distorted consistency (.08; Clements 2002) by comorbid psychopathology, such as (Bauman et al., 1999), ■ The SASSI may be susceptible to positive depression (Horrigan, Schroeder, & impression management (i.e., attempts Schaffer, 2000), and trauma (Savonlahti, to minimize substance use in order to Pajulo, Helenius, Korvenranta & Piha, avoid social exclusion or other negative 2004) consequences; Myerholtz & Rosenberg, 1997) ■ In one of the largest samples examined, the SASSI was found to have a sensitivity ■ Although the SASSI provides treatment of only 33 percent (Svanum & McGrew, recommendations for interpreting scores, 1995). The SASSI failed to classify 41–50 there is no empirical evidence to support percent of those who self-reported drug use these interpretations (Feldstein & Miller, in an intake interview (Horrigan & Piazza, 2007) 1999) ■ The SASSI-3 and SASSI-A are no more ■ The internal consistency of the SASSI-3 effective than several briefer screening is quite variable, with alphas ranging from instruments in detecting substance use very low to very high (.27–95) and highest disorders (e.g., CAGE, DAST, MAST; values associated with the “face validity” Clements, 2002; Rogers et al., 1997) and “direct” subscales. Other scales show ■ The SASSI-A Correctional (COR) scale does not appear to be related to measures of

84 Instruments for Screening and Assessing Co-Occurring Disorders

criminal activity and thus may be of limited ■ The TCUDS V has been revised to align value in predicting recidivism (Stein et al., with the DSM-5 diagnostic criteria for 2005) substance use disorders ■ No studies report internal consistency ■ The TCUDS V is available at no cost for the full SASSI-A (Feldstein & Miller, ■ The TCUDS is one of the most frequently 2007) used substance use screening instruments within state correctional systems (Moore & Availability and Cost Mears, 2003; Peters et al., 2004) The SASSI-3 costs approximately $140 for a ■ The TCUDS was found to be one of the set of materials that includes the administration most effective screening instruments in manual, a user’s guide, a scoring key, and 25 identifying inmates with severe substance questionnaires and profile sheets. The SASSI-3 is use disorders in a study comparing the available for purchase at the following site: https:// psychometric properties of several different ecom.mhs.com/(S(fyc3pvmieljp5vnkmkvepf45))/ screening instruments (Peters et al., 2000) product.aspx?gr=cli&prod=sasi&id=overview ■ The TCUDS had among the highest sensitivity (85 percent) and overall Texas Christian University Drug accuracy (82 percent) among several Dependence Screen V (TCUDS V) substance use screening instruments examined in a corrections-based study, and The TCUDS V is a 17-item public domain also has good specificity (78 percent; Peters instrument that was derived from a substance et al., 2000) use diagnostic instrument (Brief Background ■ The TCUDS examines major DSM Assessment–Drug-Related Problems section) diagnostic symptoms of substance use developed by the Texas Christian University, disorders Institute of Behavioral Research as part of ■ TCUDS scores of greater than 5 among an intake assessment for the Drug Abuse prison inmates are associated with Treatment for AIDS-Risk Reduction (DATAR) increased risk for recidivism (Baillargeon project, a NIDA-funded initiative evaluating et al., 2009) the effectiveness of new treatment intervention ■ The TCUDS is significantly correlated with strategies (Simpson & Knight, 1998). The the ASI (Pankow et al., 2012), supporting TCUDS V provides a self-report measure of the convergent validity of the instrument substance use problems within the past 12 months, ■ Test-retest reliability of the TCUDS among and is based on the DSM-5 criteria for substance incarcerated individuals is quite good use disorders. The instrument provides a brief (.89–.95; Knight, Simpson, & Morey, 2002; screen for frequency of substance use, history of Peters et al., 2000) treatment, substance use disorder symptoms, and ■ The TCUDS has good internal consistency motivation for treatment. A cut-off score of > 4 on in different correctional treatment settings the TCUDS V indicates the presence of a moderate (mean alpha = .87; alphas range .84–.89) substance use disorder, and a score of > 6 indicates and across gender (Simpson, Joe, Knight, a severe disorder. Rowan-Szal, & Gray., 2012) Positive Features ■ Concordance between self-report and interview information obtained from ■ The TCUDS V is brief to administer and an earlier version of the TCUDS (Brief can be easily administered and scored by Background Assessment) was quite high nonclinicians, without significant training (Broome, Knight, Joe, & Simpson, 1996)

85 Screening and Assessment of Co-Occurring Disorders in the Justice System

Concerns transition to the new classification system. ■ The validity of the TCUDS V has not been Recommendations for screening of substance examined among people who have CODs use disorders also include instruments that can be integrated within an SBIRT approach. Based ■ The factor structure of the TCUDS has not been well validated, and the instrument on these considerations, the following screening may have a different factor structure across instruments are recommended to examine populations and levels of substance use substance use disorders: severity (Simpson et al., 2012) 1. Either the Texas Christian University ■ The TCUDS may not be the most effective Drug Screen V (TCUDS V) or the Simple singular measure for examining alcohol use Screening Instrument (SSI) to identify disorders (Pankow et al., 2012) substance use symptoms and substance use ■ When administering the TCUDS with severity. The Alcohol Use Identification incarcerated individuals, it may be useful Test (AUDIT) may be combined with to concurrently screen for deception, as either the TCUDS V or the SSI if a more approximately 7 percent of responses may detailed screening for alcohol use is be invalid due to “faking good,” and 8 needed. percent of responses may be invalid due to “faking bad” (Richards & Pai, 2003) (or)

Availability and Cost 2. The ASSIST, which screens for a wide range of substances (including alcohol, The TCUDS V and related information other drugs, and tobacco) and includes a about instrument development, scoring, and brief intervention component in addition to interpretation can be obtained from the following recommendations for treatment. site: http://ibr.tcu.edu/forms/tcu-drug-screen/ Each of these screening instruments requires The following site contains a variety of other approximately 5–10 minutes to administer and useful screening and assessment instruments score. for use in criminal justice and behavioral health settings: http://ibr.tcu.edu/forms/ Screening Instruments for Mental Recommendations for Substance Use Disorders Screening Instruments A wide range of mental health screening Information regarding substance use screening instruments are reviewed in this section. Without instruments is based on a review of the literature use of a formal screening approach, mental and research examining and comparing the disorders are often undetected in criminal justice efficacy of these instruments. Factors considered settings. As a result, staff are less likely to in recommending specific screening instruments anticipate suicidal behavior and other mental include empirical evidence supporting the health problems, and the effectiveness of treatment reliability and validity of the instrument, relative is reduced. Failure to detect mental disorders cost of the instrument, ease of administration, among offenders also leads to delay in triage and previous use in the justice system. Although to mental health services, behavioral problems summaries of the instruments include research that may be attributed to other causes, early based on the DSM-IV criteria, recommendations dropout from substance use treatment, rapid are made considering the degree to which cycling through community emergency services, instruments align closely with the new DSM-5 and rearrest and reincarceration (Hiller et al., criteria and whether they allow for a seamless 2011). A wide range of mental health screens

86 Instruments for Screening and Assessing Co-Occurring Disorders are available for use in the criminal justice depressive severity to assist in treatment system, including several that are in the public planning domain and downloadable from the internet. ■ The BDI-II is clearly and concisely The following section describes mental health worded, and the measure can be completed screening instruments that are widely used in the in 5-10 minutes justice system, that have been validated for use ■ Only a fifth grade reading level is required with offenders, or that show significant promise to complete the BDI-II for use with offenders, including those who have ■ The BDI-II has been validated for use co-occurring disorders (CODs). with adult offenders (Kroner, Kang, Mills, Harris, & Green., 2011) Screening Instruments for Depression ■ The BDI-II has been successfully used as a screening instrument and outcome measure Beck Depression Inventory-II (BDI-II) of depression among prisoners (Harner, The BDI-II (Beck, Steer, & Brown, 1996) is a Hanlon & Garfinkel, 2010; Johnson & 21-item self-report instrument that examines the Zlotnick, 2008; Gussak, 2006). The intensity of depressive symptoms and suicidality. instrument has frequently been used with This instrument is one of the most widely people with substance use disorders and used measures of depression. The BDI-II was has been found to be useful in the screening and assessment of depression with this developed to correspond to DSM-IV criteria of population (Buckley, Parker, & Heggie, depression and reviews key symptoms, including 2001) agitation, difficulty in concentration, feelings of worthlessness, and loss of energy. Elevated ■ The BDI-II is correlated with instruments scores on items related to suicidal ideation and examining both alcohol and drug use and with severity of substance use problems hopelessness should be attended to carefully, (Dum, Pickren, Sobell, & Sobell, 2008) since these items are the most highly predictive of suicidal behavior. The BDI-6 is a recently ■ The BDI-II has been validated with developed, shorter version of the instrument diverse cultural populations and has been translated into several languages (Grothe (Aalto, Elovainio, Kivimäki, Uutela, & Pirkola, et al., 2005; Penley, Wiebe, & Nwosu, 2012; Beck, Ward, Mendelson, Mock, Erbaugh, 2003). The instrument has been found to 1961). Despite its usefulness in screening for be unbiased in use among ethnic/racial depression and suicide, the BDI-II should not be groups (Sashidharan, Pawlow & Pettibone, used in diagnosing depression (as reported for the 2012). The instrument has excellent BDI-I; Sundberg, 1987), which requires a more content, convergent, and divergent validity intensive assessment process. The recommended across different populations, age groups, BDI-II cut-off score for identifying depression and gender groups (Arnau, Meagher, is ≥ 16 (Beck et al., 1996; Sprinkle et al., 2002). Norris, & Bramson 2001; Dum et al., 2008; Computerized versions of the instrument are Krefetz, Steer, Gulab, & Beck 2002; Steer, available, as well as a version in Spanish. Beck, & Garrison, 1986; Storch, Roberti & Roth, 2004). Scores on the BDI-II are Positive Features significantly correlated with other indices ■ The BDI-II requires minimal training, of depression, including the Hamilton and can be administered and scored by a Rating Scale for Depression (HAM-D, r nonclinician score = .71) and the Beck Hopelessness ■ The BDI-II includes scoring instructions Scale (r score = .68) and interpretation of different levels of ■ Among females offenders, the BDI-II shows good convergent validity with

87 Screening and Assessment of Co-Occurring Disorders in the Justice System

another measure of depression, the Beck current and past diagnoses of depression Hopelessness scale (r score = .55). The (Aalto et al., 2012) instrument is also useful in predicting ■ The BDI-6 has good internal consistency self-harm (Perry & Gilbody, 2009) and in (alpha=.83; Aalto et al., 2012) identifying suicidal ideation (Kroner et al., ■ A cut-off score ≥1 or 2 in the BDI-6 is 2011) recommended for identifying depression ■ The BDI-II provides a unidimensional within the past 12 months, and a score of construct of depression across cultures ≥ 4 or 5 is recommended for identifying (Nuevo et al., 2009; Shafer, 2006), although depression within the past two weeks it reviews several underlying components (Aalto et al., 2012) of depression (e.g., somatic, affective, and ■ The BDI has higher sensitivity (94 percent) cognitive symptoms; Arnau et al., 2001; and specificity (59 percent) than the Raskin Dum et al., 2008; Steer, Ball, Ranieri, & Depression Scale, the Hamilton Depression Beck, 1999) Rating Scale (HAM-D), and the Symptom ■ Among people with substance use Checklist 90-Revised (SCL-90-R; problems, the BDI-II exhibits good Rounsaville, Weissman, Rosenberger, sensitivity (86–96 percent), specificity (86 Wilber, & Kleber, 1979). The BDI-II is percent), and negative predictive value (97 also able to distinguish among varying percent) in diagnosing depression (Scott et levels of depressive severity (Steer, Brown, al., 2011; Seignourel, Green, & Schmitz, Beck, & Sanderson, 2001) 2008). Previous studies examining the BDI also indicate moderately good sensitivity Concerns (67 percent) and specificity (69 percent) in ■ The BDI is not available in the public diagnosing depression among individuals domain and is fairly costly to purchase with alcohol problems (Willenbring, 1986) ■ Higher BDI cut-off scores may be ■ Several studies demonstrate high internal warranted among males with substance use consistency within the BDI-II, including disorders and male prisoners, as studies those examining female offenders, suggest that these populations have higher alpha=.90 (Kroner et al., 2011) and levels of depression than other groups substance-involved populations (alpha=.95; (Beck et al., 1996; Boothby & Durham, Dum et al., 2008; Buckley et al., 2001). 1999; Buckley et al., 2001; Steer, Kumar, For the Spanish version of the BDI-II, the Ranieri & Beck, 1998) average coefficient alpha is .91 (range ■ First-time offenders tend to have higher =.89–.93; Wiebe & Penly, 2005) scores on the instrument (Boothby & ■ The BDI-II demonstrates good test-retest Durham, 1999) reliability over 1 week (r score =.74–.96; ■ Further validation of the BDI-II is needed Beck et al., 1996; Leigh & Anthony- in criminal justice settings. For example, Tolbert, 2001; Sprinkle et al., 2002), a research is needed to explore the diagnostic finding replicated with the Spanish version accuracy (e.g., sensitivity and specificity) of the instrument (Wiebe & Penly, 2005) of the BDI-6 among offenders and to ■ Use of the BDI-6 in the general population identify recommended cut-off scores for indicates good convergent validity with the depression BDI-II (r score =.88), and higher scores ■ The factor structure of the BDI-II among reflect more severe depression or more prisoners is somewhat different than in recent depression. The BDI-6 exhibits the general population, suggesting that the good sensitivity (93–80 percent) and instrument may measure other components specificity (89–70 percent) in identifying

88 Instruments for Screening and Assessing Co-Occurring Disorders

of depression that are unique to offenders Availability and Cost (Boothby & Durham, 1999) The BDI-II can be purchased from Pearson ■ The BDI-II may have low specificity with Clinical Assessment at the following site: substance-involved populations (Seignourel http://www.pearsonclinical.com/psychology/ et al., 2008) products/100000159/beck-depression-inventoryii- ■ The instrument should not be used as a bdi-ii.html?Pid=015-8018-370 sole indicator of depression but rather in conjunction with other instruments (Weiss The cost is $79 for one manual and 25 record & Mirin, 1989; Willenbring, 1986). Like forms. other screening instruments, the BDI- II is not a diagnostic tool, and elevated Center for Epidemiological Studies– scores do not necessarily reflect a major Depression Scale (CES-D) depressive disorder but rather the presence of depressed mood during the past 2 weeks The Center for Epidemiological Studies- ■ Because the BDI measures subjective Depression Scale (CES-D) is a 20-item self-report feelings of depression, it is difficult to screen that examines the frequency and duration discriminate between normal individuals of symptoms associated with depression. Items who are experiencing sadness and those review symptoms that have occurred during the individuals who are clinically depressed past week. A 10-item version of the CES-D (Hesselbrock, Hesselbrock, Tennen, Meyer, is also available (Kohut, Berkman, Evans, & & Workman, 1983) Cornoni-Huntley, 1993) and was developed with ■ The BDI-II does not differentiate among an elderly population. The CES-D screen can varying types of mood disorders (e.g., also be administered as a structured interview. major depressive disorder and dysthymia; The recommended cut-off score in identifying Richter, Werner, Heerlein, Kraus, & Sauer, depression is ≥ 16 for the 20-item version of the 1998) CES-D (Radloff, 1977) and ≥ 4 for the 10-item ■ Women score significantly higher than men version (Irwin, Artin, & Oxman, 1999). on the BDI-II, but these gender differences are not reflected across age and racial/ Positive Features ethnic groups. Despite gender differences ■ The original 20-item CES-D is a public being acknowledged by the authors (Steer, domain instrument Beck, & Brown, 1989), only a single set of ■ The CES-D takes approximately 5 interpretive guidelines is provided minutes to administer and 1–2 minutes to ■ Definitions of depression and the score. The instrument does not require experience of depression may differ across professional clinical training to administer countries (Nuevo et al., 2009) or score ■ An alternate version of the BDI-6 ■ Cut-off scores are available for use includes items (Beck et al., 1961; Bech, with different clinical and nonclinical Gormsen, Loldrup, & Lunde, 2009) that populations are based on core features of the Hamilton ■ The CES-D has been used in criminal Depression Scale (HAM-D), including justice settings to screen for depression depressed mood, guilt, work inhibition, (Bland et al., 2012; Tatar, Kaasa & difficulty making decisions, indecisiveness, Cauffman, 2012; Scheyett et al., irritability, and fatigue (Bech et al., 2009). 2010). Among people with a history However, recommended cut-off scores are of incarceration, the CES-D is strongly not provided for this version of the BDI-6 correlated with other validated measures of depression (Bland et al., 2012; Tatar et

89 Screening and Assessment of Co-Occurring Disorders in the Justice System

al., 2012). The CES-D has good internal ■ The CES-D has good psychometric consistency when used with offenders properties for use with adolescent and (alphas=.71–.94; Bland et al., 2012; Tatar elderly populations (Dozema et al., 2011; et al., 2012). The short form of the CES-D Prescott et al., 1998; Sheehan, Fifield, also demonstrates good internal consistency Reisine, & Tennen, 1995; Wancata, among offenders (Nyamathi et al., 2011) Alexandrowicz, Marquart, Weiss, & ■ The CES-D has been used with substance- Friedrich, 2006), and has sensitivity of involved populations (Khosla, Juon, Kirk, 74–84 percent, and specificity of 60–74 Astemborski & Mehta., 2011; Perdue, percent (Haringsma, Engels, Beekman, & Hagan, Thiede, & Valleroy, 2003) and Spinhoven, 2004; Prescott et al., 1998) has been found to be suitably effective in Concerns detecting symptoms of depression and in measuring change in these symptoms over ■ Offenders and people with substance use time (Boyd & Hauenstein, 1997) disorders may exhibit elevated scores on the CES-D relative to other populations, ■ The CES-D has been used with a variety which may warrant higher cut-off scores in of clinical and nonclinical populations screening for clinical depression (Bland et (Atkins, Marin, Lo, Klann, & Hahlweg, al., 2012; Khosla et al., 2011; Perdue et al., 2010 ; Bakitas et al., 2009; Barnes & 2003; Tatar et al., 2012) Meyer, 2012; Giese-Davis et al., 2011) ■ Further validation in justice settings ■ The CES-D has been validated for use with is needed to examine specificity and different racial/ethnic groups and has been sensitivity in detecting depression translated into several foreign languages ■ The CES-D may be biased by gender ■ The CES-D short forms show good (Stommel et al., 1993), and there may be psychometric properties across clinical differences in rates of depression by gender, and nonclinical populations and across even after accounting for measurement gender, race/ethnicity, and different bias (Van de Velde; Bracke, Levecque, & cultures (Al-Modallal, Abuidhail, Sowan, Meuleman, 2010) & Al-Rawashdeh, 2010; Carleton et al., 2013; Cheung & Bagley, 1998; Clark, ■ The CES-D short form may contain two Mahoney, Clark, & Eriksen, 2002; underlying factors of negative affect and Cole, Rabin, Smith, & Kaufman, 2004; lack of positive affect (Zhang et al., 2012) Kohut et al.,1993; Makambi et al., 2009; ■ The CES-D has shown to have from two Milette, Hudson, Baron, & Thombs, 2010; to four underlying factors across different Opoliner, Blacker, Fitzmaurice, & Becker, populations (Al-Modallal et al., 2010; 2013; Radloff, 1977; Roberts, 1980; Santor Carleton et al., 2013; Lee et al., 2008; & Coyne, 1997; Zhang et al., 2012). The Makambi et al., 2009; Shafer, 2006; CES-D is strongly correlated with other Rivera-Medina, Caraballo, Rodriguez- measures of depression such as the BDI Cordero, Bernal, & Dávila-Marrero, 2010) (Cole et al., 2004; Zhang et al., 2012) Availability and Cost ■ The CES-D contains four factors (somatic, depressed affect, anhedonia, interpersonal The CES-D is available at no cost, and can problems) that are consistent across clinical be obtained at the following address: NIMH, and nonclinical populations, gender, and 6001 Executive Blvd. Room 8184, MSC 9663, race/ethnicity (Bush, Novack, Schneider, & Bethesda, MD 20892-9663; (301) 443-4513. The Madan, 2004; Makambi, Williams, Taylor, instrument can also be downloaded at http://www. Rosenberg, Adams-Campbell., 2009; emcdda.europa.eu/html.cfm/index3634EN.html Shafer, 2006)

90 Instruments for Screening and Assessing Co-Occurring Disorders

General Screening Instruments for jail populations (Steadman et al., 2009) Mental Disorders and is recognized as an effective tool in identifying severe mental disorders (Ogloff, Davis, Rivers & Ross, 2007) Brief Jail Mental Health Screen (BJMHS) ■ Among jail inmates, the BJMHS is equally The BJMHS was developed through funding by effective in identifying lifetime diagnosis the National Institute of Justice (NIJ) and was for a variety of mental disorders, as validated using a sample of over 10,000 detainees determined by results from the Structured in four jails. The BJMHS was derived from Clinical Interview for DSM-IV (SCID-I; the Referral Decision Scale (RDS), which was Eno Louden, Skeem, & Blevins, 2012) designed to aid correctional staff in identifying ■ The BJMHS exhibits adequate sensitivity individuals who have severe mental disorders (64–81 percent), good specificity (76-84 (Steadman, Scott, Osher, Agnese, & Robbins, percent) and an acceptable false negative 2005). In developing the screen, the total rate (8–15 percent) across gender groups number of RDS items was reduced, several items for mental disorders (Eno Louden et al., were rephrased, and the assessed time span for 2012; Steadman et al., 2009; Steadman et symptom occurrence was changed from lifetime al., 2005) to the past 6 months. The BJMHS consists of ■ The sensitivity and specificity of the six items that examine the occurrence of mental BJMHS are similar to those of the K6 health symptoms for nine DSM-IV diagnoses, instrument (Eno Louden et al., 2012) and including mood disorders and psychotic disorders. the Jail Screening Assessment Tool (JSAT) The instrument includes two additional items in identifying severe mental disorders such as schizophrenia, bipolar disorder, and that review prior hospitalization for mental depressive disorder (Baksheev, Ogloff, & health problems and current use of psychotropic Thomas, 2012) medication. Individuals who endorse two or more items or who indicate either use of psychotropic ■ The BJMHS has adequate internal consistency (alpha=.63; Eno Louden et al., medication or a history of prior psychiatric 2012) hospitalization are classified as needing additional mental disorder screening. The recommended Concerns cut-off score for identifying a mental disorder is ≥ ■ Further validation in criminal justice 2 (Steadman et al., 2005). settings is needed to examine the instrument’s specificity and sensitivity Positive Features ■ The BJMHS screens only for severe mental ■ The BJMHS is available in the public domain disorders and does not address anxiety or personality disorders (Steadman et al., ■ The BJMHS requires only 5 minutes to 2009). The absence of items related to administer and includes scoring procedures, anxiety disorders likely diminishes the cut-off scores, and interpretation regarding instrument’s sensitivity (Steadman et al., the need for further screening of mental 2009). For example, the BJMHS performs disorders poorly in identifying anxiety disorders ■ Little training is required to administer and among males (Ford, Trestman, Wiesbrock, score the instrument & Zhang, 2007). Among offenders, the ■ The BJMHS has been tested in forensic Jail Screening Assessment Tool (JSAT; populations and is readily adaptable for Nicholls, Roesch, Olley, Ogloff, & a range of correctional settings. The Hemphill,, 2005) demonstrates better instrument has been widely used among sensitivity than the BJMHS for any Axis

91 Screening and Assessment of Co-Occurring Disorders in the Justice System

I disorder, inclusive of anxiety disorders Global Indices: Global Severity Index (GSI), (Baksheev et al., 2012) measuring overall psychological distress; Positive ■ The BJMHS may be more effective for Symptom Distress Index (PSDI), measuring male rather than female inmates, as the rate the intensity of symptoms; and the Positive of “false-negatives” is significantly higher Symptom Total (PST), measuring the number among female inmates (24–35 percent) of self-reported symptoms. A shorter version, than male inmates (8–15 percent; Steadman the Brief Symptom Inventory-18 (BSI-18) can et al., 2005; Steadman et al., 2009). The be completed in approximately 4 minutes. The BJMHS also provides higher “false BSI-18 includes three Symptom Dimensions positive” rates among women in detecting (Somatization, Depression, and Anxiety) and a mood and psychotic disorders (Steadman Global Severity Index (GSI). A profile report is et al., 2005; Steadman, Robbins, Islam, & also provided, which presents raw and normalized Osher, 2007) T scores for each of the Primary and Global ■ In comparison to the Correctional Mental Scales. An interpretive report (not available with Health Screen-Male (CMHS-M), the the BSI-18) provides a narrative summary of BJMHS provides considerably higher symptoms and scale scores. A progress report is rates of “false positives” for the presence available to monitor an individual’s progress over of DSM-IV Axis I or II mental disorders time. The recommended cut-off score to identify among males (48–59 percent, versus 22–29 psychopathology and psychiatric distress for the percent; Ford et al., 2007) BSI is ≥ 63 on the GSI (Derogatis, 1993) and the ■ The K6 appears to have higher sensitivity cut-off score for the BSI-18 is ≥ 57 (Zabora et al., than the BJMHS (70 percent versus 46 2001). percent) in detecting the presence of a DSM-IV Axis I mental disorder, as Positive Features determined by the Composite International ■ The BSI requires only 8–10 minutes Diagnostic Interview Schedule-SF (CIDI- to complete, and a sixth grade reading SF; Swartz, 2008) level. The instrument can be administered Availability and Cost via paper and pencil, audiocassette, or computer The BJMHS may be obtained at no cost at the following site: http://www.prainc.com/wp-content/ ■ The BSI includes scoring instructions, cut- off scores for each scale and for the GSI, uploads/2015/10/bjmhsform.pdf and interpretation of cut-off scores in the context of psychological symptoms and Brief Symptom Inventory (BSI) distress The BSI (Derogatis & Melisaratos, 1983) is ■ The BSI has been widely used with a 53-item self-report screen for mental health different populations in assessing psychiatric symptoms and distress, symptoms. The instrument was adapted from including offenders (Borduin, Schaeffer its predecessor, the Symptom Checklist 90– & Heiblum, 2009; Houck & Loper, Revised (SCL90-R), and is particularly useful in 2002; Kroner et al., 2011), nonclinical monitoring treatment outcomes and providing populations (Kellett, Beail, Newman, & a summary of symptoms at a specific point in Frankish, 2003), and clinical populations time. The BSI includes nine Primary Symptom such as people with substance use disorders Dimensions (scales), including Somatization, (Li, Armstrong, Chaim, Kelly, & Shenfeld, Obsessive-Compulsive, Interpersonal Sensitivity, 2007; Meredith, Jaffe, Yanasak, Cherrier, & Depression, Anxiety, Hostility, , Paranoid Saxon, 2007; Schwannauer & Chetwynd, Ideation, and Psychoticism. There are also three

92 Instruments for Screening and Assessing Co-Occurring Disorders

2007; Booth, Leukefeld, Falck, Wang, & 90-R (Benishek, Hayes, Bieschke, Carlson, 2006) & Stöffelmayr, 1998; Derogatis, & ■ The BSI is highly correlated with Melisaratos, 1983; Hayes, 1997; Prinz indicators of psychiatric distress among et al., 2013; Ruipérez, Ibáñez, Lorente- female offenders (Warren, Hurt, Loper, & Rovira, Moro, & Ortet-Fabregat, 2001) Chauhan, 2004) and has varying factor structures among the different populations sampled. These ■ Over 400 studies examining the reliability findings suggest that the BSI subscale and validity of the BSI indicate that it is scores should be interpreted with caution. a suitable alternative to the SCL-90-R Exploratory factor analyses of the BSI- (Zabora et al., 2001). These studies 18 demonstrate inconsistent results with demonstrate good evidence of convergent the original study findings that supported and construct validity with results of use of subscales related to somatization, diagnostic interviews (Beail, Mitchell, depression, and anxiety (Derogatis & Vlissides, & Jackson, 2013) Savitz., 2000). Several studies indicate that ■ The dimensions of the BSI are highly the BSI may be measuring a single factor correlated with those of the SCL-90-R as related to psychological distress (Asner- are the BSI’s Global scores (> .90) Self, Schreiber, Marotta, 2006; Daoud & ■ The BSI-18 contains three factors (somatization, depression, and anxiety) that & Kokkinos, 2008; Prelow, Weaver, are identified consistently across different Swenson, & Bowman, 2005) clinical populations and cultures (Dura ■ The original nine BSI subscales may not be et al., 2006; Recklitis et al., 2006; Wang, appropriate for use with juvenile offenders, Kelly, Liu, Zhang, & Hao, 2013; Wang et as a six-factor structure better fits the al., 2010) results obtained with this population. ■ Both test-retest and internal consistency Whitt & Howard (2012) suggest that the reliabilities are very good for the different BSI factor structure may be due BSI’s Primary Symptom Dimensions to greater variation in mental disorders with offenders and treatment-referred among adolescent psychiatric populations, populations (Beail et al., 2013; Kellett et in comparison with adults al., 2003) Availability and Cost ■ The BSI has been translated into several languages The BSI can be purchased by a qualified health care professional from Pearson Assessments at the Concerns following site: http://www.pearsonassessments. ■ The BSI is not a public domain instrument com/tests/bsi.htm and is relatively costly Costs vary depending on the desired formats and ■ Separate norms are not provided for additional materials purchased, such as profile criminal justice populations forms, scoring forms, and interpretation forms. ■ The BSI does not distinguish between The required manual, profile forms (50), and different types of anxiety disorders and answer sheets (50) cost approximately $132. instead measures overall anxiety (Derogatis & Savitz, 2000) Correctional Mental Health Screen ■ Several studies involving psychiatric and substance-involved clinical populations, (CMHS) college populations, and Latino populations The Correctional Mental Health Screen (CMHS; indicate that the BSI does not reflect Ford & Trestman, 2005) is a brief self-report the nine-factor structure of the SCL-

93 Screening and Assessment of Co-Occurring Disorders in the Justice System

Steadman et al., 2005; Steadman et al., screening tool for mental disorders in correctional 2007). For example, at a cut-off score of settings. The CMHS was developed using a large 5, the CMHS-F exhibited higher accuracy correctional inmate sample that included men in detecting DSM-IV Axis I or II disorders (N = 1,526) and women (N = 670). An original than the BJMHS (62 percent) and had a composite screening measure included 56 items lower false negative rate (21 percent versus that examined DSM-IV Axis I and II disorders. 35 percent; Steadman et al., 2005) Separate screening versions were developed ■ The cut-off scores for the CMHS-F and for male offenders (CMHS-M; 12 items) and CMHS-M effectively differentiate between female offenders (CMHS-F; 8 items) and consist offenders who have mental disorders and of dichotomous (yes/no) items. Six items are those who do not (Ford et al., 2007; Ford, identical in both versions, and the remaining Trestman, Wiesbrock, & Zhang, 2009) two to six items are unique to each version of ■ At a cut-off score of 6, the CMHS-M the CMHS. The shortened item pool in the two exhibits good sensitivity (80–86 percent) CMHS screens was found to significantly predict and adequate specificity (61–71 percent) in depression; anxiety; PTSD; and DSM-IV Axis detecting mental disorders, as demonstrated II disorders, excluding antisocial personality within large samples of male and female disorder. Recommended cut-off scores on the inmates (Ford et al., 2007). The specificity CMHS are ≥ 6 and ≥ 5 for males and females, and sensitivity of the CMHS are similar for respectively. Response cards are provided that African American and White inmates. In include columns describing staff comments for comparison to other screening measures, each item (e.g., “refused to answer” or “did not the CMHS-F has quite high sensitivity know the answer”) as well as general comments in screening for mental disorders among (e.g., “individual was intoxicated”). female African American inmates. Overall, these findings support the generalizability Positive Features of the CMHS among different ethnic/racial ■ The CMHS is a public domain instrument groups (Ford et al., 2007) ■ Both versions of the CMHS are brief to ■ Overall accuracy for the CMHS is 75–80 administer (3–5 minutes; U.S. Department percent in detecting any mental disorder or of Justice, 2007) personality disorder (except ASPD; Ford et al., 2007; Ford et al., 2009) ■ The CMHS provides detailed administration instructions, including ■ A follow-up study validating the CMHS scoring and interpretation of scores (Ford et al., 2009) showed an improvement for service referral. For example, in false negative rates on the CMHS-F (25 recommendations are provided for “routine percent) in detecting mental disorders as referral” if the cut-off score is met or if compared with findings from the original staff have concerns about the respondent’s validation study and relative to the BJMHS psychological functioning. “Urgent (35 percent; Steadman et al., 2005). False referral” indicates severe emotional positive rates are lower for the CMHS-F problems such as suicide risk in comparison to the BJMHS (8–16 percent) in detecting mental disorders and ■ The CMHS was developed for use in personality disorders (Steadman et al. 2005; criminal justice settings (Ford & Trestman, Steadman et al., 2007) 2005) ■ A key psychometric indicator, Area Under ■ The CMHS-F may be more effective in the Curve (AUC) is high for both the screening for mental disorders among CMHS-M (73 percent) and CMHS-F (80 female inmates than other measures percent), indicating effective identification developed for use with offenders (see of mental disorders (Ford et al., 2009)

94 ■ The convergent validity of both the Availability and Cost CMHS-F and CMHS-M is supported by The CMHS-F and CMHS-M are available strong correlations with indices of mental for download at no cost. The instruments disorders from correctional records. and accompanying information regarding Both forms of the CMHS also exhibit interpretation, validation, and scoring can be good discriminant validity and are not significantly correlated with non-mental obtained at the following site: https://www.ncjrs. health indicators (e.g., risk for violence, gov/pdffiles1/nij/216152.pdf sex offending, education level; Ford et al., 2007) K6 and K10 Scales ■ Interrater reliability for the CMHS-M and CMHS-F is quite high (Ford et al., 2007; The K6 and K10 scales were developed for the 2009), with kappas for the CMHS-M U.S. National Health Interview Survey to examine ranging .66–1.0 and for the CMHS-F psychological distress (Kessler et al., 2003). The ranging .62–1.0 K6 is a 6-item screen that was derived from the 10-item K10, and evidence suggests that the K6 ■ Internal consistency for the CMHS-M (r score = .76) and CMHS-F (r score= .82) is is as sensitive in detecting mental disorders as also quite good (Ford et al., 2007, 2009) the K10. The six core domains of the screens are nervousness, hopelessness, restlessness, ■ Test-retest reliability of the instrument was depression, feeling as though everything takes adequate across several studies (Ford et al., 2007; 2009) for both the CMHS-M (r score effort, and feelings of worthlessness. The K10 = .84) and the CMHS-F (r score = .82) also addresses functional impairment related to mental disorders and examines whether psychiatric Concerns symptoms are attributable to medical problems. ■ The CMHS-F exhibits lower sensitivity Both measures identify severe mental illness and specificity for mental disorders among (SMI), which is defined as meeting psychiatric female African American inmates at the diagnosis of one of the DSM-IV mood or anxiety cut-off score of 6. As a result, lower disorders, inclusive of significant distress or cut-off scores are recommended (e.g., ≥ 2 impairment (Kessler et al., 2003). The K10 has or ≥ 3) that increase sensitivity (75–100 been found to be somewhat more effective than percent), but yield rates of specificity that the K6 in identifying anxiety and mood disorders are relatively lower (29–71 percent) than (Furukawa, Kessler, Slade, & Andrews, 2003). those obtained for White female inmates. Recommended K6 cut-off scores for identifying In general, the CMHS-F exhibits lower SMI is ≥ 6 for offenders and ≥ 13 in the general specificity for mental disorders than the population (Eno Louden et al., 2012; Kubiak, BJMHS and the RDS Beeble, & Bybee 2009; Kessler et al., 2002). The ■ Further validation is needed among K10 is included in the National Comorbidity offender subpopulations Survey Replication (NCS-R) and in the national ■ The false negative rate for mental disorders surveys conducted by the WHO’s World Mental on the CMHS-M (18–26 percent) is higher Health initiative. The scales are available in both than on the BJMHS (5–15 percent; Ford et interviewer-administered and self-administered al., 2007; Steadman et al., 2005) forms. ■ The CMHS-M has lower specificity in detecting anxiety disorders than other Positive Features mental disorders (42 percent; Ford et al., ■ The K6 and K10 are available in the public 2007) domain

95 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ The K6 and K10 are brief and can be easily Louden et al., 2012). The K6 has better administered and scored by nonclinicians. sensitivity and specificity than other Guidelines for scoring and interpretation of screening tools, such as the Addiction the K6 and K10 are available Severity Index and the Psychiatric ■ The instruments have been translated into Diagnostic Screening Questionnaire several languages and have been shown to (PDSQ; Rush et al., 2013) have adequate sensitivity and specificity ■ Studies conducted in several different in correctly identifying mental disorders countries indicate that the K6 provides (Carrà et al., 2011) good results related to Area Under the ■ Although the K6 and K10 instruments were Curve (AUC; 77–89 percent) in detecting validated in a general health setting, studies mental disorders (Kessler et al., 2010) indicate that the measures are useful in ■ Psychometric properties of the K6 are criminal justice settings (Swartz & Lurigio, both consistent and good across socio- 2005). Lower cut-off scores are used in demographic subsamples; cultures; and offender populations in comparison to the different populations, including offenders general population and people with substance use disorders ■ A number of studies have examined the K6 (Andrews & Slade, 2001; Eno Louden et for use with criminal justice populations, al., 2012; Furukawa et al., 2003; Kessler people with substance use disorders, and et al., 2002; Kessler et al., 2003; Kubiak people who have co-occurring disorders et al., 2009; Patel et al., 2008; Rush et al., and support the effectiveness of the K6/ 2013; Sakurai et al., 2011; Slade, Johnston, K10 scales with these populations (Hides Oakley-Browne, Andrews, & Whiteford, et al., 2007; Kubiak et al., 2009; Kubiak, 2009; Swartz & Lurigio, 2006) Kim, Fedock, & Bybee, 2013; Rush, ■ The K10 has been used among juvenile Castel, Brands, Toneatto, & Veldhuizen, offenders as an index of overall 2013; Swartz, 2008; Swartz & Lurigio, psychological distress (Kenny, Lennings, & 2005; Swartz & Lurigio, 2006) Munn, 2008) ■ The scales appear to accurately Concerns discriminate between individuals who meet criteria for a diagnosis of a mental ■ The K6 may not be as sensitive in detecting disorder and those who do not, across specific mental disorders in comparison to large epidemiological samples inclusive other mental health instruments, such as the of different cultures and age groups CIDI (Composite International Diagnostic (Anderson et al., 2013; Andrews & Slade, Interview) and the PHQ-9 (Patient Health 2001; Baggaley et al., 2007; Furukawa et Questionnaire), and is intended to identify al., 2003; Kessler et al., 2003; Kessler et the general presence of a serious mental al., 2010; Patel et al., 2008; Sakurai, Nishi, disorder (Kessler et al., 2010) Kondo, Yanagida, & Kawakami, 2011) ■ The K6 may have lower sensitivity in ■ The K6 shows adequate sensitivity (76–86 identifying mental disorders in comparison percent) and specificity (65–75 percent) in to the BJMHS when different cut-off scores detecting mental disorders among people are used. For example, among substance- with substance use disorders (Rush et al., involved samples, a cut-off score of 13 on 2013; Swartz & Lurigio 2006) and has the K6 yields sensitivity of 62 percent, in similarly good psychometric properties comparison to 76 percent for the BJMHS. for use with offenders (sensitivity = 62–76 However, when a cut-off of 6 is used, percent; specificity = 86–90 percent) and the sensitivity of the K6 improves to 76 across gender groups (Swartz, 2008; Eno percent, which is equivalent to that of the BJMHS. Thus, it is important to calibrate

96 Instruments for Screening and Assessing Co-Occurring Disorders

the cut-off scores according to the specific al., 2007b). A qualified mental health professional population examined (Eno Louden et al., should review responses to determine whether a 2012; Kubiak et al., 2009; Rush et al., follow-up assessment or diagnostic workup and 2013) treatment recommendations are needed. ■ The K6 may exhibit a unidimensional factor structure when used in general Positive Features community samples, while a two-factor ■ The MHSF-III is quite brief to administer, structure has been found (representing requiring approximately 15 minutes anxiety and depression) in a treatment- ■ The instrument was designed for use referred clinical sample (Sunderland, with individuals who have co-occurring Mahoney, & Andrews, 2012). substance use and mental disorders Availability and Cost ■ English and Spanish versions of the MHSF- III are available The K6 and K10 scales include interview- administered, self-administered, and translated ■ The MHSF-III has good convergent validity, including strong correlations with versions. Information regarding scoring, cut-off reported trauma, and clinically elevated scores, and validation research are available at no scale scores on the PAI scales (e.g., anxiety, cost at the following site: http://www.hcp.med. depression, borderline personality features). harvard.edu/ncs/k6_scales.php The MHSF-III also has good discriminant validity, as indicated by clinical scale The Mental Health Screening Form-III scores on the PAI (Ruiz et al., 2009). (MHSF-III) The 13-item version of the MHSF-III demonstrates similarly good psychometric The MHSF-III was designed as an initial mental properties (Ruiz et al., 2009) health screening for use with clients entering ■ In two studies of prisoners who were substance use treatment programs. The 18-item enrolled in substance use treatment, the measure contains yes/no questions examining MHSF-III showed adequate sensitivity (81– current and past mental health symptoms. 90 percent) and specificity (48–68 percent), Positive responses indicate the possibility of a with overall accuracy of 73 percent in current problem and should be followed up by detecting a mental disorder (Sacks et al., questions regarding the duration, intensity, and 2007a; Sacks et al., 2007b). In identifying co-occurrence of symptoms. The following more severe mental disorders, the MHSF- disorders are addressed in the MHSF-III: III provides good specificity (89–93 schizophrenia, depressive disorders, PTSD, percent) and adequate sensitivity (35–43 phobias, intermittent explosive disorder, delusional percent), with overall accuracy of 75–76 disorder, sexual and gender identity disorders, percent across gender groups eating disorders, manic episode, panic disorder, ■ The MHSF-III has outperformed the Co- obsessive-compulsive disorder, pathological occurring Disorders Screening Instrument gambling, learning disorders, and developmental for Mental Disorders (CODSI-MD) and the disabilities. A 13-item version of the MHSF-III Modified Mini Screen-MMS (MINI-M) in is described in the literature and has equivalent overall accuracy and sensitivity in detecting psychometric properties to the 18-item original mental disorders (Sacks et al., 2007a). These differences are more pronounced version (Ruiz, Peters, Sanchez, & Bates, 2009). among female inmates (Sacks et al., 2007b) The preferred mode of MHSF-III administration is via interview, although the instrument can also be ■ The MHSF-III demonstrates good internal self-administered. The recommended cut-off score consistency among jail inmates (alpha = .89; Ruiz et al., 2009) for identifying mental disorders is ≥ 3 (Sacks et

97 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ The MHSF-III has excellent content Symptom Checklist 90–Revised (SCL- validity and adequate test-retest reliability 90-R) and construct validity (Carroll & McGinley, 2001) The SCL-90-R is an updated version of the Hopkins Symptom Checklist (Derogatis, Lipman, ■ Test-retest reliability for the MHSF-III over a 1-week period is acceptable (kappas Rickels, Uhlenhuth, & Covi, 1974) and the range 63–77 percent) in identifying people SCL-90. The instrument provides a 90-item, with “any” and “severe” mental disorders multidimensional self-report inventory that is (Sacks et al., 2007b) designed to assess physical and psychological distress during the previous week. The Concerns instrument examines nine major dimensions ■ The cut-off scores provided for the MHSF- of psychopathology, including somatization, III vary based on the purpose of screening obsessive compulsiveness, interpersonal and are accompanied by different levels of sensitivity, depression, anxiety, hostility, phobic specificity, sensitivity, and overall accuracy anxiety, paranoid ideation, and psychoticism. The (Sacks et al., 2007a, 2007b) Global Severity Index (GSI) for the SCL-90-R ■ The MHSF-III may not be as sensitive provides a summary score of psychopathology. as the CODSI-MD in detecting mental A cut-off score of ≥ 63 on the GSI can be used disorders among prisoners involved in to identify psychiatric distress and the presence substance use treatment, because cut-off of psychopathology (Derogatis, 1993). The scores may provide fairly low sensitivity in SCL-90-R is available in three formats: paper identifying “any” mental disorder (43–51 and pencil, audiocassette, and computerized percent; Sacks et al., 2007a, 2007b) and administration. The BSI is an abbreviated version “severe” mental disorders (48 percent; of the SCL-90-R (53 items), is somewhat easier to Sacks et al., 2007b) score, and includes nine subscales similar to that ■ There is only a moderate amount of of the original SCL-90-R. Other short forms of published research examining the MHSF- the SCL-90-R (Prinz et al., 2013) include the SCL- III, and further reliability and validity 27 (27 items, six subscales: depressive, dysthymic, testing is needed in criminal justice vegetative, agoraphobic, social ), the SCL- settings. When used with inmates, there are several items within the MHSF-III that 14 (14 items, three subscales: depression, phobic detract from internal consistency, and some anxiety, somatization), and the SCL-K-9 (9 items, items may also be difficult to understand unidimensional scale reflecting global severity of among this population (Ruiz et al., 2009) distress).

Availability and Cost Positive Features The MHSF-III is available to download at no cost ■ The SCL-90-R and other versions of the at the following site: http://www.bhevolution.org/ instrument require no training and are brief public/screening_tools.page to administer. Interpretative profile reports are available for scoring The instrument along with guidelines for ■ When used to screen for mental disorders administration, interpretation, and scoring in nonpsychiatric populations, and using is available from the National Center for a cut-off score of ≥ 63, sensitivity and Biotechnology Information: http://www.ncbi.nlm. specificity range 73–88 percent and 80–92 nih.gov/books/NBK64187/ percent, respectively (Peveler & Fairburn, 1990) ■ In criminal justice settings, the SCL-90-R has been found to outperform other general

98 Instruments for Screening and Assessing Co-Occurring Disorders

measures of psychological functioning with no differences in internal consistencies among substance-involved populations across forms and high correlations between (Davison & Taylor, 2001; Franken & subscales (r scores = .85–.98; Prinz et al., Hendriks, 2001) 2013) ■ The SCL-90-R has been frequently used Concerns with substance-involved, forensic, and offender populations to assess overall ■ The SCL-90-R is not a public domain psychiatric distress (Brooner et al., 2013; instrument and is fairly costly Chambers et al., 2009; Fridell & Hesse, ■ Additional work is needed to establish the 2006; Kidorf et al., 2010; Pardini et al., validity of the SCL-90-R with subgroups of 2013; Sander & Jux, 2006) offenders ■ In criminal justice settings, the SCL- ■ The SCL-90 has poor specificity (39 90-R and its subscales demonstrate percent) in diagnosing depression among moderate to strong correlations with other alcoholics (Rounsaville et al., 1979) validated measures of psychological ■ An examination of the factor structure of distress, including the Comprehensive the SCL-90-R when used with substance- Psychopathological Rating Scale (CPRS; involved populations suggests a single Asberg & Schalling, 1979) and the Present factor of general psychopathology, State Examination (PSE; Wing, Cooper, indicating that the SCL-90-R fails to & Sartorius,1974; Wilson, Taylor, & differentiate among mental disorders in Robertson 1985), supporting the convergent these settings (Zack, Toneatto, & Streiner, validity of the SCL-90-R 1998) ■ Among veterans, the 25-item version of the ■ A study involving an outpatient population SCL-90-R demonstrates good sensitivity failed to support the original nine- (85 percent) and adequate specificity (65 factor structure proposed by Derogatis percent) in identifying people with PTSD et al., 1974, and instead found evidence (Weathers et al., 1996). Within general of a single factor reflecting general medical populations, the SCL-90-R psychological distress (Schmitz et al., depression scale exhibits good sensitivity 2000) (89 percent) and specificity (61 percent; ■ Other studies indicate that the SCL-90-R is Aben et al., 2002) composed of eight rather than nine factors ■ The SCL-90 has good internal consistency, when used in both clinical and nonclinical based on results from the normative settings (Arrindell, Barelds, Janssen, sample, and alphas that range .77–.90 Buwalda, & van der Ende, 2006; Arrindell (Derogatis, Melisaratos, Rickles, & & Ettema, 2003) Rock, 1976). Similar results have been ■ An Item Response Theory (IRT) analysis obtained with other clinical and nonclinical of the SCL-90-R indicates that 28 items populations (Olsen, Mortensen, & Bech, could be removed from the instrument and 2004; Paap et al., 2011; Schmitz, Kruse, also suggests a single underlying factor that Heckrath, & Tress, 1999) measures psychological distress (Olsen et ■ The short forms of the instrument (SCL-14, al., 2004) SCL-K-9; SCL-27) are strongly correlated with other measures of psychopathology Availability and Cost (BDI) and with the BSI (Prinz et al., The SCL-90-R can be purchased by qualified 2013), and have favorable psychometric health care professionals from Pearson properties (Prinz et al., 2013; Kuhl et al., Assessments at the following site: http:// 2010). For example, the short forms have www.pearsonclinical.com/psychology/ good internal consistency (alpha > .70),

99 Screening and Assessment of Co-Occurring Disorders in the Justice System products/100000645/symptom-checklist-90- Screening Instruments for Co- revised-scl-90-r.html occurring Mental and Substance Use The required manual, profile forms (50 forms) Disorders and answer sheets (50 sheets) cost approximately $132. Costs vary, depending on the desired Several screening instruments have been formats. developed that address both mental and substance use disorders. These screening instruments differ Recommendations for Mental Health in the scope and depth of coverage of co-occurring Screening Instruments disorders and in the amount of research support for their validity and use in criminal justice settings. Information regarding screening instruments for Two of these screens (GAIN-SS, MINI-S) are mental disorders is based on a critical review of linked with “families” of screening and assessment the literature and research comparing the efficacy instruments, and these larger sets of instruments of these instruments. Factors considered in are described in another section, entitled recommending specific screening instruments “Assessment and Diagnostic Instruments for Co- include empirical evidence supporting the occurring Mental and Substance Use Disorders.” reliability and validity of the instrument, relative cost of the instrument, ease of administration, and previous use in the justice system. Although The Behavior and Symptom summaries of the instruments include research Identification Scale (BASIS-24) that was based on the DSM-IV criteria, The BASIS-24 is a 24-item self-report measure recommendations are made considering the degree used to identify a wide range of mental health to which instruments align closely with the new symptoms and problems. The instrument DSM-5 criteria and that allow for a more seamless examines the degree of difficulty experienced transition to the new classification system. during the previous week across six domains Recommended instruments for screening mental of functioning: depression and functioning, disorders are those that address co-occurring interpersonal relationships, self-harm, emotional mental health issues and are geared specifically lability, psychosis, and substance use. The towards the criminal justice system. Based on BASIS-24 was derived from its predecessor, the the literature review and these considerations, the BASIS-32, to provide a brief, yet comprehensive following screening instruments are recommended screen of mental health symptoms and to examine mental disorders: psychosocial functioning that can be used 1. Either the Correctional Mental Health Screen over time to examine changes in mental health (CMHS-F; CMHS-M) status. The BASIS-32 assesses both functional domains (self-understanding, daily living (or) skills, interpersonal relations, role functioning, impulsivity, substance use) and psychopathology 2. The Mental Health Screening Form-III (mood disturbance, anxiety, suicidality, and (MHSF-III) to address mental health psychosis). Items on both measures are rated on a problems five-point scale (0 = no difficulty and 4 = extreme (or) difficulty). Both measures include scoring and interpretive reports that indicate the severity of 3. The Brief Jail Mental Health Screen. problems (none, a little, moderate, quite a bit, extreme) according to the symptom area. Both Each of these instruments requires approximately versions require a scoring algorithm, and can 5–10 minutes to administer and score. be scored by hand or by use of computerized

100 Instruments for Screening and Assessing Co-Occurring Disorders software. The software provides summary scores validity and reliability compared to the and domain-specific scores, with higher scores BASIS-32 (Eisen et al., 2006) indicating greater symptom severity. Both the ■ The BASIS-24 has better reliability BASIS-32 and BASIS-24 application guides and validity in detecting substance use provide scoring instructions and interpretation that disorders than the BASIS-32 (Eisen et al., include cut-off scores that distinguish between 2004) clinical and nonclinical samples. ■ Convergent validity of the BASIS-24 among inpatients and outpatients and Positive Features across ethnic/racial groups is supported ■ The BASIS-24 requires 5-15 minutes by high correlations with other measures to complete and can be administered of mental health (Eisen et al., 2006), such via interview, self-report instrument, or as the Short Form Health Survey (SF-12) computer and the Global Assessment of Functioning ■ Only a fifth-grade reading level is required, (GAF). The BASIS-24 also yields elevated and the instrument can be administered by subscale scores for depressive functioning, paraprofessionals psychotic symptoms, alcohol and drug use, and emotional lability among people ■ The BASIS has been translated into Spanish diagnosed with depression, psychosis, substance use disorders, and bipolar ■ An internet-based scoring tool (Webscore) disorders (Eisen et al., 2006) is available that provides scoring of the BASIS-24 and a summary of results ■ In a psychiatric sample of people diagnosed with depression, the BASIS-24 subscales ■ Both the English and Spanish versions of depression functioning, emotional of BASIS-24 can be used to reliably lability, and self-harm are highly correlated measure change in symptoms (Eisen, with measures of depression (CES-D), Gerena, Ranganathan, Esch, & Idiculla, worry (Penn State Worry Questionnaire; 2006; Eisen, Normand, Belanger, Spiro, Meyer, Miller, Metzger, & Borkovec, & Esch, 2004) and have been used with 1990), emotional lability, and substance populations that have mental and/or misuse, (Kertz, Bigda-Peyton, Rosmarin, substance use disorders (Goodman, McKay, & Bjorgvinsson, 2012) supporting the & DePhilippis, 2013) convergent validity of the measure ■ The instrument has been widely used ■ Discriminant validity of the BASIS-24 in identifying and monitoring mental is supported by studies indicating health problems and outcomes among that inpatients with greater overall populations that have CODs (Deady, 2009; psychopathology have higher scores than Matevosyan, 2010), including veterans outpatient samples (Cameron et al., 2007; (Fasoli, Glickman, & Eisen, 2010; Slattery, Eisen et al., 2006) The substance abuse Dugger, Lamb, & Williams, 2013) and scale, and psychosis scale are also able those mandated to treatment (Livingston, to identify individuals with substance use Rossiter, & Verdun-Jones, 2011) problems and psychosis among people in ■ The BASIS-32 has also been used with residential treatment, community mental offender populations (Cosden, Ellens, health patients, and primary health care Schnell, Yamini-Diouf, & Wolfe, 2003) patients (Cameron et al., 2007) ■ Several studies provide support for the ■ The Spanish version of the BASIS-24 convergent, divergent, and concurrent shows good convergent validity, because validity of the BASIS-32 and the BASIS-24 the summary score is significantly (Eisen, Dickey, & Sederer, 2000; Eisen correlated with other self-reported et al., 2004). The BASIS-24 has better measures of mental health (Eisen et

101 Screening and Assessment of Co-Occurring Disorders in the Justice System

al., 2010). The BASIS-24 subscales ■ The Spanish version of the BASIS-24 of depressive functioning, psychotic may have poor discriminant validity symptoms, and alcohol/drug use also show for subscales of emotional lability and significant differences between those who interpersonal relationships (Eisen et al., are diagnosed with and without these 2010) disorders in an inpatient psychiatric sample. ■ The BASIS-24 demonstrates poorer test- The Spanish version of the BASIS-24 retest reliability for inpatient samples, also has good discriminant validity for particularly on subscales related to psychotic and self-harm symptoms (Eisen interpersonal relationships, emotional et al., 2010) lability, and alcohol/drug use, as indicated ■ Statistical analysis indicates a good fit by intraclass correlation coefficients (ICCs) for the six BASIS-24 subscales among of .43–.89 (Eisen et al., 2010) inpatient and outpatient samples, and across ethnic groups (Eisen et al., 2006, 2010) Availability and Cost ■ The BASIS-24 and its subscales have good The BASIS-24 instrument is available from internal consistency across racial/ethnic McLean Hospital at the following site: http://www. groups, clinical psychiatric populations, ebasis.org/basis24.php primary care populations , and general populations (alphas > .70; Cameron et al., The cost of the BASIS-24 is based on the number 2007; Eisen et al., 2006; Kertz et al., 2012; of sites licensed to use the instrument. There is an Livingston et al., 2011) annual fee of $300 for the first site, $100 for the second site, and $50 for the third site. Concerns Staff at McLean Hospital can also be contacted for ■ The BASIS instruments have not been extensively examined within criminal information regarding the BASIS-24 at spereda@ justice settings mcleanpo.mclean.org or (617) 855-2424. ■ The measure was originally designed to The BASIS-32 instrument can be downloaded free assess treatment outcomes and to increase of charge at the following site, but materials do consumer involvement in care, and not not include interpretation or scoring information: necessarily for diagnostic purposes http://infotechsoft.com/products/aspect_forms. ■ The BASIS-32 impulsivity, substance aspx?formID=BASIS-32 abuse, and psychotic symptoms scales may not be sensitive to change over time (Russo et al., 1997; Trauer & Tobias, 2004) Centre for Addiction and Mental Health– Concurrent Disorders Screener (CAMH- ■ The BASIS-24 subscales and summary CDS) score may not effectively distinguish between inpatients and outpatients among The CAMH-CDS is a computer-administered African American and Latino populations, questionnaire that screens for 11 mental disorders, as no significant differences in scores were including substance use disorders. The instrument found between these treatment populations. was developed to provide a brief assessment The BASIS subscales of emotional lability for co-occurring disorders and is designed to may not be able to distinguish between determine whether DSM diagnostic criteria those with and without bipolar disorder are likely to be met for both current and past for these same racial/ethnic groups, across disorders. The CAMH-CDS requires 5–20 inpatient and outpatient settings (Eisen et al., 2006) minutes to administer, depending on the number of disorders reported. The instrument was validated

102 Instruments for Screening and Assessing Co-Occurring Disorders

using three large substance use treatment-seeking ■ The CAMH-CDS has not been widely used samples. or tested with criminal justice populations ■ Interrater reliability may be lower for Positive Features schizophrenia/schizophreniform disorders ■ The CAMH-CDS requires only minimal (kappas range 65–69 percent; Negrete et mental health training to administer al., 2004), suggesting that the CAMH-CDS ■ Test results can be generated by computer, may not correctly classify these disorders immediately following administration ■ Test-retest reliability was determined ■ The CAMHS-CDS has good sensitivity after instructing participants that they (86–92 percent) in identifying mental would be readministered the instrument, disorders for a variety of populations. For thus potentially compromising the results mood disorders, anxiety disorders, and (Negrete et al., 2004) schizophrenia/schizoaffective disorders, the CAMH-CDS exhibits good sensitivity Availability and Cost (78–80 percent) and adequate specificity The CAMH-CDS is currently included in (56–68 percent; Negrete, Collins, Turner, & TREAT, an electronic roster of assessment and Skinner, 2004) outcome measures developed by CAMH. A ■ The CAMH-CDS has excellent test-retest license is required to use the measures stored on reliability for and anxiety TREAT, and further costs may be required to use disorder modules and has moderately good copyrighted instruments. Information regarding reliability for the schizophrenia module the CAMH-CDS and TREAT may be accessed at (kappas range .72–.94; Negrete et al., 2004) the following site: http://www.treat.ca/tools.html

Concerns Global Appraisal of Individual Needs ■ The CAMH-CDS has only limited ability to discriminate among different mental (GAIN) disorders The Global Appraisal of Individual Needs (GAIN; ■ Although the instrument has a high level of Dennis, Titus, White, Unsicker, & Hodgkins, sensitivity in detecting mental disorders, it 2006) includes a set of instruments developed to has significantly lower specificity (40–74 provide screening and assessment of psychosocial percent) in both double blind and clinical issues related to mental and substance use samples. For example, with disorders and disorders. Among the available GAIN instruments symptom presentations such as , are the GAIN-Short Screener (GAIN-SS), the bipolar disorder–mania, and schizoaffective GAIN-Quick (GAIN-Q), the GAIN-Initial mania, the CAMH-CDS exhibits relatively (GAIN-I), the GAIN-Monitoring (90 Day), and the low sensitivity (57–62 percent; Negrete et al., 2004). Using the previous DSM multi- GAIN-Quick Monitoring. The full set of GAIN axial system, the CAMH-CDS often does instruments is reviewed in the section entitled not effectively discriminate between mental “Assessment and Diagnostic Instruments for disorders and personality disorders Co-occurring Mental Health and Substance Use Disorders.” The following section focuses on the ■ The criterion measure for validating the instrument was an unstructured clinical GAIN Short Screener (GAIN-SS). evaluation conducted by a group of trained The GAIN-SS includes 20 items and requires psychiatrists who were asked to indicate approximately 5 minutes to administer. The whether, in their clinical judgment, certain instrument is suitable for use with both adults disorders were present within 2 weeks of the administration of the CAMH-CDS and adolescents. Four subscales of the GAIN- SS address internal disorders (IDS), behavioral

103 Screening and Assessment of Co-Occurring Disorders in the Justice System disorders (EDS), substance use disorders (SDS), norms are available by gender, race/ and crime and violence (CVS). There are low ethnicity, co-occurring disorders, and (score of zero), moderate (score of 1–2) and high involvement in the juvenile and criminal risk levels (score of > 3), which are used for the justice system individual scales and for the total score or total ■ The GAIN-SS has been widely used as disorders screener (TDS). The recommended a screening tool for mental disorders cutoff score for the GAIN-SS is ≥ 3 for identifying among offenders (Balyakina et al., 2013; a mental disorder on the TDS, for both adults Friedmann, Melnick, Jiang, & Hamilton, and adolescents (Dennis, Scott, Funk, & Foss, 2008; Sacks et al., 2007b; Zlotnick et al., 2005). However, those who score ≥1 on any of the 2008) and substance-involved populations individual scales are likely to achieve a positive (Friedmann et al., 2008; Lucenko, diagnosis on the full GAIN assessment instrument Mancuso, Felver, Yakup, & Huber, 2010) for that particular scale. All versions of the ■ Mental health diagnostic impressions from GAIN can be administered via clinical interview, the GAIN-SS are highly correlated with computer, paper/pencil, or self-report. independent psychiatric diagnoses, across a range of disorders (Dennis et al., 2006) Positive Features ■ Among offenders, the GAIN-SS cut-off ■ The GAIN-SS is quite brief to administer score of 2 shows good sensitivity (82 and is one of the few available screens that percent) and overall accuracy (73 percent) addresses both mental health and substance for any mental disorder. At a cut-off score use problems of 5, the GAIN-SS shows good specificity ■ Software is available for scoring and (96 percent) for severe mental disorders interpretation of the GAIN-SS, with (schizophrenia, major depression, bipolar comments provided regarding diagnosis disorder) across gender (Sacks et al., and treatment planning. Personal feedback 2007b), as determined by the Structured reports (PFR) are also available, as well Clinical Interview for Axis I DSM-IV as software designed for federal grantees, disorders–SCID-I for DSM-IV (First, using the Government Performance and Spitzer, Gibbon, & Williams, 2002) Results Act (GPRA) measures ■ The GAIN-SS has good sensitivity (91 ■ Computerized versions of the GAIN percent) and specificity (92 percent) in instrument are available that facilitate identifying mental disorders among adults, administration and interpretation. Validity as indexed by the full GAIN instrument reports are also provided that identify (Dennis et al., 2006). The GAIN-SS also inaccurate or missing data has high specificity (91–99 percent) and sensitivity (92–100 percent) for identifying ■ A wide variety of instrument support internalizing disorders, externalizing services are available through the GAIN disorders, substance use disorders, and Coordinating Center crime/violence (Dennis et al., 2006). ■ The GAIN-SS instrument is available in Similar results have been found among Spanish adolescents (Dennis et al., 2006) ■ Two different versions of the GAIN-SS are ■ The GAIN-SS is highly correlated with the available that address problems occurring full GAIN-I and its subscales (Dennis et al., in “the past 12 months” or across different 2006) time spans (e.g., “past month,” “2–12 ■ Test-retest reliability of the GAIN-SS is months ago,” “over a year ago,” “never”) good for any mental disorder and for severe ■ Norms for the GAIN instrument have been mental disorders, as indexed by respective developed for adults and adolescents and for different levels of care. Additional

104 Instruments for Screening and Assessing Co-Occurring Disorders

agreement percentages of 77 percent and 83 ■ The GAIN-SS IDS subscale appears to percent (Sacks et al., 2007b) show better specificity at a cut-off score of ■ Among adolescents, the GAIN-SS and its 5 (compared to the traditional cut-off score subscales (IDS, EDS, SDS), in addition of 3) for offenders who have severe mental to the internalizing and externalizing disorders summary score (IEDS), are highly ■ The GAIN-SS cut-off scores vary in correlated with other measures of mental adult populations 1–3 to provide optimal health, including DSM-IV disorders, Youth specificity and sensitivity of subscales Self-Report syndrome scales, and the (Dennis et al., 2006) CRAFFT Substance Abuse Screening Test, ■ Although the authors state that the GAIN’s for their respective disorders and symptoms sensitivity is favored over specificity, (McDonell, Comtois, Voss, Morgan & Ries, specificity is quite low for the IDS subscale 2009) (26 percent) and for the EDS subscale (19 ■ The GAIN-SS demonstrates good percent), suggesting that the instrument sensitivity for the following disorders may have a high rate of “false negatives” among adolescents: IDS (100 percent), ■ Test-retest reliability for the GAIN-SS EDS (89 percent), SDS (88 percent), and for any mental disorder and for severe IEDS (74 percent), resulting in correctly mental disorders is relatively low at a cut- classifying 75 percent, 65 percent, 88 off score of 2 (kappas range .38–.49), in percent, and 78 percent of respective comparison to screens such as the Mental participant groups on these subscales Health Screening Form-III and the MINI (McDonell et al., 2009) Neuropsychiatric Interview–Modified, ■ The GAIN-SS SDS subscale yields MINI-M (Sacks et al., 2007b) good agreement with another measure of ■ Agreement between GAIN-SS IDS and concurrent validity, the CRAFFT (kappa of EDS subscales and other validity measures .76; McDonell et al., 2009). The GAIN-SS (Youth Self-Report [YSR] internalizing also has good internal consistency among scale, YSR externalizing scale, YSR total adolescents (alpha = .81; McDonell et al., problems) is relatively poor, with kappas 2009) ranging .08–.46. This indicates that the GAIN-SS may not be examining the same Concerns constructs as these other measures ■ The GAIN-SS is a copyrighted instrument, ■ The GAIN-SS subscales demonstrate and requires a license agreement and a poorer internal consistency among separate user agreement, which is relatively adolescents than adults, with alphas ranging costly .55–.89 (McDonell et al., 2009) ■ The GAIN web version is distinct from the paper instrument and is quite costly Availability and Cost but provides administrative, scoring and The GAIN instrument license can be purchased interpretive reports by emailing the GAIN developer at gaininfo@ ■ Further validation of psychometric chestnut.org or by calling (309) 451-7762. properties, including predictive utility of diagnoses, is needed in adult offender The GAIN instrument can be downloaded in both populations English and Spanish at the following website, but ■ The GAIN-SS contains only five items they are copyrighted: https://chestnut.box.com/v/ related to substance use and does not GAIN-SS-Materials. Information regarding include an interval measure of alcohol or administration, scoring, and interpretation of the drug use frequency GAIN-SS, along with the instruction manual, can

105 Screening and Assessment of Co-Occurring Disorders in the Justice System be downloaded free of charge. This website also However, the Modified Mini Screen (MMS) is a provides psychometric information across age 22-item measure that assesses mood, anxiety, and groups, including scales and variable descriptions psychotic disorders only. Therefore, the difference for all versions of the GAIN. between the MINI Screen and the MMS is that the MMS does not include items aimed at screening Training is available for administration, scoring, for drug/alcohol use disorders. Recommended and interpretation of the GAIN-SS. Unlimited cut-off scores range 6–9 and are interpreted by a training is provided for users at a cost of either clinician (Alexander, Haugland, Lin, Bertollo, & $150 for 3 months or $500 for 12 months of McCorry, 2008). access. Costs for utilizing the GAIN depend on the number of users within an agency accessing the Positive Features cloud-based system, a one-time set up fee, and the ■ Only brief training is required to use the annual user fee for each authorized user. A quote instrument based on project needs can be requested by email ■ In a combined sample consisting of those at [email protected] or by calling (309) 451- in alcohol and drug treatment, in primary 7900. health care settings, and in community mental health treatment, the Modified Mini The Mini International Neuropsychiatric Screen (MMS) demonstrates adequate Interview (MINI) sensitivity (63–82 percent) and specificity (61-83 percent) at cut-off scores of 6–9 The Mini International Neuropsychiatric Interview for the Structured Clinical Interview for (MINI; Sheehan et al., 1998) is a 120-item DSM-IV Axis I (SCID-I) diagnoses of structured diagnostic interview that is used to mood, anxiety, and psychotic disorders, and identify DSM and International Classification 37–57 percent of participants were referred of Disease (ICD) mental and substance use for further assessment. Similar results have disorders. The instrument was designed as a brief been obtained for different gender and race/ diagnostic screening and has been examined in ethnicity groups (Alexander et al., 2008). numerous research and clinical settings. The In a study involving participants in family assistance programs, the MMS exhibited MINI is composed of a family of instruments that adequate specificity (63–86 percent) and includes the MINI, MINI-Screen, the Modified sensitivity (61–96 percent) at cut-off scores Mini Screen-MMS (or MINI-M), the MINI-Kid, of 6–12, with overall accuracy ranging 76– and MINI-Plus. The full set of MINI instruments 77 percent for SCID-I diagnoses and 43–58 is reviewed in the section entitled “Assessment percent for referral to treatment (Alexander, and Diagnostic Instruments for Co-occurring Layman, & Haugland, 2013) Mental Health and Substance Use Disorders.” The ■ The MMS was found to have higher following section focuses on the MINI-Screen and sensitivity and specificity than other the MINI-M instruments. screens, such as the Brief Jail Mental Health Screen (BJMHS) and the K-6 The MINI-Screen refers the examiner to complete (improved sensitivity only over the K-6; a follow-up module for a particular disorder, if Alexander et al., 2008) the respondent endorses a threshold screening question. If the respondent does not endorse ■ Among offenders, the MINI-M or the item, the interviewer moves to the next MMS demonstrates good sensitivity (71 percent) at a cut-off score of 5, with section. The MINI screen contains 24 items, overall accuracy of 69 percent for any including items that assess mood disorders, mental disorder as indexed by the SCID-I anxiety disorders, drug/alcohol disorders, and (Sacks et al., 2007b). Findings are similar psychotic disorders, based on DSM-IV criteria. across gender groups. For severe mental

106 Instruments for Screening and Assessing Co-Occurring Disorders

disorders (schizophrenia, major depression, harmresearch.org/index.php/mini-international- and bipolar disorder) identified by the neuropsychiatric-interview-mini/ SCID-I, at a cut-off score of 10, the MMS/ MINI-M exhibits adequate specificity (84 Psychiatric Diagnostic Screening percent) and overall accuracy (70 percent; Sacks et al., 2007b). The MMS has good Questionnaire (PDSQ) internal consistency (alphas = .90–.92), The Psychiatric Diagnostic Screening and interrater reliability is quite good Questionnaire (PDSQ) is a 126-item self- (92 percent). Test-retest reliability over administered instrument that can be used for a period of 1 week was found to be quite screening and diagnosis of mental disorders (e.g., high (Alexander et al., 2008, 2013) mood disorders, anxiety disorders, psychotic Concerns disorders) and substance use disorders. The PDSQ provides separate subscales for alcohol ■ Further validation of the MINI-M is needed in offender populations for screening use disorders and drug use disorders. The mental disorders PDSQ examines 13 frequently occurring mental disorders and was designed to evaluate recent ■ In comparison to clinical interviews, use of the MINI results in more frequent diagnosis psychopathology and to provide background of co-occurring disorders (Black, Arndt, information prior to a more extensive diagnostic Hale, & Rogerson, 2004) evaluation. The PDSQ is described in more detail in the section entitled “Assessment and ■ The MINI-Screen includes only one Diagnostic Instruments for Co-occurring Mental question related to alcohol use and one question examining drug use. The and Substance Use Disorders.” instrument does not include an interval Positive Features measure of frequency or quantity of substance use ■ The PDSQ is 126-item measure that addresses 13 of the DSM-IV Axis I ■ The MINI-M/MMS appears to exhibit disorders and includes a 6-item screen for poor specificity for any mental disorder psychosis (61 percent) at a cut-off score of 5, as determined by the SCID-I, and has poor ■ The PDSQ requires approximately 15-20 sensitivity (42 percent) in detecting severe minutes to administer mental disorders at a cut-off score of 10 ■ The PDSQ includes cut-off scores for (Sacks et al., 2007b) individual DSM diagnoses, yielding a sensitivity of > 90 percent (Zimmerman & Availability and Cost Mattia, 2001b) The MINI-Screen can be obtained from the ■ The PDSQ reflects a single underlying developers’ website as part of the entire MINI dimension, indicating that the instrument package, inclusive of the MINI-Screen. For $2, examines a unitary construct, with 15 the screen may be downloaded up to 2 times; symptom domains that are independent however, a download does not indicate a licensing but all contribute to the unitary construct agreement. If an organization purchases the MINI (Gibbons, Rush, & Immekus, 2009) package inclusive of the MINI-Screen, price varies ■ With the exception of the psychosis based on number of uses. For instance, at the time and somatization subscales, the internal of this writing, 25 administrations is $125. consistency of the PDSQ subscales are > .70, with a mean value of .86, (Zimmerman The MINI package that includes the MINI-Screen & Mattia, 1999b, 2001a, 2001b; Gibbons et can be obtained at the following site: http:// al., 2009)

107 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ Test-retest reliability of the instrument to the PDSQ, and only 10 of these were ranges .61–.83, using relatively aligned with DSM-IV diagnoses. No stringent criteria, with 9 of 15 subscales major factor was extracted for psychosis, demonstrating reliability of > .80 (mean of and there was little differentiation between .83) (Zimmerman & Mattia, 1999b, 2001a, panic and agoraphobia disorders, and 2001b) between somatization and ■ Diagnostic accuracy of the PDSQ is quite disorders good, with sensitivities ranging .80–.90 and Availability and Cost specificity .66–78 (Zimmerman & Mattia, 2001b) The PDSQ can be purchased at the following site: http://www.wpspublish.com/store/p/2901/ ■ A receiver operating characteristic (ROC) curves analysis demonstrates that the psychiatric-diagnostic-screening-questionnaire- PDSQ predicts diagnoses significantly pdsq better than chance, in reference to the The cost to purchase the PDSQ is $136.50 for 25 SCID-IV (Sheeran & Zimmerman, 2004) test booklets, 25 summary sheets, an instruction Concerns manual, and a CD containing 13 follow-up interview guides (one for each of 13 disorders). ■ The PDSQ requires significantly more time to administer than other screens for mental disorders Recommendations for CODs Screening Instruments ■ The PDSQ generates multiple cut-off scores for different mental disorders, and Information describing screening instruments that may require more time to interpret than address both mental and substance use disorders screening instruments that provide uniform (CODs) is based on a critical evaluation of cut-off scores for mental disorders available instruments and a review of research ■ Results from studies investigating the comparing the efficacy of these screeners. Key PDSQ may not be generalizable to other factors used in comparing the instruments include clinical populations, specifically those that empirical evidence supporting both the reliability include people who have psychosis and and validity of the instrument, relative cost of other serious mental disorders. Validation the instrument, ease of administration within the studies have been limited primarily to criminal justice settings, and previous use and outpatient populations, and further research evidence of effectiveness within the criminal is needed to examine the psychometric justice system. Although validity indices for properties of the PDSQ with a broader screens described in this section are typically range of clinical populations based on previous versions of the DSM (e.g., ■ The PDSQ is not frequently used in the DSM-IV), recommendations regarding instruments criminal justice system, and there is little are predicated on their alignment with the recently validation research involving offenders developed DSM-5, allowing for a more seamless ■ There is poor internal consistency for transition from DSM-IV to DSM-5. The following two of the PDSQ subscales (psychosis, is a recommended screening instrument that somatization), with alphas < .70. addresses both mental and substance use disorders: (Zimmerman & Mattia, 2001a, 2001b) ■ The MINI-Screen addresses a range of ■ Positive predictive values for some PDSQ subscales are quite low .30–.32 co-occurring mental and substance use (Zimmerman & Mattia, 2001b) problems. The MINI-Screen requires approximately 15 minutes to administer ■ A factor analysis indicated that only 13 of and score 15 subscales emerged as factors related

108 Instruments for Screening and Assessing Co-Occurring Disorders

In addition, separate screening instruments for mental disorders, and 20 percent have used mental and substance use disorders can be used in psychotropic medications (Hayes, 2010). combination. The Brief Jail Mental Health Screen (BJMHS) or the Correctional Mental Health Although most jails have written policies and Screen (CMHS-F/CMHS-M) can be combined procedures regarding assessment of suicide risk, with the Texas Christian University Drug Screen these are not always effective. For example, 77 V (TCUDS V). Refer to the sections "Screening percent of jail screenings assess suicide risk at Instruments for Mental Disorders" and "Screening intake, but only 31 percent of correctional officer Instrument for Substance Use Disorders" for reporting protocols include risk for suicide, and descriptions and availability information. suicide risk is followed up by correctional staff in only 27 percent of cases in which suicide risk is identified (Hayes, 2010). In cases of Screening and Assessment completed suicide, 37 percent of inmates were Instruments for Suicide Risk assessed for suicide risk by a clinician, and just People with mental disorders account for a under half of completed suicides occurred within majority of completed and attempted suicides 3 days of clinical assessments. Although many (Cavanagh, Carson, Sharpe, & Lawrie, 2003; correctional facilities provide close observation Nock et al., 2008), and approximately 63 percent for those deemed to be at risk for suicide, these of individuals who complete suicide have a observational periods are not continuous and are substance use disorder (Duberstein, Conwell & typically of short duration (e.g., 15 minutes at Caine, 1994; Conwell et al., 1996; Schneider, a time; Hayes, 2010). Given the high rates of 2009). Although mental disorders account for suicide in criminal justice settings, implementation approximately 10 percent of completed suicides, of evidence-based instruments for screening and suicide risk increases to 14–19 percent with the assessment of suicide risk is of critical importance. presence of a substance use disorder (Office of In order to provide a comprehensive approach Applied Studies, 2006). The risk for suicide is to screening and assessment of suicide risk, it seven times higher among people who have two or is useful to examine two major components: more disorders (Nock et al., 2009; Rush, Dennis, (1) desire, and (2) capability (see description Scott, Castel & Funk, 2008). of these factors in the section entitled “Special Suicide is a major concern within the criminal Clinical Issues in Screening and Assessment for justice system, in which inmates have a 6–7.5 Co-occurring Disorders in the Justice System”). times greater risk than the general population Therefore, suicide risk instruments should address (Jenkins et al., 2005). Males account for 93 both of these areas. A number of instruments percent of completed suicides, and among jail examine the interaction of these two factors in the inmates, the risk for suicide is highest within the context of suicide risk, while other instruments first month of incarceration. In fact, over half of examine a broader range of risk factors related completed suicides in jail occur within the first 2 to suicide. The following section describes both weeks of incarceration. Among jail inmates, 80 interview and self-report instruments that examine percent of suicides occur within 2 days of a court risk for suicide. Interview approaches typically hearing (Hayes, 2010). Almost half of inmates address not only desire and capability but other who commit suicide have substance use problems risk and protective factors as well. The self-report (Hayes, 2010). In addition, 20 percent of inmates instruments, although shorter to administer, do who complete suicide are under the influence not typically address the full range of risk and of drugs or alcohol. Mental health problems protective factors. Further information regarding also contribute to suicides in jail; specifically, suicide risk factors within the criminal justice 38 percent of inmates who commit suicide have system is provided in the section entitled “Special

109 Screening and Assessment of Co-Occurring Disorders in the Justice System

Clinical Issues in Screening and Assessment for by measures assessing the frequency of Co-occurring Disorders in the Justice System.” suicidal ideation and contemplation and the As noted previously, all offenders who screen critical items. The ASIQ more effectively positively for suicide risk should be immediately predicts multiple suicide attempts than referred for a more comprehensive assessment to other suicide risk instruments, such as the determine the need for treatment services, close BSS and RASQ (Horon et al., 2013) monitoring, and other interventions. ■ In a psychiatric sample, the ASIQ is moderately to strongly correlated with Suicide Risk Screening Instruments other measures of suicidal ideation, including the BSS, the Suicide Probability The Adult Suicidal Ideation Scale (SPS), the BHS, the Beck Depression Questionnaire (ASIQ) Inventory (BDI), and the Beck Anxiety Inventory (BAI; Bisconer & Gross, 2007) The ASIQ (Reynolds, 1991) is a 25-item self- ■ Among psychiatric outpatients, the ASIQ report measure that was adapted from the 30- items load highly on a factor related item Suicide Ideation Questionnaire (Reynolds, to suicidal ideation, as measured by a 1987). The ASIQ addresses frequency of suicidal composite variable of the ASIQ and the thoughts, plans, and preparation for suicide during Inventory of Depression and Anxiety the past month. Respondents indicate frequency Scales (IDAS), supporting the convergent of thoughts on a 7-point scale (0 = never had this validity of the instrument (Naragon-Gainey thought, 6 = almost every day). Six critical items & Watson, 2011) are included that are best able to discriminate ■ The ASIQ distinguishes between those between those who attempt suicide and non- at risk for suicide and “controls” in a attempters (Reynolds, 1991). A cut-off score of 14 psychiatric sample (Bisconer & Gross, is recommended in clinical samples, and a score 2007) of 31 is recommended in community samples ■ The ASIQ is able to discriminate between (Osman et al., 1999; Reynolds, 1991). those with and without a history of suicide attempts in a psychiatric sample (Osman et Positive Features al.,1999) ■ The ASIQ has been used with offenders ■ The ASIQ predicts suicide attempts (Horon, McManus, Schmollinger, Barr & during a 3 month follow-up period among Jimenez, 2013) psychiatric patients who have previously ■ The ASIQ is correlated with other indices attempted suicide, supporting the predictive of suicidal ideation, including the Beck validity of the instrument (Osman et al., Hopelessness Scale (BHS), the Beck Scale 1999) for Suicide Ideation (BSS), and Reasons ■ The ASIQ’s area under the curve (AUC) in for Attempting Suicide (RASQ). Scores identifying multiple suicide attempters is on the ASIQ are negatively correlated quite good (AUC = .80 total scale; AUC = with protective factors as identified by the .69 for critical items; Horon et al., 2013) Suicide Risk Assessment Scale (SRAC), supporting the convergent and discriminant ■ The instrument’s specificity is quite good validity of the measure with offenders in psychiatric samples (78 percent) when (Horon et al., 2013) compared with historical records of suicidal ideation and behaviors (Bisconer & Gross, ■ The ASIQ is able to discriminate between 2007) offenders who have multiple suicide attempts and those who have had a single ■ A confirmatory factor analysis yields a attempt or no attempts, as evidenced single factor, indicating that the ASIQ

110 Instruments for Screening and Assessing Co-Occurring Disorders

measures a unitary construct of suicide attempts. If the respondent positively endorses ideation (Osman et al., 1999) item #4 (desire to make an active suicide attempt) ■ Internal consistency of the entire ASIQ is or #5 (duration of suicidal ideation), then items quite good (alpha = .95–.96; Bisconer & 6–19 are also completed. The instrument requires Gross, 2007; Horon et al., 2013; Reynolds, approximately 5–10 minutes to administer and 1991), as well as for the critical items score. Total scores range 0–38, with 0–2 points (alpha = .85; Horon et al., 2013) among assigned to each item, and with higher scores offender and community samples indicating a higher risk for suicide. ■ The ASIQ’s test-retest reliability over a 1-week interval is quite good (r score = .95; Positive Features Reynolds, 1991) ■ The BSS is brief to administer and score ■ The BSS has been used with offenders Concerns (Horon et al., 2013; Kroner et al., 2011; ■ The ASIQ has not been widely studied in Lohner, & Konrad, 2006; Palmer & criminal justice settings Connelly, 2005; Senior et al., 2007; Way, ■ The ASIQ is not a public domain Kaufman, Knoll, & Chlebowski, 2013) instrument ■ Among offenders who have CODs, the ■ Cut-off scores for the ASIQ may BSS has good convergent validity with vary between clinical and nonclinical other measures of suicide risk, including populations the ASIQ, RASQ, and the SRAC (Horon et al., 2013) ■ The sensitivity (51 percent) of the ASIQ is lower than use of historical records in ■ The BSS and the BSS screening items identifying suicidal ideation and behaviors are able to discriminate between multiple in a psychiatric sample (Bisconer & Gross, attempters and non-attempters or single 2007) attempters and are able to more effectively predict multiple suicide attempts in Availability and Cost comparison to other measures of suicide The ASIQ can be purchased from Psychological risk, including the ASIQ and RASQ (Horon Assessment Resources, Inc. (PAR), at the et al., 2013) following site: http://www4.parinc.com/Products/ ■ Among offenders, the BSS is related to Product.aspx?ProductID=ASIQ#Items other indices of suicide, including suicidal ideation, suicidal thoughts, and past suicide An introductory kit costs approximately $100, attempts, as measured by the Depression which includes 25 copies of the instrument and an Hopelessness Suicide Screening form, administration manual that provides instructions providing support for its convergent for administration, scoring, and interpretation. validity (Kroner et al., 2011) ■ BSS scores for current suicidal ideation Beck Scale for Suicide Ideation (BSS) among offenders reporting multiple suicide attempts is significantly higher than for The BSS (Beck & Steer, 1991) is a 21-item those with only one reported suicide self-report scale that examines thoughts, plans, attempt, supporting the validity of the BSS and intent to commit suicide and includes five among offenders who have mental health screening items. The BSS items inquire about the problems (Way et al., 2013) desire to live, suicidal intent, plans and preparation ■ The BSS area under the curve (AUC) is for suicide, and openness about sharing suicidal quite good (.74) as is the AUC for the BSS thoughts with others. Two additional items screening items (.71), in classifying people examine the frequency and severity of past suicide

111 Screening and Assessment of Co-Occurring Disorders in the Justice System

who have multiple prior suicide attempts ■ Caution should be taken when interpreting (Horon et al., 2013) BSS suicide risk severity scores, as ■ Studies involving several international offenders may not be willing to report offender populations provide support for suicidal ideation and may underreport the convergent and concurrent validity of the true severity of suicidal thoughts and the BSS (Lohner & Konrad, 2006; Senior desires (Way et al., 2013) et al., 2007) ■ Analysis of the BSS among clinical ■ Among veterans, the BSS is able to samples indicates that it may consist of distinguish between those with and without two to four factors (Beck et al., 1997; suicidal ideation. The instrument also Beck, Weissman, Lester, & Trexler, 1976; detects higher rates of suicidal ideation Witte et al., 2006; Kingsbury, 1993; among veterans who have CODs in Spirito, Sterling, Donaldson, & Arrigan, comparison to those who have mental 1996). Several studies indicate a three- disorders only, supporting the validity of factor solution but provide ambiguous the BSS (Bahraini et al., 2013). The BSS results about the nature of the factors demonstrates good internal consistency (Beck, Kovacks, & Weissman, 1979; among offenders (alpha = .85; Horon et Steer, Rissmiller, Ranieri, & Beck, 1993). al., 2013) and has high levels of internal Thus, caution should be exercised when consistency (alpha = .84), temporal interpreting BSS scores stability, and predictive validity when Availability and Cost used to make decisions about hospital admissions (Beck, Brown, & Steer, 1997) The BSS is commercially available and can be purchased from the Pearson Assessment website: ■ The BSS has better specificity and positive predictive value in identifying suicide risk http://www.pearsonclinical.com/psychology/ than the BHS and the BDI (Cochrane- products/100000157/beck-scale-for-suicide- Brink, Lofchy, & Sakinofsky, 2000) ideation-bss.html ■ A computerized version of the BSS The administration manual costs approximately $7 is available. In a study comparing and provides scoring and interpretation, while a computerized self-report, pen and paper package including 25 forms of the instrument costs self-report, and clinician report, both self- approximately $54. report versions of the BSI correlated highly (r score > .90) with the clinician reports (Beck, Steer, & Ranieri, 1988) Interpersonal Needs Questionnaire (INQ)/Acquired Capability for Suicide Concerns Scale (ACSS) ■ The BSS is not a public domain instrument The Interpersonal Needs Questionnaire (INQ) ■ Additional research is needed to determine and the Acquired Capability for Suicide Scale the psychometric properties of the BSS (ACSS; Van Orden et al., 2012) are two self- with offenders who have CODs. The BSS may not be related to prior suicide attempts report instruments that are administered as a in some criminal justice samples (Way et single screening protocol. These are based on al., 2013) the Suicide Risk Decision Tree approach. These instruments provide a direct measure of both ■ Mean scores on the computerized self- suicidal desire and capability. The INQ contains reported measure are higher than the clinical ratings, indicating that this measure two subscales, one that assesses feelings of may yield elevated levels of suicidal burdensomeness (seven items) and another that ideation (Beck et al., 1988) assesses lack of belonging (five items). The ACSS measures suicide capability (five items). Higher

112 Instruments for Screening and Assessing Co-Occurring Disorders scores on the ACSS reflect greater suicidal desire Inventory–Suicidality Subscale (Davidson, and capability and greater suicide risk. Although Wingate, Rasmussen, & Slish, 2009) the INQ and ACSS can be used independently, ■ Both subscales of the INQ (feelings of in combination they provide a comprehensive burdensomeness, lack of belonging) are measure of suicide risk. The INQ/ACSS has not correlated with alcohol problems among been evaluated in criminal justice settings but college students (Lamis & Malone, 2011) shows significant promise in studies of community ■ Higher depression and samples. in college students are correlated with feelings of burdensomeness, supporting the Positive Features construct validity of the INQ among people ■ The INQ is a public domain instrument who have mental disorders (Davidson, ■ The INQ is brief to administer and easy to Wingate, Grant, Judah, & Mils, 2011) score ■ The two-factor structure of the INQ ■ Among psychiatric outpatients, INQ (feelings of burdensomeness, lack of scores for depression and feelings of belonging) is supported by a study burdensomeness and ACSS scores for involving a military sample (Bryan, 2011) acquired capability are correlated with ■ Internal consistency of the INQ and clinician-rated risk of suicide, and INQ ACSS is quite good, with alphas for the scores are also associated with suicide INQ ranging .83–.94 and alphas for the capability and desire (Van Orden, ACSS ranging .83–.85 (Bryan et al., 2012; Witte, Gordon, Bender, & Joiner, 2008), Nademin et al., 2008) supporting the convergent validity of the instrument (Van Orden et al., 2008) Concerns ■ As detected by the INQ, both feelings of ■ As noted previously, there has been little burdensomeness and lack of belonging are research examining the INQ/ACSS with associated with increased PTSD symptoms offender populations and poor mental health in a military ■ The INQ/ACSS does not yield a threshold sample, supporting the concurrent validity or cutoff score indicating high risk for of the instrument (Bryan, 2011) suicide ■ Among people involved in substance use ■ For young adults who report suicidal treatment, INQ scores related to feelings ideation, the interaction of feelings of of burdensomeness and lack of belonging burdensomeness and lack of belonging predict risk of suicide attempts, supporting does not predict suicide attempts, thus the validity of the instrument (Connor, introducing concern about the validity in Britton, Sworts, & Joiner, 2007) using the INQ/ACSS with this population ■ INQ/ACSS scores for feelings of (Joiner et al., 2009) burdensomeness and suicidal capability ■ In a military sample, suicide capability are correlated with scores on the Suicidal is related to lack of belonging but not Behavior Questionnaire-Revised (SBQ-R; feelings of burdensomeness, suicidality Osman et al., 2001). The combination of scores, or symptoms of depression. Thus, these two factors is also correlated with suicide capability should not be used as suicidality, providing additional support for an independent measure to predict risk the convergent validity of the INQ/ACSS of suicide with this population (Bryan, (Bryan, Clemens, & Hernandez, 2012) Cukrowicz, West, & Morrow, 2010) ■ The INQ/ACSS is correlated with suicidal ideation among college students, as measured by the Depressive Symptom

113 Screening and Assessment of Co-Occurring Disorders in the Justice System

Availability and Cost plan and preparation for executing the plan (Joiner The INQ/ACSS is a public domain instrument and et al., 1999). is available at the following site: http://psy.fsu. Availability and Cost edu/~joinerlab/measures/ACSS-FAD.pdf Although no formal SRDT instrument is publicly Suicide Risk Assessment Instruments available, guidelines are available that describe how to administer the SRDT interview and include Suicide Risk Decision Tree Interview a visual representation of the decision tree matrix and sample items. The guidelines are available in The Suicide Risk Decision Tree (SRDT; the publication and at the web link listed below: Cukrowicz et al., 2004; Joiner et al., 1999; Joiner et al., 2009) is a clinician-administered Cukrowicz, K. C., Wingate, L. R., Driscoll, interview that addresses both desire and capability K. A., & Joiner Jr, T. E. (2004). A standard in determining suicide risk. Although several of care for the assessment of suicide risk self-report instruments (Interpersonal Needs and associated treatment: The Florida State Questionnaire, INQ; and the Acquired Capability University Psychology Clinic as an example. for Suicide Scale, ACSS) also examine these areas, Journal of Contemporary , 34(1), the interview provides a more comprehensive 87–100. http://link.springer.com/article/10.1023/ assessment of the suicide risk framework and B:JOCP.0000010915.77490.71 is appropriate when more time is available for suicide risk assessment. The SRDT interview Recommendations for Suicide Risk also includes open-ended questions that allow Screening Instruments the interviewer to probe for further information Information describing suicide screening regarding individual items and investigates a wide instruments is based on a critical review of the range of risk factors, including those related to existing literature. Key areas considered in mental disorders. The SRDT interview examines making recommendations about suicide screens suicide risk and suicidal desire. Questions include empirical evidence supporting the investigate two components of desire: (1) lack reliability and validity of instruments, the relative of belonging, and (2) burdensomeness. The costs of instruments, ease of administration, use interview also reviews the capability for suicide, within the criminal justice system, and alignment including suicidal plans and preparations, duration with theoretical frameworks that have been and intensity of suicidal ideation, history and established for assessment of suicide risk. As number of past suicide attempts, means and noted previously, offenders who are screened opportunities, fearlessness of death, and recent as having significant suicide risk should be stressful life events. This combined environmental immediately referred for further assessment and psychosocial information yields a suicide to determine the need for treatment, close risk level. Low risk applies to people who have supervision, and other services. suicidal ideation but no plans or preparation and few other risk factors. Moderate risk is attributed For brief suicide screening, the following to people who have multiple prior suicide instruments are recommended: attempts but no other current risk factors or “non- 1. The Interpersonal Needs Questionnaire attempters” who have moderate to severe suicidal (INQ) coupled with the Acquired Capability ideation and desire but no plans or preparation. for Suicide Scale (ACSS). The INQ/ACSS High risk is reserved for people who have multiple was developed based on the Suicide Risk suicide attempts or non-attempters who have Decision Tree and measures specific factors multiple risk factors; high risk endorses both a associated with suicide risk, including

114 Instruments for Screening and Assessing Co-Occurring Disorders

suicidal desire (feelings of burdensomeness, provides broader coverage of suicide risk factors, lack of belonging) and capability. it requires additional time to administer.

(or) Screening and Diagnostic 2. The Beck Scale for Suicide Ideation (BSS). Instruments for Trauma and PTSD (or) People with CODs have very high rates of trauma and posttraumatic stress disorder (PTSD) in 3. The Adult Suicidal Ideation Questionnaire comparison to the general population, and these (ASIQ). rates are augmented in the criminal justice system The BSS and ASIQ assess some, but not all (Elbogen et al., 2012; Lynch et al., 2013; Proctor, components of the prevailing suicide risk 2012; Proctor & Hoffmann, 2012; Steadman et al., assessment framework, but both instruments have 2013). Trauma is often overlooked in screening been examined within the criminal justice system, within the criminal justice system, particularly and have been found to reliably predict suicide in substance use treatment settings. Failure to risk. identify trauma within this population often leads to poor treatment outcomes (Prendergast, 2009; Each of the previously described instruments Ruiz, Douglas, Edens, Nikolova, & Lilienfeld, requires between 10–15 minutes to administer and 2012; Steadman et al., 2013). Several specialized score. screening and assessment instruments have been developed to examine the history of trauma and If additional time is available to provide a more PTSD, which may be useful within criminal detailed assessment of suicide risk, the following justice settings. Several other general mental instrument is recommended: health screening and assessment instruments that ■ The Suicide Risk Decision Tree (SRDT), also examine trauma and PTSD (e.g., CMHS, a clinician-administered interview that MINI, PAI, SCID-IV) are described in previous provides a comprehensive assessment of sections of this monograph. Screens for trauma environmental and psychosocial factors and PTSD are generally brief, noninvasive, and associated with suicide risk. The SRDT do not require administration by a mental health examines factors that are fully aligned with professional. Two types of screening instruments the theoretical framework for suicide risk are available: (1) those that address stressful life assessment, and its open-ended response events and their effects, and (2) those that address format facilitates additional interviewer severity of symptoms based on DSM criteria. probes to follow up on specific questions. The diagnostic screens are somewhat longer to The SRDT interview requires approximately 20 administer but provide a formal diagnosis of PTSD minutes to administer. and are often used as follow-ups to brief screens. As mentioned previously, screening for trauma/ In contrasting the recommended suicide risk PTSD can be conducted by nonclinicians through instruments, considerations should include the use of standardized self-report instruments, which cost of these instruments. The BSS and ASIQ are require minimal training. However, all staff who commercially available and are more expensive to administer trauma screens should be fully aware administer than the INQ/ACSS instruments, which of appropriate referral sources and the nature of are available in the public domain. However, the trauma-related services. Offenders who screen validity of the INQ/ACSS has not been determined positively as having significant problems related within criminal justice settings. Although the to trauma and PTSD should receive a thorough Suicide Risk Decision Tree (SRDT) interview

115 Screening and Assessment of Co-Occurring Disorders in the Justice System assessment by a trained and licensed/certified Screening Instruments for Trauma/ mental health professional. PTSD Changes to the DSM-5 Diagnostic Impact of Events Scale–Revised (IES-R) Criteria for PTSD There are several major differences between the The IES is a 15-item self-report measure DSM-IV criteria for PTSD and the more recent describing the current level of subjective stress DSM-5 criteria (APA, 2013). The DSM-IV experienced as a consequence of experiencing a defined PTSD with the following criteria: A— traumatic event (Horowitz, Wilner, & Alvarez, traumatic event experienced, including severity, 1979). The revised IES-R (Weiss, 2004; Weiss frequency, and intensity; B—re-experiencing & Marmar, 1997) includes 22 items, with six traumatic events; C—avoidance of trauma; and additional items examining hyperarousal (e.g., D—hyperarousal. Criterion E assessed duration exaggerated startle, psychophysiological arousal of traumatic symptoms and Criterion F assessed when reminded of the event) and one item that related functional impairment. Under DSM- examines re-experiencing traumatic events. IES 5, PTSD is included in a new section, entitled, items are based on DSM-III-R/DSM-IV criteria. “Trauma and Stress-related Disorders.” Criterion The three scales include avoidance, intrusion, and A now explicitly addresses sexual violation as a hyperarousal. Respondents indicate distress from traumatic event and includes reoccurring exposure zero (not at all) to four (extremely) on each item to traumatic events, such as those faced by law and questions inquire about symptoms experienced enforcement or paramedics. Moreover, Criterion over the past 7 days. The cut-off score for the A no longer requires a response of intense fear, presence of PTSD is ≥33. Guidelines for scoring helplessness, or horror. A new Criterion D and interpretation are provided. The IES-R is (“negative cognitions and mood”) has been added one of the most widely used measures of PTSD to capture symptoms related to distorted thinking symptoms. Unlike the majority of trauma/PTSD and negative emotions. These symptoms were instruments, the IES-R addresses a wide range of originally addressed in DSM-IV Criterion C. The traumatic experiences. new criterion includes items aimed at assessing Positive Features persistent feelings of blame (self or others), ■ The IES has adequate reliability and detachment from others, anhedonia (inability concurrent and discriminant validity, and to experience pleasure), and difficulty recalling has a cohesive factor structure (Creamer, traumatic events. Criterion E (“alterations in Bell, & Failla, 2003) arousal”) now examines changes in arousal and ■ The IES is easy to administer and has been reactivity. Items include irritability and anger, used with a variety of populations reckless or impulsive behaviors, hypervigilance, difficulty sleeping, and difficulty concentrating. ■ The IES has been used with offenders Criterion F has also been revised to describe the (Austin-Ketch et al., 2012) duration of symptoms, while the new Criterion G ■ The IES-R uses a parallel format to that of assesses functional impairment. the SCL-90-R, allowing for comparison of symptoms across instruments (Weiss, 2004) ■ The IES-R can be used as an alternative to the PCL-C ■ The IES-R is available in several languages, including Spanish (Báguena et al., 2001), Chinese (Wu & Chan, 2003), French (Brunet, St-Hilaire, Jehel, & King,

116 Instruments for Screening and Assessing Co-Occurring Disorders

2003), German (Maercker & Schuetzwohl, the Peritraumatic Dissociative Experiences 1998), and Japanese (Asukai et al., 2002) Questionnaire (PDEQ, Marmar, Weiss, & ■ The IES-R has been used with veterans Metzler, 1997), the Peritraumatic Distress (Amdur & Liberzon, 2001; Forbes et Inventory (PDI, Brunet et al., 2001), and al., 2003) and people with substance use Depression and Global Symptom Index disorders (Rash, Coffey, Baschnagel, (GSI) scores on the SCL-90-R Drobes, & Saladin, 2008; Schumacher, ■ Factor analyses of the IES-R support a Coffey, & Stasiewicz, 2006) three-factor structure, in accordance with ■ Among those who have substance use the three scales of avoidance, intrusion, and disorders with and without PTSD (Rash hyperarousal (Weiss & Marmar, 2004) et al., 2008), the IES-R shows good ■ Internal consistency of the IES-R is quite diagnostic accuracy at a cut-off score of 33, good across the three scales, including as indicated by the Clinician Administered avoidance (alpha = .84), intrusion (alpha = PTSD Scale (CAPS). The IES-R also .89), and hyperarousal (alpha = .82; Weiss has good overall accuracy (73 percent), & Marmar, 2004). Internal consistency sensitivity (73 percent), specificity (72 across the IES-R scales is also quite good percent), positive predictive value (78 among veterans (alphas range .81–.87; percent), and negative predictive value Creamer et al., 2003) and people who have (67 percent). The IES-R demonstrates substance use disorders (alphas range .85– good convergent validity with the CAPS .91; Rash et al., 2008). Internal consistency (r scores range .36–.60) and concurrent of translated versions of the IES-R is also validity with the SCL-90-R (r scores range quite good (alphas range .83–.91; Weiss & .47–.72) among people who have substance Marmar, 2004) use disorders (Rash et al., 2008) ■ The test-retest reliability of the IES-R is ■ The IES-R has good diagnostic accuracy quite good (r scores range .89–.94) over a among treatment-enrolled veterans who 6-month period (Weiss & Marmar, 1996). meet PTSD criteria (Creamer, Bell, & Test-retest reliability of translated versions Failla, 2003), as indicated by the PTSD of the IES-R is also good (r scores range checklist (PCL; Weathers, Litz, Herman, .52–.86; Weiss & Marmar, 2004) Huska, & Keane, 1993), with an overall accuracy of 88 percent at a cut-off score of Concerns 33, sensitivity of 91 percent, specificity of ■ Instructions must be provided to 82 percent, positive predictive value of 90 respondents for IES-R questions that ask percent, and negative predictive value of about specific traumatic events 84 percent. The IES-R and its subscales ■ The IES-R does not provide a diagnosis of also have good convergent validity with the PTSD and instead provides an evaluation PCL within this same population (r scores of avoidance and intrusive symptoms range .70–.86; Creamer et al., 2003) ■ The IES-R has not been widely studied ■ In a large law enforcement sample, among criminal justice populations the IES-R and its subscales show good ■ At a cut-off score of 33, accuracy in convergent validity with the Mississippi determining the presence of PTSD may be Scale for Combat-Related PTSD, Civilian low (kappa = .47; Rash et al., 2008) Version (Keane, Caddell, & Taylor, 1988), with r scores ranging .53–.57 (Weiss ■ There has been inconsistent support for & Marmar, 2004). The IES-R is also a three-factor structure of the IES-R, as highly correlated with other measures several studies indicate one and two-factor of concurrent validity (r scores ranged structures (Báguena et al, 2001; Creamer .31–.50; Weiss & Marmar, 2004), including et al., 2003; Taylor, Kuch, Koch, Crockett,

117 Screening and Assessment of Co-Occurring Disorders in the Justice System

& Passey, 1998; Wagner & Waters, 2014). of Veterans Affairs suggests a cut-off score of 38 Other studies support a different three- for determining PTSD diagnosis (Weathers et al., factor structure (intrusion/hyperarousal, 2013). The previous version of this instrument avoidance, and sleep/irritability/ included the PCL (Posttraumatic Stress Disorder concentration; Asukai et al., 2002), or a Checklist), a 17-item self-report measure that is four-factor structure (Amdur & Liberzon, based on the DSM-IV criteria. The PCL is used to 2001; King, Leskin, King, & Weathers, screen for PTSD symptoms, provide a diagnostic 1998). These findings suggest that the impression for PTSD, and monitor change in IES-R may measure general trauma-related symptoms over time (Weathers et al., 1993). distress rather than symptoms of PTSD ■ Internal consistency of the IES-R is Several versions of the previous PCL instrument somewhat low across the three scales (based on DSM-IV PTSD criteria) were designed among veterans enrolled in treatment for military (PCL-M) and civilian (PCL-C) (alpha range .52–.83, Creamer et al., 2003) populations. The PCL-M queries about symptoms related to traumatic military experiences and may Availability and Cost be used with veterans or active service personnel. The IES can be obtained at no cost at the following When considering which version to use, one site: http://serene.me.uk/tests/ies-r.pdf should also take into account that individuals in the military may also have premilitary trauma The instrument can also be found in the following experiences, and as such the PCL-C may also articles: (1) Weiss, D. S., & Marmar, C. R. (1996). have utility for the veteran population. The The impact of event scale–revised. In J. Wilson PCL-C queries about symptoms related to & T. M. Keane (Eds.), Assessing psychological traumatic life events and can be used with various trauma and PTSD (pp. 399–411). New York: populations. The PCL-Specific (PCL-S) queries Guilford. (2) Weiss, D. S., & Marmar, C. R. (2004). The impact of event scale–revised. In about symptoms related to a specific traumatic J. P. Wilson & T. M. Keane (Eds.), Assessing life event. Symptoms identified by the PCL can psychological trauma and PTSD, (2nd ed., pp. refer to one or more traumas experienced. Prior 168–189). New York: Guilford. to administering the PCL, it is important to screen respondents for Criterion A of DSM criteria for PTSD or the experience of an actual stressor Posttraumatic Stress Disorder Checklist involving actual or threatened death, serious injury for DSM-5 (PCL-5) to self or others, or actual or threatened sexual The most recent version of the PCL, the violence. The PCL requires approximately 10 Posttraumatic Stress Disorder Checklist for DSM- minutes to administer. Respondents are asked to 5 (PCL-5; Weathers et al., 2013), includes 20 items rate the severity of symptoms, according to “how that examine the expanded DSM-5 PTSD criteria. much you have been bothered by the problem” The National Center for PTSD, operated by the during the past month, on a 1–5 scale. Total U.S. Department of Veterans Affairs, recommends symptom severity is reflected in the summed score that the PCL-5 be administered in conjunction of the 17 PCL items. Thresholds for symptom with the Life Events Checklist for DSM-5 (LEC- severity include ratings of 3 or above on criterion 5) to obtain a more comprehensive measure of B (re-experiencing symptoms, questions 1–5), 3 traumatic events experienced (Criterion A related or above on Criterion C (avoidance of symptoms, to PTSD; VA, 2015). A severity score on the PCL- questions 6–12), and 2 or above on Criterion D 5 can be obtained by summing the scores for each (hyperarousal, questions 13–17). Suggested cut- of the 20 items. Preliminary recommendation by off scores for the PCL are 30–35 in community the National PTSD Center and the Department samples, 36–44 in medical clinics (e.g., VA primary care), and 45–50 in mental health

118 Instruments for Screening and Assessing Co-Occurring Disorders settings (Blanchard, Jones-Alexander, Buckley, (93 percent), specificity (90 percent), and & Forneris, 1996). The TCU Mental Trauma and overall diagnostic accuracy (90 percent) PTSD Screen (TCU TRMAForm) is a version ■ Among women with substance use of the PCL used with offenders that is available disorders (Harrington & Newman, 2007) from the Texas Christian University Institute of and at a cut-off score of 44, the diagnostic Behavioral Research. accuracy of the PCL is better than the CAPS in identifying PTSD, with good Positive Features overall accuracy (76 percent), sensitivity ■ The PCL has been widely used with (76 percent), specificity (79 percent), offenders (Ball, Karatzias, Mahoney, positive predictive value (68 percent), and Ferguson, & Pate, 2013; Owens, Rogers, negative predictive value (80 percent) & Whitesell, 2011; Pankow et al., 2012; ■ The concurrent validity of the PCL Rowan-Szal, Joe, Bartholomew, Pankow, among female offenders was established & Simpson, 2012; Wolff, Frueh, Shi, & in reference to the TCU Drug Screen Schumann, 2012), including use to monitor (TCUDS), the TCU Psychological change in PTSD symptoms while offenders Functioning Scale, and the TCU social are involved in treatment (Ball et al., 2013; functioning scales (Rowan-Szal et al., Wolff et al., 2012) 2012). Concurrent validity of the PCL ■ The PCL has been found to have greater was also established across measures of diagnostic accuracy than several other mental health and substance use among screens (McDonald & Calhoun, 2010), male offenders, individuals enrolled including the four-item SPAN (startle, in community substance use treatment physically upset by reminders, anger, and (Pankow et al.,2012), and parolees and numbness; Yeager, Magruder, Knapp, probationers (Owens et al., 2011) Nicholas, & Frueh, 2007) and the Primary ■ Interrater reliability of the PCL is Care PTSD Screen (PC-PTSD; Prins et al., acceptable among community and clinical 2003) samples (Blanchard et al., 1996; Bollinger, ■ The PCL can be used to monitor change Cuevas, Vielhauer, Morgan, & Keane, in symptoms over time, particularly in 2008; Keen, Kutter, Niles, & Krinsley, treatment settings (McDonald & Calhoun, 2008) and veterans (Weathers et al., 1993) 2010) ■ Internal consistency of the PCL and its ■ Across clinical, primary care, veteran, scales is quite good among offenders hospital, and community settings (alphas range .73–.94 Rowan-Szal et al., (McDonald, & Calhoun, 2010), the 2012) and those who have severe mental different versions of the PCL provide fair disorders (.72–.87; Mueser et al., 2001) to good diagnostic accuracy at a cut-off ■ Confirmatory factor analysis indicates score of 50, as determined by the CAPS, that the PCL has a three-factor structure, the SCID, and the MINI. However, other reflecting the three scales of re- cut-off scores may be preferred based on experiencing, avoidance, and hyperarousal the particular setting (Rowan-Szal et al., 2012) ■ Among a military primary care sample ■ Test-retest reliability of the PCL-C is good (Gore et al., 2013), and using a cut-off over intervals of 1 hour (r score = .92), 1 score of 31, the PCL-C shows good week (r score = .87–88), and 2 weeks (r diagnostic accuracy in comparison to the score = .68) among undergraduate students PTSD Symptom Scale Interview (PSS-I, who had experienced a traumatic event Foa, Riggs, Dancu, & Rothbaum, 1993) (Adkins, Weathers, McDevitt-Murphy, at a cutoff of 31, with good sensitivity & Daniels, 2008; Ruggiero, Del Ben,

119 Screening and Assessment of Co-Occurring Disorders in the Justice System

Scotti, & Rabalais, 2003). The test-retest Availability & Cost reliability of the PCL-M is quite good The PCL-5 can be obtained free of charge by among military combat veterans, over a completing an electronic request form, and 1-week interval (r score = .96; Weathers et information regarding changes from the previous al., 1993) PCL-C (based on the DSM-IV) to the newer Concerns PCL-5, including administration, scoring, and ■ Further study is needed to determine the interpretation can be found at the following site: diagnostic validity of the PCL among http://www.ptsd.va.gov/professional/assessment/ offenders adult-sr/ptsd-checklist.asp ■ The PCL does not assess all DSM criteria, The previous PCL instrument and all of its including the types of traumatic event versions (e.g., PCL-C) can be downloaded at no experienced, the duration of symptoms, cost at the following site: http://at-ease.dva.gov.au/ negative cognitions, and clinical professionals/assess-and-treat/ptsd/ impairment related to daily functioning ■ The PCL should not be used as the sole The Life Events Checklist for DSM-5 (LEC-5) diagnostic instrument for PTSD, as it is a public domain instrument, and is available does not demonstrate the same diagnostic for download at the following site: http://www. effectiveness as clinician-administered ptsd.va.gov/professional/assessment/te-measures/ interviews (McDonald & Calhoun, 2010; life_events_checklist.asp National Center for Posttraumatic Stress Disorder, 2008), and further, it is geared The TCU Mental Trauma and PTSD Screen (TCU toward DSM-IV TRMAForm) can be downloaded at no cost at the ■ PTSD symptoms often overlap with following site: http://ibr.tcu.edu/forms/client-%20 other mental health symptoms and thus health-and-social-risk-forms/ can contribute to low rates of diagnostic accuracy (e.g., false positives) when using Primary Care PTSD Screen (PC-PTSD) the PCL (McDonald & Calhoun, 2010) ■ Various cut-off scores are recommended The PC-PTSD (Prins et al., 2003) is a four-item for different samples. Those administering screen for PTSD in primary care settings. The the PCL should thus be aware of population PC-PTSD examines several symptoms of PTSD, base rates and specific cut-off scores for including re-experiencing a traumatic event, these populations emotional numbing, avoidance, and hyperarousal. ■ The factor structure of the PCL-S may Instructions query about traumatic experiences differ across settings, particularly because in the past month. The cut-off for indicating it references specific trauma rather than the presence of PTSD is a score of ≥ 3 positive overall trauma history. Thus, scores on the responses. The PC-PTSD has variable cut-off PCL should be interpreted with caution, scores, depending on the base rates of PTSD in and interpretation should take into account different populations. Maximizing sensitivity over the type of sample and related base rates for specificity is preferred in clinical settings in order trauma history (Elhai et al., 2009) to minimize false negatives, which can prove to be ■ Interrater reliability of the PCL varies across more costly in the diagnostic process (Calhoun et samples. Particularly, low kappas (≤.50) al., 2010). In using the PC-PTSD for screening of have been found in primary care settings PTSD among those with CODs and in determining (Walker, Newman, Dobie, Ciechanowksi, & diagnoses, it is important to consider overlapping Katon, 2002; Yeager et al., 2007) mental health and substance problems and their relationship with PTSD symptoms. People

120 Instruments for Screening and Assessing Co-Occurring Disorders screened as positive on the instrument should determined by the SCID-IV for PTSD receive further clinician-administered assessment (Calhoun et al., 2010) related to PTSD. ■ At a cut-off score of 2 in a sample of veterans in primary care settings Positive Features (Ouimette, Wade, Prins & Schohn, 2008), ■ The PC-PTSD is widely used in VA the PC-PTSD has higher specificity (96 primary care settings (U.S. Department percent) and overall diagnostic accuracy of Veterans Affairs [VA], 2004; VA/ (93 percent) than the General Health Department of Defense, 2003) Questionnaire (GHQ-12; Goldberg & ■ The PC-PTSD is designed for those with an Williams, 1988) and provides greater eighth-grade reading level or higher predictive validity than the GHQ in identifying PTSD ■ The PC-PTSD has been used in various criminal justice settings (Ford, Chang, ■ Item response theory (IRT) analyses Levine, & Zhang, 2012; Ford & Trestman, indicate that the PC-PTSD performs 2005; Ford et al., 2007), including veteran consistently well in screening for PTSD treatment courts (Slattery et al., 2013) across gender groups (Oliver, 2013) ■ The Correctional Mental Health Screen ■ The test-retest reliability of the PC-PTSD is (CMHS) has adapted items from the PC- quite good in primary care settings (r score PTSD (Ford & Trestman, 2005; Ford et = .83; Prins et al., 2003) al., 2007) to screen for PTSD in criminal justice settings Concerns ■ The PC-PTSD was designed for use in ■ Among those enrolled in substance use treatment, the PC-PTSD demonstrates primary care settings and has not been acceptable sensitivity (67 percent) and widely studied in criminal justice settings specificity (72 percent) relative to a SCID- ■ The PC-PTSD does not identify specific IV PTSD diagnosis (van Dam, Ehring, traumatic life events related to PTSD Vedel, & Emmelkamp, 2010) symptoms (VA, 2013) ■ In primary care settings, as compared Availability and Cost to the CAPS, the PC-PTSD shows good diagnostic accuracy at a cut-off score of The PC-PTSD can be downloaded for free at the 3, indicated by the AUC (92 percent), in following site, which also provides instructions addition to good sensitivity (85 percent), for administration and scoring of the instrument: specificity (82 percent), and negative http://www.ptsd.va.gov/PTSD/professional/pages/ predictive value (98 percent; Freedy et assessments/assessment-pdf/pc-ptsd-screen.pdf al., 2010). Using a cut-off score of 3 in military primary care settings (Gore, Engel, Trauma Symptom Checklist (TSC-40) Freed, Liu, & Armstrong, 2008), the PC- PTSD shows good sensitivity (70 percent), The TSC-40 (Elliot & Briere, 1992) is a 40-item specificity (92 percent), and negative self-report measure of posttraumatic distress and predictive value (97 percent) relative to the associated symptoms related to events occurring Posttraumatic Symptom Scale Interview throughout the lifespan. Respondents rate how (PSS-I, Foa et al., 1993) often they have experienced each event on a ■ Among veterans, the PC-PTSD shows good four-point scale. The instrument contains six sensitivity (83 percent), specificity (85 scales: anxiety, depression, dissociation, sexual percent), and overall diagnostic accuracy abuse trauma index, sexual problems, and sleep (85 percent) at a cut-off score of 3, as disturbance. The TSC-40 is an improved version of the TSC-30 and includes items related to sexual

121 Screening and Assessment of Co-Occurring Disorders in the Justice System problems and sleep disturbance. The instrument that people with exposure to five or more is scored by summing each domain and/or by traumatic events (as determined by the calculating a total score. Overall scores range LSC-R) have higher mean scores on TSC- 1–40. The recommended cut-off score for the 40 subscales (Messina et al., 2007) presence of PTSD related traumatic stress is ≥ ■ The concurrent validity of the TSC-40 23. The TSC-40 should not be used as a stand- among female drug court participants alone instrument to identify PTSD but should (Hannah et al., 2009) is supported rather be used in combination with a screening or by significant correlations between assessment instrument for PTSD. experiences of interpersonal abuse and child abuse, as determined by the LSC-R (r Positive Features scores range .60–.61). In addition, 3-month ■ The TSC-40 is a public domain instrument follow-up scores on the TSC-40 for both anxiety and total score are significantly ■ The TSC-40 is brief to administer correlated with substance use (r scores ■ The TSC-40 has been used with offenders, range .50–.51) including those with CODs (Covington, ■ The TSC-40 can be used to monitor change Burke, Keaton, & Norcott, 2008; Grella, in symptoms of PTSD during treatment Stein & Greenwall, 2005; Hannah, Young (Zlotnick et al., 2009; Covington et al., & Moore, 2009; Messina & Grella, 2006; 2008) Messina et al., 2007; Zlotnick, Johnson, Najavits, 2009) ■ The TSC-40 has good test-retest reliability, as demonstrated by significant correlations ■ Among female offenders, for every between baseline and 3-month follow-up additional exposure to childhood traumatic scores across subscales (r scores range events (as indicated by the LSC-R), the .50–.56) likelihood of a positive screen on the TSC- 40 increases by 27 percent, supporting the ■ The TSC-40 total score has excellent concurrent and convergent validity of the internal consistency (Elliot & Briere, 1992; TSC-40 (Messina & Grella, 2006) alpha = .90), as do the sleep disturbances (alpha = .77) and sexual problems (alpha ■ Among psychiatric inpatients, the total = .73) scales. Other studies show similar score of the TSC-40 correctly identifies 84 results, with alphas ranging .66–.77 for the percent of individuals with sexual abuse, as subscales; and alphas for the total score determined by the Self-Rating Traumatic ranging .89–.91 (Briere, Elliott, Harris, & Stress Scale (SR-TSS; Davidson, Book, & Cotman, 1995) Colket, 1995), supporting the concurrent validity of the instrument (Zlotnick et al., Concerns 1996). Used alone, the TSC-40 sexual ■ The psychometric properties of the TSC-40 abuse trauma index correctly identifies have not been widely examined in criminal 77 percent of people who have a history justice settings of sexual abuse. Also supporting its concurrent validity, the TSC-40 scales ■ The TSC-40 was primarily designed for of dissociation, anxiety, depression, and research purposes sexual abuse trauma index are moderately ■ The TSC-40 may not be as comprehensive to strongly correlated with the SCL-90 in scope as the TSI scales of depression and anxiety, and the ■ The TSC-40 does not examine traumatic SR-TSS total scores (r scores range .40– life events that are experienced but rather .64) associated posttraumatic distress and ■ Among offenders, the concurrent validity general psychological distress of the TSC-40 is supported by findings

122 Instruments for Screening and Assessing Co-Occurring Disorders

Availability and Cost reliable index of change in symptoms over time. The TSC-40 is a public domain instrument and An alternate version is also available for the TSI-2 can be downloaded at no cost at the following (the TSI-2A). site, which also provides information regarding Positive Features scoring and administration: http://bhpr.hrsa. ■ The TSI is easy to administer and has been gov/grants/areahealtheducationcenters/ta/Files used extensively in a variety of clinical percent20for percent20Veterans percent20Mental settings percent20Health percent20CE/traumachecklist.pdf ■ A survey of members of the International Society for Traumatic Stress Studies The Trauma Symptom Inventory (TSI) (ISTSS) indicates that the TSI is one of the most widely used self-report instruments The TSI is a 100-item self-report inventory that for PTSD (Elhai, Gray, Kashdan, & evaluates the presence of acute and chronic trauma Franklin, 2005) symptoms. The instrument requires approximately ■ Computerized scoring of the instrument is 20 minutes to administer. The TSI contains 10 available clinical scales that examine affective, cognitive, and physical issues related to trauma. Clinical ■ The TSI has been used with offenders scales include the following: Anxious Arousal (Bradley & Follingstad, 2003; Day et (AA), Depression (D), Anger/Irritability (AI), al., 2008; Goldenson, Geffner, Foster, & Clipson, 2007) and substance-involved Intrusive Experiences (IE), Defensive Avoidance populations (Adams et al, 2011; Najavits, (DA), Dissociation (DIS), Sexual Concerns (SC), & Walsh, 2012) Dysfunctional Sexual Behavior (DSB), Impaired Self-Reference (ISR), and Tension Reduction ■ The TSI contains three validity scales designed to detect the level, typicality, and Behavior (TRB). Three validity scales are consistency of responses (Briere, 1995) included to detect efforts to either underreport or exaggerate symptoms. These include Atypical ■ The ATR validity scale is effective in Responses (ATR), Response Level (RL), and detecting feigned PTSD symptoms across Inconsistent Responding (INC). Items are based race/ethnicity groups (Briere, 2010) on the DSM-IV symptom criteria for PTSD. ■ Scores on the sexual concerns scale of Respondents rate the frequency of each symptom the TSI are correlated with longer stay in experienced on a four-point scale. substance use treatment among women (Adams et al., 2011) Separate TSI norms are available for men and ■ In a community sample of people women, as well as for different age groups. There (McDevitt-Murphy, Weather, & Adkins, is an 86-item alternative version (TSI-A) that does 2005) reporting a traumatic event, TSI not examine sexual concerns or dysfunctional clinical scales are moderately to strongly sexual behavior scales. A revised version of the correlated with relevant cluster symptoms TSI is also available (TSI-2; Briere, 2010), which of the CAPS. For example, the Intrusive provides improved validity scales for detecting Experiences scale is correlated with Cluster malingering or feigned PTSD symptoms. The B symptoms of re-experiencing trauma on TSI-2 contains 136 items, two validity scales, the CAPS (r score = .59). The TSI clinical 12 clinical scales, 12 subscales, and four factors. scales also are positively correlated with The TSI-2 was normed on a large U.S. sample. other measures of convergent validity, including the IES- R (r scores range Additional clinical scales include Insecure .36–.68), the PCL (r scores range .32–.65), Attachment (IA), Somatic Preoccupations (SOM), the Civilian Mississippi Scale (CMS; r and Suicidality (SUI). The instrument provides a scores range .36– 66), and the Anxiety-

123 Screening and Assessment of Co-Occurring Disorders in the Justice System

Related Disorders Scale (ARD-T) on the ■ Information is not available regarding test- Personality Assessment Inventory (PAI, retest reliability of the TSI scales r scores range .35–.73). This same study found that the TSI demonstrates good Availability and Cost diagnostic accuracy across subscales, as The TSI instrument is commercially available determined by the CAPS, with sensitivity from the Psychological Assessment Resources, ranging 63–94 percent and specificity Inc., P.O. Box 998, Odessa, FL 33556; (800) 331- ranging 59–91 percent. Cut-off scores were 8378. as follows: Defense Avoidance (T ≥62), Anxious Arousal (T ≥ 63), Depression (T The TSI-2 can be purchased online at the ≥ 58), Atypical Response (T ≥ 52), and following site: http://www4.parinc.com/products/ Intrusive Experiences (T ≥ 51) Product.aspx?ProductID=TSI-2 ■ Among undergraduates instructed to feign PTSD symptoms, the Atypical The TSI introductory kit is relatively costly ($205) Response Scale was able to accurately and contains the professional manual, 10 reusable detect malingering as determined by the item booklets, 25 hand-scorable answer sheets, Personality Assessment Inventory (PAI) and 25 profile forms. Computerized software that Negative Impression Management scale includes scoring is relatively costly, at $355. (NIM). At a cut-off score of 7, the TSI ATR scale accurately classifies 74 percent Screening Instruments for Traumatic (sensitivity) of malingerers, and 77 percent Life Events and Associated Symptoms (specificity) of those experiencing “true” PTSD distress, with an overall correct Life Stressor Checklist (LSC-R) classification rate of 75 percent (Briere, 2010) The LSC-R (Wolfe & Kimerling, 1997) is a self- report measure that assesses stressful life events. ■ The internal consistency of the TSI across subscales is quite good (alphas range .84– The LSC-R contains 30 items that query about .97) in community, clinical, and domestic exposure to traumatic events, including natural violence samples (Kaysen et al., 2007), disasters; accidents; physical/sexual abuse; and among undergraduate students (Burns, other stressful life events, such as divorce, foster Jackson, & Harding, 2010), and in military care, and financial difficulties. Some events, like samples (Briere, 1995) sexual abuse, are queried for occurrence in both ■ The TSI has good internal consistency childhood and adulthood. The instrument also (alphas range .74–.90) and good sensitivity includes an item specific to women (occurrence of (91 percent) and specificity (92 percent; abortion). For each item, respondents are asked Briere, 1995) to provide their age at the time of the event, and as relevant, the presence of a threat or serious Concerns injury to self/others, fear/helplessness experienced, ■ Psychometric properties of the TSI have and duration of distress. Respondents are asked not been established in criminal justice to indicate up to three events that have caused settings the most impairment. Individuals who endorse ■ The TSI is not a public domain instrument traumatic events should be further assessed to and is somewhat costly determine the presence of PTSD. ■ Advanced clinical training is recommended for staff assigned to interpret TSI test Positive Features results ■ The LSC-R is brief to administer ■ The LSC-R includes information specific to trauma experienced by women

124 Instruments for Screening and Assessing Co-Occurring Disorders

■ The LSC-R explicitly measures criterion child abuse, as identified by the LSC-R, A2 of the DSM-IV (experience of are more likely to have alcohol or drug helplessness or horror) use disorders (Hannah et al., 2009). ■ The LSC-R has been used in criminal Additionally, female offenders who have justice settings (Grella, Stein, & Greenwall, mental disorders have significantly higher 2005; Hannah et al., 2009; Messina & rates of exposure to traumatic life events, as Grella, 2006; Messina et al., 2007; Wolff et identified by the LSC-R, particularly those al., 2011) who have experienced sexual abuse (Wolff et al., 2011) ■ The LSC-R has been used with law enforcement (Inslicht et al., 2010; Maguen ■ Among females who have CODs, the et al., 2009; McCaslin et al., 2006), people LSC-R has acceptable to excellent test- with substance use disorders (Hannah retest reliability over a 1-week interval et al., 2009; Harrington & Newman, across different types of events (kappas 2007; Ouimette, Read, & Brown, 2005; range .52–.97; McHugo et al., 2005) Stewart, Grant, Ouimette, & Brown, 2006; ■ The interrater reliability of the LSC-R is Toussaint, VanDeMark, Bornemann, & quite good, as indicated by high agreement Graeber, 2007), and those with CODs (79–98 percent) across endorsed events (Brown & Melchior, 2008; Giard et al., among females who have CODs (McHugo 2005) et al., 2005) ■ Among offenders, the LSC-R’s concurrent Concerns validity is supported by significant correlations with different types of ■ The psychometric properties of the LSC-R traumatic events, including physical abuse, have not been established in criminal sexual abuse, violence, and incarceration justice settings of a family member (Messina et al., 2007). ■ The ability of the LSC-R to predict PTSD Support for the concurrent validity of the has not been widely studied LSC-R is also found among sex offenders, ■ The LSC-R describes other stressful life whose risk for sexual offending is predicted events that may not meet Criterion DSM- by experiences of sexual abuse, physical IV A1 for PTSD neglect, emotional abuse, and family violence (Jennings, Zgoba, Maschi, & Availability and Cost Reingle, 2013) The LSC-R is a public domain instrument and can ■ Female offenders with a history of conduct be downloaded without charge at the following disorders, substance use treatment, and site: http://www.ptsd.va.gov/PTSD/professional/ homelessness have greater exposure assessment/te-measures/lsc-r.asp to traumatic events in childhood, as determined by the LSC-R, supporting the concurrent validity of the instrument Stressful Life Events Screening (Messina & Grella, 2006). Female Questionnaire-Revised (SLESQ-R) offenders experiencing childhood traumatic The SLESQ-R (Goodman, Corcoran, Turner, events (e.g., death of a family member, Yuan, & Green, 1998) is a 13-item self-report assault, accident), as determined by the LSC-R, also have a higher incidence of questionnaire that measures lifetime exposure violent criminal behavior (Grella, Stein, & to traumatic life events. The SLESQ-R was Greenwall, 2005) developed as a screening tool for potential PTSD. The stressful life events are those considered ■ The concurrent validity of the instrument is also supported by findings that female drug traumatic by Criterion A1 in the DSM-IV. The court participants who have experienced instrument includes 11 questions that examine

125 Screening and Assessment of Co-Occurring Disorders in the Justice System

specific events experienced and 2 general ■ The SLESQ-R should not be used as a questions that assess any other traumatic life stand-alone instrument to identify PTSD, events. Questions review experiences of physical/ and those who endorse a traumatic event sexual abuse, military trauma, threatened death should receive a more comprehensive or injury to self or others, and actual death or assessment for PTSD and trauma by a injury to others. Respondents indicate whether trained clinician. the particular event occurred, the age at which ■ Respondents may report the same incident the event occurred, frequency and duration of the for multiple SLESQ-R questions, leading event, and hospitalization or other consequences to inflation of scores. Thus, those related to the event. Endorsement of a traumatic administering the instrument should event should be followed by a formal assessment follow-up and record responses in the most of PTSD symptoms. appropriate category. ■ The SLESQ-R only assesses criterion A1 of Positive Features PTSD (experience of a traumatic life event) ■ The SLESQ-R is brief to administer and does not query about other PTSD criteria ■ The SLESQ-R is available in Spanish ■ The SLESQ-R may not provide broad ■ Among people who have severe mental disorders, use of the SLESQ-R is coverage of all traumatic events included recommended prior to administration of the in criterion A1, thus potentially under- PCL identifying those with PTSD symptoms (Long et al., 2008) ■ The SLESQ accurately identifies a range of traumatic life events experienced ■ Estimates of reliability and validity of by low-income minority respondents the SLESQ-R were established with (Green, Chung, Daroowalla, Kaltman, & undergraduate students and not with diverse DeBenedictis, 2006) populations ■ There may be differences in the reliability ■ Among undergraduate students, those with multiple traumatic life events identified by of reported traumatic events on the self- the SLESQ endorse higher trauma-related report and interview versions of the SLESQ. stress, as determined by the Traumatic Specifically, under-reporting of events such Symptom Inventory (Green, Goodman et as experienced child sexual/physical abuse al., 2000) may occur on the self-report version of the instrument (Green et al., 1998) ■ The reliability of the self-report and interview-administered versions of the ■ The SLESQ can misidentify “true” SLESQ among undergraduate students is traumatic events among low-income quite good across different traumatic life minority respondents (Green et al., 2006). events (mean kappa = .77; median kappa = For example, robbery, being threatened .64; Goodman et al., 1998) with a weapon, and attempted rape are sometimes identified by the SLESQ as ■ The test-retest reliability of the SLESQ stressors rather than as “true” traumatic over a 2-week interval is quite good among events. However, miscarriage, abortion, undergraduate students (r score = .89; emotional abuse, substance use, and eating Goodman et al., 1998) disorders are sometimes identified as “true” traumatic events experienced but Concerns are not classified as traumatic events by ■ The psychometric properties of the the SLESQ. Therefore the SLESQ may SLESQ-R have not been widely studied in not accurately identify “true” traumatic criminal justice settings

126 Instruments for Screening and Assessing Co-Occurring Disorders

events experienced by minorities, leading ■ The THQ is designed for both clinical and to potential under-diagnosis of PTSD research settings ■ Test-retest reliability in undergraduate ■ The THQ is available in Spanish students may be lower for life threatening ■ The THQ has been used with offenders, events, attempted sexual assault, and including those who have substance use “other” traumatic events, as indicated by disorders and CODs (Komarovskaya, kappas lower than .60 (Green et al., 1998) Booker-Loper, Warren, & Jackson, 2011; Lynch, Fritch, & Heath, 2012; Sacks, Availability and Cost Sacks, McKendrick et al., 2008; Sacks, The SLESQ-R is a public domain instrument and McKendrick, Sacks, Banks, & Harle, can be downloaded without charge at the following 2008; Sacks, McKendrick, Hamilton et al., site: http://ctc.georgetown.edu/toolkit Direct link 2008; Salgado, Quinlan, & Zlotnick, 2007; to the SLESQ-R form: https://georgetown.app.box. Sarkar, Mezey, Cohen, Singh, & Olumoroti, com/s/nzprmm2bn5pwzdw1l62w 2005) ■ The THQ has been used among people who Alternatively, the measure can be requested by have severe mental disorders (Lommen & e-mailing the developer of the measure, Dr. Lisa Restifo, 2009; Kilcommons & Morrison, A. Goodman, at [email protected] 2005; Mueser et al., 2008, Mueser et al., Information describing the SLESQ-R can be found 2007) at the following site: http://www.ptsd.va.gov/ ■ Offenders who receive psychiatric services professional/assessment/te-measures/stress-life- have higher rates of traumatic events on the events.asp THQ, particularly for physical and sexual abuse, in comparison to non-offender psychiatric patients (Sarkar et al., 2005) Trauma History Questionnaire (THQ) ■ One study of the THQ found that all The THQ (Green, 1996) is a 24-item self-report offenders were exposed to at least one measure that examines traumatic events within traumatic event prior to committing different categories. The categories include an offense (Payne, Watt, Rogers, & crime-related events (items 1–4, e.g., robbery), McMurran, 2008) general disaster (items 5–17, e.g., accidents ■ Female offenders determined by the THQ involving injury to self/death of others, military to have been exposed to interpersonal trauma, natural disaster), and physical/sexual violence show significant levels of PTSD experiences (items 18–24, e.g., physical attacks, symptoms, as indicated by the PCL; sexual assaults). Respondents are asked to general psychiatric distress, as indicated by the BSI; and recent substance use. indicate if they were exposed to the event, if it Repeated interpersonal violence identified occurred repeatedly, the age at which it occurred, by the THQ predicts PTSD symptoms and and the frequency of the event. The THQ requires general psychiatric distress (Lynch et al., approximately 10–15 minutes to complete. The 2012) THQ can be provided in an interview and requires ■ According to the THQ, female offenders approximately 15–20 minutes to administer. with polysubstance use disorders report Positive endorsement of items should be followed higher rates of exposure to trauma in up with a more formal assessment of PTSD comparison to people with single types symptoms. of substance use problems, supporting the concurrent validity of the instrument Positive Features (Salgado et al., 2007) ■ The THQ is brief to administer

127 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ The convergent validity of the THQ with ■ It may be difficult to identify traumatic the SLESQ is quite good, with kappas events as defined by PTSD Criterion A, as for individual items ranging .61–1.00 in the THQ does not explicitly examine the a large sample of depressed low-income newly revised DSM-5 PTSD Criterion A women (Goodman et al., 1998). Similarly, ■ Respondents may underreport, overreport, the THQ exhibits significant correlations or distort traumatic events, contributing to with a measure of exposure to conflict, the lower validity and reliability of the measure Conflict Tactics Scale (r score = .46), in a (Hooper, Stockton, Krupnick, & Green, sample of battered women (Humphreys, 2011) Lee, Neylan, & Marmar, 1999) ■ The reliability of the THQ can ■ Supporting the predictive validity of the be compromised during repeated instrument among inpatient and outpatients administrations if the respondent reports who have severe mental disorders, the the same traumatic event under a different frequency of trauma events identified by category (Hooper et al., 2011) the THQ predicts PTSD symptoms, as ■ Test-retest reliability of the THQ for determined by the PCL (Mueser et al., general events (e.g., other serious injury 1998). In a law enforcement sample, or other unwanted sexual incident) may be the THQ contributes unique variance in somewhat low (r score = .47; Hooper et al., predicting PTSD symptoms (Lilly, Pole, 2011) Best, Metzler, & Marmar, 2009). Other studies also show that the THQ is related Availability and Cost to PTSD symptoms (Golier et al., 2003; Green, Krupnick et al., 2000; Najavits et The THQ is a public domain instrument and can al., 1998; Spertus, Yehuda, Wong, Halligan, be downloaded at no cost at the following site: & Seremetis, 2003) and depression http://ctc.georgetown.edu/toolkit. Direct link (Spertus, Burns, Glenn, Lofland, & to the THQ: https://georgetown.app.box.com/ McCracken, 1999, Spertus et al., 2003) s/9ol8x4rwz8jgwo1bwgo8 ■ Test-retest reliability of the THQ over a Paper copies of the instrument can be obtained 2-week interval ranges from acceptable to by sending a written request to the address listed excellent (kappas = .57–.82; Mueser et al., below: 2001) across traumatic events reported by psychiatric inpatients. Similarly, interrater Bonnie L. Green, Ph.D. reliability is quite good (kappas = .76–1.00) Department of Psychiatry across reported traumatic events (Mueser et Georgetown University al., 2001) 611 Kober Cogan Hall ■ Test-retest reliability of the THQ among Washington, DC 20007 college students is adequate over a 2–3 month period (r scores range .51–.90) across events (Green, Goodman et al., The Trauma History Screen (THS) 2000; Green et al., 2005) The THS (Carlson et al., 2011) is a brief 13- item self-report measure that examines lifetime Concerns traumatic events experienced. The measure ■ As with other trauma screens, the THQ inquires about exposure to 11 specific events should not be used as a stand-alone (e.g., military trauma, accident, natural disaster, instrument in diagnosing PTSD and rather should be used in combination with other physical/sexual abuse) and general events (any instruments that examine symptom severity other threatening event). For each positively endorsed event, the respondent indicates the

128 Instruments for Screening and Assessing Co-Occurring Disorders number of times the event occurred. The total 2013; Murphy et al., 2012), active duty number of events identified provides an index of and military veterans (Carlson et al., 2011; high magnitude stressors (HMS). A follow-up Fanning & Pietrzak, 2013; Stein et al., screening question asks if any of the positively 2012), and community samples (Carlson, endorsed event(s) causes significant distress. The Smith, & Dalenberg, 2013) total number of events endorsed as causing distress ■ The convergent validity of the THS reflects the number of traumatic stressors (TS). high magnitude stressors (HMS) and persistent posttraumatic distress (PPD) is For events that are causing distress, the respondent quite good among a sample of veterans is asked to complete information regarding the age who are homeless and have high rates of at which the event occurred; a description of the mental disorders (Carlson et al., 2011), event; if the event represented a threat that could as evidenced by strong correlations with lead to death or injury; and if there were feelings trauma indicated by military records (r of helplessness, horror, and/or dissociation scores range .57–.87) experienced because of the event. The THS also ■ The THS (Carlson et al., 2011) is highly examines the duration of distress (“not at all” to correlated with another validated measure “a month or more”) and uses a five-point scale of stressful life events, the Traumatic Life to measure the amount of distress experienced Events Questionnaire (TLEQ), for reported (“not at all” to “very much”). The THS is based HMS (r score = .77) and is also correlated on DSM-IV PTSD criteria and reviews persistent with the PCL-C for reported HMS and PPD posttraumatic events (PPD) by describing the among veterans who are homeless (r scores number of events that involved actual/threatened range .25–.41), hospital trauma patients (r death or injury (Criterion A1 related to PTSD); scores range .33–.38), university students (r scores range .18–.22), other young adults (r experiences of fear, helplessness, or horror scores range .30–.34), and adults (r scores (Criterion A2); duration of distress of 1 month range .32–.37) or more (Criterion E); and severity of distress. This information can be used to provide a ■ Interrater reliability of the THS on HMS and PPD is quite good among veterans diagnostic impression related to PTSD, but should who are homeless (kappas = .70, .75, be followed-up by use of a formal diagnostic respectively), hospital trauma patients instrument. The THS requires less than 10 (kappa = .61, HMS only), university minutes to complete. students (kappa = .74, HMS only), and young adults (kappa = .74, HMS only; Positive Features Carlson et al., 2011) ■ The THS can be used in both clinical, nonclinical, and research settings ■ The test-retest reliability of HMS and PPD is high over a 1-week interval among ■ The THS requires only a sixth-grade veterans who are homeless (r scores range reading level .73–.93), hospital trauma patients (.74–.95), ■ The THS is brief to administer university students (.82–.87), and other ■ The THS explicitly assesses DSM-IV young adults (.73–.77; Carlson et al., 2011) Criterion A2 for PTSD (intense fear, helplessness/horror) Concerns ■ The THS has not been studied in criminal ■ The THS has been used in a variety of justice settings populations, including people with severe mental disorders (Zimbrón et al., 2013), ■ The THS is a fairly new measure and college students who endorse at least one requires further research to determine heavy drinking episode (Monahan et al., relevant psychometric properties

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■ Scoring rules for the THS must be obtained comprehensive and valid approach for diagnosing from the original development paper PTSD than use of brief screening instruments. (Carlson et al., 2011) The psychometric properties presented below ■ The THS has more global items than other under positive features and concerns are based on trauma instruments and could result in the prior DSM-IV version of the CAPS. high “false negatives” because it may not accurately assess all traumatic stressors. Major changes to the CAPS-5 include that the Conversely, the instrument may produce respondent report of PTSD symptoms is based on high rates of “false positives” because it only one indexed traumatic life event, and each does not define the interval of persistent symptom is rated with a single severity score, distress (Carlson et al., 2011) on a scale from 0 (“Absent”) to 4 (“Extreme/ incapacitating”) that accounts for both frequency Availability and Cost and intensity of symptoms. A diagnosis of PTSD The THS is a public domain instrument and can is made if an individual endorses moderate or be downloaded without cost at the following site: higher severity (≥ 2) symptoms for at least one http://www.midss.ie/sites/www.midss.ie/files/ item from Criterion B, one item from Criterion trauma_history_screen.pdf C, two items from Criterion D, and two items from Criterion E. The disturbance, as in DSM-IV, Information describing the THS and paper forms should last at least 1 month and cause significant of the instrument can be obtained at the following distress or impairment. Symptom cluster severity site: http://www.ptsd.va.gov/professional/ scores are generated by summing severity scores assessment/te-measures/ths.asp for items corresponding to a particular DSM-5 Diagnostic Instruments for PTSD cluster. It is recommended that questions related to Criterion A are supplemented by administration of the Life Events Checklist for DSM-5 (LEC-5), The Clinician-Administered PTSD Scale which examines lifetime exposure to 16 events, for DSM-5 (CAPS-5) and any other event that may potentially cause The Clinician-Administered PTSD Scale for trauma and PTSD. The CAPS requires 45–60 DSM-5 (CAPS-5) is a 30-item structured, minutes to administer. Scoring and interpretation clinician-administered interview that assesses guidelines are included in the CAPS-5. PTSD diagnostic criteria for DSM-5 (CAPS-5; Weathers et al., 2013). The CAPS-5 is a structured As mentioned previously, instructions for the interview that includes standardized questions CAPS-5 recommend administering the LEC-5 and probes examining 20 PTSD symptoms, as (or another structured screen that reviews past reflected in revisions to the DSM-5 criteria that traumatic life events) in advance of inquiring were described previously in this section. The about specific events that might be related to instrument was developed to enhance the validity PTSD. The LEC-5 is a 17-item instrument that and reliability of PTSD diagnoses (Blake et al., can be administered via self-report or interview. 1995) by rating the frequency and intensity of An extended self-report version is available to each of the diagnostic symptoms of PTSD. Three identify the “worst” event (if there was more versions of the CAPS-5 are available to assess for than one) that occurred during the designated PTSD symptoms occurring in the past week, the time period. The interview version of the LEC- past month, and over the lifetime. There is also a 5 provides this same information, and helps to version for children and adolescents (CAPS-CA) determine whether Criterion A for PTSD has been that is being revised for DSM-5. The instrument met. can also be used to monitor changes in symptoms over the course of treatment and provides a more

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Positive Features high correlations between its subscales and ■ The CAPS is considered to be the “gold the PSS-I (Foa & Tolin, 2000) standard” for diagnosing PTSD ■ Intraclass correlations with the CAPS total ■ The CAPS assesses current and past score is quite good among people who have symptoms of PTSD severe mental disorders, (.97; Mueser et al., 2008), as are correlations across each ■ The CAPS provides explicit anchors and criterion (ICCs range .91–.99; Mueser et behavioral referents to guide ratings al., 2001) ■ In forensic settings, the CAPS is ■ Interrater reliability for a PTSD diagnosis recommended for assessment of PTSD is quite good among samples of people who symptoms and diagnosis (Huang, Zhang, have severe mental disorders (kappas range Momartin, Cao, & Zhao, 2006; Keane, .91–1.0; Mueser et al., 2001; Mueser et al., Buckley, & Miller, 2003; Zlotnick, 2008) Najavits, Rohsenow, & Johnson, 2003; Zlotnick et al., 2009) ■ Interrater reliability among veterans is quite good for a categorical diagnosis of PTSD ■ The CAPS has been translated into (kappa = .92; Calhoun et al., 2005) Bosnian, Chinese, French, German, and Swedish ■ Interrater reliability (Hovens et al., 1994) is high across frequency (kappas range ■ The instrument has been used with diverse .92–1.00), intensity ratings (kappas range populations, including people who have .93–.98), and global severity ratings (r mental and substance use disorders score =.89) ■ The CAPS has been used with offenders ■ Internal consistency is quite good for (Spitzer et al., 2001; Trestman, Ford, frequency (alphas range .63–.85), intensity Zhang, & Wiesbrock, 2007) (alphas range .71–.81), and total score ■ The CAPS has demonstrated excellent (alpha = .94; Mueser et al., 2001) among psychometric properties (convergent, people who have severe mental disorders. discriminant, diagnostic validity, and Similar results were found among clinical sensitivity to clinical change) among and nonclinical samples, with alphas clinical and research populations ranging .71–.88 (Foa & Tolin, 2000) (Weathers, Keane, & Davidson, 2001) ■ Test-retest reliability of the CAPS over a ■ Relevant scales of the PCL are highly 2-week interval among people with severe correlated with the CAPS (r scores range mental disorders is acceptable (kappa = .63; .58–.74), supporting the convergent validity Mueser et al., 2001) and at a severity score of the CAPS (Palmieri, Weathers, Difede, of ≥ 65, reliability is higher (kappa = .90) & King, 2007). Additionally, in support of the concurrent validity of the CAPS, Concerns PTSD severity among veterans is higher for ■ The CAPS is quite lengthy to administer those with a history of arrest, depression, ■ A significant amount of training is required and substance use (Calhoun, Malesky, to conduct CAPS interviews Bosworth, & Beckham, 2005) ■ The CAPS is designed for research ■ In clinical and nonclinical samples, the purposes and may not be ideally suited for CAPS demonstrates high agreement with routine use in clinical settings the Posttraumatic Stress Scale-Interview (PSS-I) for diagnosis of PTSD, when ■ The psychometric properties of the CAPS employing scoring rules defined by have not been widely studied in criminal Blanchard et al. (1995; kappas ≥ .55; Foa & justice settings Tolin, 2000). The CAPS also demonstrates

131 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ The intensity ratings for individual PTSD of the PDS, including (1) a trauma checklist; symptoms may be difficult to ascertain (2) description of traumatic events provided by from the range of symptoms identified the respondent, with queries for injuries, serious ■ Scoring rules for diagnosis of PTSD using threats to life, helplessness, and terror; (3) the CAPS may vary by definition (see assessment of 17 DSM-IV PTSD symptoms; and Blanchard et al., 1995; Weathers, Ruscio, & 4) functional impairment. Total severity scores Keane, 1999), and liberal versus stringent on the PDS range 0–51. The recommended scoring criteria can result in different rates cut-off score for diagnosis of PTSD is ≥ 27. A of PTSD diagnosis, and inconsistencies in profile report can be generated that reviews PTSD diagnostic agreement between the CAPS diagnosis, symptom frequency, symptom severity, and other interview measures of PTSD and level of functional impairment. The PDS can (PSS-I; Foa & Tolin, 2000) be used for screening of PTSD symptoms and for Availability and Cost diagnosis of PTSD. The Clinician-Administered PTSD Scale for Positive Features DSM-5 (CAPS-5) is a public domain instrument ■ The PDS is highly recommended for that can be obtained at no cost via an online assessment of PTSD symptoms (Keane, request form at the following site: http://www. Silberbogen, & Weierich, 2008) ptsd.va.gov/professional/assessment/adult-int/ ■ The PDS is a commonly used tool among caps.asp the International Society for Traumatic Information regarding scoring of the CAPS-5 is Stress Studies (ISTSS; Elhai et al., 2005) available at the same website. In the past, a CAPS ■ The PDS has been used with offenders training manual and a CAPS training CD could (Harner, Budescu, Gillihan, Riley, & Foa be obtained from the National Center for PTSD, 2013; Messina, Grella, Cartier, & Torres operated by the U.S. Department of Veterans 2010; Sacks et al., 2008) Affairs. ■ Concurrent validity of the PDS is quite good (Foa, Cashman, Jaycox & Perry, The Life Events Checklist for DSM-5 (LEC-5) 1997), as demonstrated by strong is a public domain instrument and is available correlations with the State-Trait Anxiety for download at the following site: http://www. Inventory (STAI) and the IES-R ptsd.va.gov/professional/assessment/te-measures/ ■ The PDS demonstrates good diagnostic life_events_checklist.asp accuracy, with overall accuracy ranging 82–88 percent. At a cut-off score of 27, the Posttraumatic Stress Diagnostic Scale PDS also has acceptable sensitivity (67–89 percent), specificity (75–91 percent), and (PDS) negative predictive value (86–96 percent) The PDS (Foa, 1996) is a 49-item self-report among psychiatric outpatients and those measure that assesses severity (Criterion B, C, seeking treatment for PTSD, in addition to and D) of PTSD symptoms related to a traumatic those who are at high risk for trauma (Foa event. Items assess all DSM-IV criteria for et al., 1997; Sheeran & Zimmerman, 2002) PTSD. Current (past month) PTSD is addressed ■ Among sexual assault survivors, drinking and instructions can be adapted for other time problems to cope with PTSD symptoms is frames (e.g., lifetime). The PDS addresses a significant predictor of severity scores traumatic events experienced (Criterion A), on the PDS (Ullman, Filipias, Townsend, duration of symptoms (Criterion E), and functional & Starzynski, 2006). Moreover, severity impairment (Criterion F). There are four sections scores on the PDS are significantly correlated with alcohol problems as

132 Instruments for Screening and Assessing Co-Occurring Disorders

measured by the MAST (Ullman, Filipias, 17 items that assess DSM-IV PTSD symptoms Townsend, & Starzynski, 2005) related to re-experiencing (items 1–5), avoidance ■ The PDS shows high internal consistency (items 6–12), and hyperarousal (items 13–17). across domains (alphas range .78–.92; Foa Items inquire about frequency and severity. et al., 1997) Scoring is calculated by summing items within ■ Test-retest reliability of the PDS is quite each domain, and a total score is obtained by good for diagnosis (kappa = .74) and summing all 17 items across domains. A diagnosis severity scores (r scores range .77–.85) is made based on achieving a score of “2” or more among those endorsing a traumatic in each domain. The PSS-I asks about current experience (Foa et al., 1997) PTSD symptoms (past month or past 2 weeks). The PSS-I requires approximately 15–25 minutes Concerns to administer. ■ The PDS has not been extensively studied in adult criminal justice settings Positive Features ■ The PDS may overdiagnose PTSD, as ■ The PSS-I is a brief semi-structured indicated by high rates of “false positives” interview that performs as well as the among a sample of domestic violence CAPS in assessing PTSD and is briefer survivors (Griffin, Uhlmansiek, Resick, & to administer (International Society for Mechanic, 2004). Thus, caution should be Traumatic Stress Studies, 2013) exercised when interpreting PDS scores ■ The PSS-I has been used successfully among certain populations (Keane et al., among people who have severe 2008) mental disorders (Brunet, Birchwood, ■ The PDS is highly correlated with the Upthegrove, Michail, & Ross, 2012; BDI, and as such, the instrument may not O’Hare, Sherrer, & Shen, 2006), offenders provide adequate discriminant validity (Sacks, McKendrick, & Hamilton, 2012), in distinguishing between depressive people with substance use problems symptoms and PTSD (Foa et al., 1997; (Foa & Williams, 2010; Reynolds et Norris & Hamblen, 2004) al., 2005), those with co-occurring PTSD and substance use disorders (Foa ■ The self-report nature of the PDS may & Williams, 2010; Riggs, Rukstalis, detract from its validity in diagnosing Volpicelli, Kalmanson, & Foa, 2003), and PTSD in community samples (Bedard-Gilligan, Availability and Cost Jaeger, Echiverri-Cohen, & Zoellner, 2012; O’Hare, Sherrer, Yeamen & Cutler, 2009) The PSD has been updated to the PDS-5 for the Diagnostic and Statistical Manual of Mental ■ The diagnostic accuracy of the PSS-I is Disorders, 5th Edition. To obtain the PDS-5 with quite good in clinical and nonclinical information about its administration and use, samples (Foa & Tolin, 2000), with sensitivity ranging 71–86 percent and please contact Ellen Kubis at the University of specificity ranging 78–100 percent for Pennsylvania’s Center for the Treatment and Study different scoring approaches (Blanchard of Anxiety at [email protected]. et al., 1995; Weathers et al., 1999). An earlier study reports similarly high rates of Posttraumatic Symptom Scale– sensitivity (.97; Foa et al., 1993) Interview Version (PSS-I) ■ Agreement between the PSS-I and CAPS diagnoses of PTSD ranges 70–86 percent The PSS-I is a semi-structured interview that in clinical and nonclinical samples (Foa & provides both diagnosis of PTSD and assessment Tolin, 2000) of PTSD symptom severity. The PSS-I includes

133 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ Convergent validity for the PSS-I among posttraumatic-symptom-scale-interview-version. clinical and nonclinical samples is good, aspx as evidenced by strong correlations with the CAPS and its domains (r scores range Recommendations for Trauma/PTSD .63–.87; Foa & Tolin, 2000). Moreover, Screening, Assessment, and Diagnostic the correlations between the PSS-I and the Instruments SCID module for PTSD are equivalent to those between the CAPS and the SCID Information regarding screening and diagnostic instruments for trauma and PTSD is based on ■ Among people who have severe mental disorders, subjective distress as a critical review of the literature and research indicated by the PSS-I is related to high comparing the efficacy of these instruments. risk behaviors, including drinking and Factors considered in recommending specific attempted suicide (O’Hare et al., 2006) instruments include empirical evidence supporting the reliability and validity of the ■ In support of the PSS-I’s concurrent validity, among those with substance use instrument, relative cost of the instrument, ease and mental disorders, people diagnosed of administration, and use in the justice system. with PTSD using the PSS-I have Although summaries of the instruments included significantly higher scores on the Addiction research that was based on the DSM-IV criteria, Severity Index for medical problems and recommendations are made considering the degree higher rates of psychoticism, as measured to which instruments align closely with the new by the Brief Symptom Inventory (Reynolds DSM-5 criteria and allow for a more seamless et al., 2005) transition to the new classification system. As ■ The internal consistency of the PSS-I noted before, although trauma/PTSD screening is quite good (alphas range .65–.86) in can be conducted by nonclinicians through use clinical and nonclinical samples (Foa & of standardized self-report instruments, screening Tolin, 2000) staff should be knowledgeable about appropriate ■ The PSS-I has good interrater reliability referral sources and the nature of trauma and across domains, with agreement ranging PTSD. Offenders who screen positively as having 94–99 percent (Foa et al., 2005; Foa & significant problems related to trauma and PTSD Tolin, 2000). An earlier study reported should be referred for a comprehensive assessment similar results (kappa = .91; Foa et al., to be conducted by a trained and licensed/certified 1993) mental health professional.

Concerns Based on the review of the literature and ■ The PSS-I has not been studied extensively previously described considerations, the following in criminal justice settings screening instruments are recommended to ■ The generalizability of the PSS-I to a examine the history of traumatic events and PTSD: range of clinical settings has not yet been 1. Either the Trauma History Screen (THS), or established the Life Stressor-Checklist (LSC-R), or the ■ Test-retest reliability of the PSS-I has not Life Events Checklist-5 (LEC-5) to identify been widely examined exposure to traumatic events.

Availability and Cost (and) The PSS-I is a public domain instrument and can be downloaded without charge at the following 2. The Posttraumatic Stress Disorder Checklist site: http://www.istss.org/assessing-trauma/ for DSM-5 (PCL-5) to identify trauma symptom severity.

134 Instruments for Screening and Assessing Co-Occurring Disorders

This combined screen requires approximately A caveat to the use of motivational screens in 15–20 minutes to administer and score. For matching people who have CODs to treatment in individuals who screen positive to the previous set the criminal justice system is that this population is of screens and for whom a more comprehensive not typically motivated to participate in treatment assessment and/or diagnosis is needed, the and has a wide range of other psychosocial issues following instruments are recommended: (e.g., housing, financial support) and personality factors (e.g., antisocial cognitions and attitudes) 1. The Posttraumatic Symptom Scale (PSS-I), that may take precedence over treatment. Thus, which provides a current diagnosis of PTSD. motivation should not be viewed as a predicate for (or) placing offenders in treatment. Instead, techniques aimed at increasing self-efficacy (setting small 2. The Posttraumatic Diagnostic Scale (PDS), obtainable goals during treatment) and motivation which serves as both a screen and diagnostic (e.g., motivational interviewing techniques) instrument. for those who lack motivations and who are ambivalent about change can improve treatment (or) outcomes in the justice system (CSAT, 2005b). 3. The Clinician Assisted PTSD Scale for DSM- It is important to note several concerns regarding 5 (CAPS-5).These assessment and diagnostic the validity of motivational screening instruments. tools require approximately 25–30 minutes to First, not all of these instruments provide administer and score. equivalent types of assessment of readiness for change, as some do not directly align with the Screening Instruments for stages of changes (e.g., SOCRATES), as defined Motivation and Readiness for by the transtheoretical model (TTM; Prochaska, Treatment DiClemente, & Norcross, 1992). Moreover, these instruments may provide variable results in Several brief screening instruments have been assigning offenders to different “stages of change” developed to examine motivation and readiness or in identifying readiness for treatment, resulting for behavioral health treatment. These are in matching individuals to different levels of sometimes used to identify individuals who treatment. Thus, these measures should not be are inappropriate for admission to substance used as the primary tools to accomplish treatment use treatment, to flag issues that are important matching. to address in early stages of treatment, and to monitor changes in motivation and readiness over Screening Instruments for Motivation the course of treatment. Although motivational and Readiness for Treatment screens are not always provided during the intake process, they may be used in different settings to Circumstances, Motivation, Readiness, determine readiness for change. Motivation and and Suitability Scale (CMRS) readiness for treatment have been found to predict treatment outcomes (Hiller, Knight, Leukefeld, The CMRS (DeLeon & Jainchill, 1986) was & Simpson, 2002; Olver, Stockdale, & Wormith, developed to assess risk for dropout from a 2011), including retention in and graduation from therapeutic community (TC) program and to treatment programs, and may be particularly identify participants most likely to remain in useful in matching individuals to different levels substance use treatment. The CMRS is a 42- or “stages” of treatment. Motivation screens can item scale that takes approximately 30 minutes be administered as a repeated measure to monitor to complete. The instrument has four subscales, progress over time. Circumstances, Motivation, Readiness, and

135 Screening and Assessment of Co-Occurring Disorders in the Justice System

Suitability, that measure (1) external pressures to ■ Among offenders enrolled in TC programs, seek treatment; (2) internal reasons to seek change; treatment motivation scores on the CMR (3) perceived need for treatment to achieve predict treatment readiness (Morgen & change; and (4) acceptance of the TC approach, Kressel, 2010) reflected by the willingness to make major lifestyle ■ Among offenders in TC programs, changes, long-term commitment to an intensive treatment motivation as indexed by the treatment program, and rejection or exhaustion of CMRS is related to environmental factors, other treatment modalities or options. A shortened such as understanding the rules of conduct 18-item version of the instrument (CMR) includes and treatment goals (Goethals et al., 2012) three subscales: Circumstances, Motivation, and ■ Treatment motivation as indexed by the Readiness. CMR is directly related to treatment alliance, treatment participation, and Positive Features treatment outcomes (Melnick et al., 2001) ■ The CMRS is widely used among offenders ■ The CMRS is useful in predicting 30-day (DeLeon, Melnick, Thomas, Kressel, & retention in long-term TC treatment in the Wexler, 2000; Goethals, Vanderplasschen, community (DeLeon et al., 1994) Van de Velde, & Broekaert, 2012; ■ Young (2002) found that external factors Fiorentine, Nakashima, & Anglin, 1999; measured by the Circumstances scale of Melnick, DeLeon, Thomas, Kressel, & the CMRS predicted 90-day retention of Wexler, 2001) and people with substance criminal justice clients in community-based use disorders (Battjes, Gordon, O’Grady, residential treatment programs, while the Kinlock, & Carswell, 2003; DeLeon, Readiness scale of the CMRS predicted Melnick, & Cleland, 2010; Gholab & 180-day retention Magor-Blatch, 2013; Najavits et al., 1997) ■ Melnick et al. (1997) found that age was ■ The CMRS consistently predicts retention significantly correlated with scores on the and entry into prison-based TCs and entry CMRS and that the instrument successfully into aftercare TCs following release from predicted short-term retention rates in TC custody (DeLeon, Melnick, Thomas, treatment across age groups Kressel, & Wexler, 2000) ■ DeLeon, Melnick, Kressel, and Jainchill ■ The abbreviated CMR instrument predicts (1994) found that CMRS scales are involvement in substance use aftercare more effective predictors of 30-day and treatment following release from prison 10-month treatment retention than a range (Melnick, DeLeon, Hawke, Jainchill, & of demographic and background variables, Kressel, 1997) including legal status ■ Among participants in the Drug Abuse ■ People mismatched to treatment in the Treatment Outcome Study (DATOS), DATOS had significantly lower CMR scores on the treatment readiness scale treatment motivation scores at baseline in of the CMRS predict treatment retention comparison to those who were properly across treatment settings, supporting the matched to treatment (DeLeon et al., 2010) predictive validity of the measure (Joe, Simpson, & Broome, 1999) ■ Higher motivation for mental health treatment as indexed by the CMR predicts ■ The CMR is positively related to aftercare greater adherence to treatment among involvement in prisoners enrolled in TCs, psychiatric patients (Magura, Mateu, and higher scores on the CMR predict Rosenblum, Matusow, & Fong, 2014) aftercare entry and lower reincarceration rates at a 1-year follow-up (Melnick et al., ■ The CMR has good predictive utility 2001) for treatment outcomes across race and

136 Instruments for Screening and Assessing Co-Occurring Disorders

ethnicity (DeLeon, Melnick, Schoket, & Readiness for Change Questionnaire Jainchill, 1993) (RCQ) ■ Reliability of the CMRS total score as measured by Cronbach’s alpha is .84 The RCQ (Rollnick, Heather, Gold, & Hall, (Melnick et al., 2001), and reliabilities 1992) is a 12-item measure based on the for individual scale scores range from .53 transtheoretical “stages-of-change” model, for the Circumstances scale to .84 for the developed by Prochaska and DiClemente (1992). Readiness scale The instrument was originally developed to identify specific stages of change among heavy ■ The CMRS has good internal consistency (alphas = .84–.87; .67–.83; DeLeon et al., drinkers who are not seeking treatment, but it 1994; Goethals et al., 2012, Melnick, 1999) has been used far more broadly among a range of substance-involved populations. The RCQ- Concerns CV (clinician's version) consists of three scales, ■ CMRS scores vary significantly for Pre-contemplation, Contemplation, and Action, offenders of differing intellectual each consisting of four items. Item responses functioning (Van de Velde, Broekaert, are provided on a five-point scale ranging from Schuyten, & Van Hove, 2005) “strongly agree” to “strongly disagree,” with ■ The CMRS items are related to TCs, and higher scores on the RCQ representing greater thus, the instrument may not generalize willingness to change. The 15-item RTCQ-TV to other treatment settings for assessing (treatment version) was designed for individuals circumstances, motivation, and readiness in treatment or who are seeking treatment for change (Groshkova, 2010; Zemore & (Share, McCrady, & Epstein, 2004) and is used Ajzen, 2014) to determine the level of readiness to engage in ■ The validity of the CMRS has not been treatment and to assist in treatment planning. A examined among individuals with CODs revised 12-item version of the RTCQ-TV is also ■ The CMRS has not been thoroughly available (Heather & Honekopp, 2008). Both evaluated to determine its usefulness in the RCQ-CV and RTCQ-TV take approximately predicting retention in jail or community- 2–3 minutes to administer, are designed for both based offender treatment programs adolescents and adults, and are available in the ■ Circumstances scale scores have low public domain. The RCQ has been adapted to reliability (Van de Velde et al., 2005) measure readiness to change in other areas, such as violent behavior, criminal behaviors, and anger ■ The Circumstances scale may consist of two factors, Pressures to Enter Treatment, problems. Neither instrument requires training to and Pressures to Leave Treatment (DeLeon administer or score. et al., 2000), thus explaining difficulties related to low reliability. Caution should be Positive Features used when interpreting this scale ■ The RCQ is brief to administer ■ The self-administered format of the RCQ is Availability and Cost advantageous for use in hospital and other The CMRS manual and instruments can be settings in which there is limited time to obtained free of charge at the following site: http:// compile information (Rollnick et al., 1992). www.emcdda.europa.eu/html.cfm/index3597EN. The RCQ has been used with several html offender populations (Casey, Day, Howells, & Ward, 2007; Day et al., 2009; McMurran et al., 1998; Watt, Shepherd, & Newcombe, 2008) and with people with substance use disorders (Freeman et al., 2005; Heather,

137 Screening and Assessment of Co-Occurring Disorders in the Justice System

Luce, Peck, Dunbar, & James, 1999; significantly more injection drug use Gregoire, & Burke, 2004; Share, McCrady, relative to those in the action stage. People & Epstein, 2004; Wells-Parker, Kenne, scoring in the pre-contemplation range also Spratke, & Williams, 2000) remained in treatment for fewer weeks than ■ The RCQ has been adapted for use with those scoring in the contemplation range offenders (Readiness to Change Offending, (Napper et al., 2008) RCOQ) to address motivation to change ■ People who had received substance use criminal behaviors (McMurran et al., 1998) treatment were more likely to receive ■ The RCQ is related to a newly developed RCQ scores in the action stage. Moreover, offender instrument that examines readiness those who had better treatment outcomes for change, the Corrections Victoria were more likely to be in the action or Treatment Readiness Questionnaire contemplation stage compared with (CVTR), and demonstrates moderate to those who had poor treatment outcomes, strong correlations with the CVTR scales supporting the validity of the measure for (Casey et al., 2007) assessing readiness for change (Heather et al., 1999) ■ The RCQ has been adapted to measure readiness to change violent behaviors ■ The RCQ’s validity is supported among among offenders and is correlated a sample of offenders who were court- with another treatment readiness scale, mandated to outpatient substance use the Violence Treatment Readiness treatment because they were more likely Questionnaire (VTRQ; Day et al., 2009) to be in the action or contemplation stage compared to those not receiving treatment, ■ Convergent validity of the RCQ among even after controlling for level of substance people involved in substance use treatment use problems (Gregoire & Burke, 2004) is supported by correlations with another well-validated measure of readiness for ■ In a sample of repeat DUI offenders, those change, the URICA (r scores range .39–.56; determined to be in the contemplation Heather et al., 1999) stage by the RCQ for changing level of alcohol consumption had higher self- ■ Violent offenders who received no efficacy for controlling their drinking and intervention were more likely to be in had lower levels of alcohol consumption the pre-contemplation stage for changing relative to those in the pre-contemplation drinking behaviors compared to those stage (Freeman et al., 2005). Another receiving a treatment intervention, study (Wells-Parker et al., 2000) indicates supporting the validity of the RCQ in that those determined to be in the action assessing readiness for change (Watt et al., stage by the RCQ for reducing drinking 2008) and driving behaviors have lower rates ■ Convergent validity of the instrument of criminal recidivism. These studies is also indicated among people with support the concurrent validity of the RCQ substance use disorders, in which RCQ instrument scores indicating pre-contemplation, ■ Several other studies demonstrate the contemplation, and action stages are related discriminant and convergent validity of the to scores from the URICA, another well- RCQ in measuring readiness for change validated measure of readiness for change among DUI offenders (Freeman et al., (Napper et al., 2008) 2005; Wells-Parker & Williams, 2002) ■ Support for the concurrent validity of ■ The RCQ has good predictive validity for the RCQ is provided among a substance- changes in drinking behavior over time involved sample, in which people scoring (Share, McCrady, & Epstein, 2004) in the pre-contemplation range showed

138 Instruments for Screening and Assessing Co-Occurring Disorders

■ The revised RCQ-TV shows a good fit (alpha = .60–65; Heather et al., 1999; with a three-factor structure, supporting the Napper et al., 2008) three scales of the RCQ-TV (Heather & ■ The revised RCQ-TV shows low internal Honekopp, 2008) consistency for the Pre-contemplation ■ The revised RCQ-TV total scale score (alpha = .66) and Contemplation scales shows good internal consistency (alpha (alpha = .66; Heather & Honekopp, 2008) > .70), particularly for the Action scale ■ The RCQ (McMurran et al., 1998) (alpha = .85; Heather & Honekopp, 2008). shows low internal consistency for the Previous studies indicated that the RCQ Pre-contemplation (alpha = .60) and has satisfactory internal consistency, Contemplation (alpha = .49) scales with Cronbach’s alphas of .73 for the Pre-contemplation subscale, .80 for the Availability and Cost Contemplation scale, .85 for the Action The RCQ is copyrighted but is available free of scale (Rollnick et al., 1992; Napper et al., charge. 2008), and .71 for the entire scale (Day et al., 2009) The RCQ–CV measures and related materials ■ Test-retest reliability for the RCQ scales can be accessed at no cost at the following site, has been found to be satisfactory (Rollnick which includes information regarding scoring, et al., 1992), with correlations of .82 (Pre- interpretation, and reliability and validity of the contemplation), .86 (Contemplation), and instrument: http://www.addiction.ucalgary.ca/ .78 (Action). Test-retest reliability of the researchers/instruments RCQ among those enrolled in substance use treatment is quite good over a 3-day The revised RCQ-TV can be obtained at the interval (r scores range .69–.86 across RCQ following site, as part of a manuscript describing scales; Heather et al., 1999). Good test- the validity of the instrument. Scoring and retest reliability of the revised RCQ-TV interpretation guidelines are provided in the has also been demonstrated among people manuscript appendices: http://www.researchgate. enrolled in alcohol treatment (r scores net/publication/232067129_A_revised_edition_ range .76–.88) for all stages of change, over of_the_Readiness_to_Change_Questionnaire_ a 3-month interval (Heather & Honekopp, Treatment_Version 2008)

Concerns Stages of Change Readiness and ■ The validity of the RCQ has not been Treatment Eagerness Scale (SOCRATES) widely studied among offenders and The SOCRATES provides a family of instruments additional research on its psychometric properties among this population is needed designed to examine readiness for change among substance-involved populations, according ■ Little evidence has been found to support to the “stages-of-change” model (Prochaska concordance between interviewer- & DiClemente, 1992). The SOCRATES was determined stage of change and stage of change assessed by the RCQ (kappas range developed through funding by the National .08–.45; Addington, El-Guebaly, Duchak, Institute on Alcohol Abuse and Alcoholism & Hodgins, 1999) (NIAAA) and is a “public domain” instrument. The original instrument provided five separate ■ The internal consistency of the RCQ may scales corresponding with the stages-of-change be somewhat low (alpha = .69; Casey et al., 2007), particularly for the Pre- model, while a more recent factor analysis of the contemplation scale (alpha = .68; Napper SOCRATES has led to the development of three et al., 2008) and the Contemplation scale scales: Ambivalence, Recognition, and Taking

139 Screening and Assessment of Co-Occurring Disorders in the Justice System

Steps, each of which reflects different stages ■ The Recognition and Taking Steps scales of motivation and readiness for treatment. The of the SOCRATES have been identified SOCRATES is often used as a repeated measure as important factors in motivation for to assess change in motivation over time related change and are reliably distinguishable in to involvement in motivational interviewing the beginning of treatment (Carey, Maisto, interventions and substance use treatment. The Carey, & Purnine, 2001; Isenhart, 1997; 19-item version has the following recommended Miller & Tonigan, 1996) cut-off scores for the Recognition scale: low ■ Scores on the SOCRATES are correlated scores are ≤30, medium scores are 31–34, and with attempts to quit both alcohol and drug high scores are ≥35. For the Ambivalence scale, use (Henderson, Saules, & Galen, 2004; cut-offs for low scores are ≤ 13, medium scores Isenhart, 1997; Zhang et al., 2004) are 14–16, and high scores are ≥ 17. ■ In support of the concurrent validity of the SOCRATES 19-item version, people Several versions of the SOCRATES have been scoring higher on the Recognition scale developed for different populations, including the have greater drug use and symptoms of following: depression and anxiety than people scoring higher on the Taking Steps scale (Gossop et ■ 8D/A (19 items)—drug and alcohol al., 2007) questionnaire for clients ■ Also supporting the concurrent validity ■ 7A-SO-M (32 items)—alcohol of the SOCRATES 19-item instrument, questionnaire for significant others of people with substance use disorders who males spent a shorter amount of time in drug ■ 7A-SO-F (32 items)—alcohol questionnaire treatment were more likely to score at for significant others of females the Pre-contemplation stage compared to ■ 7D-SO-F (32 items)—drug and alcohol those scoring at the Determination and questionnaire for significant others of Action stage. Those scoring at the Action females stage also had significantly fewer days of drug use than people who were at the ■ 7D-SO-M (32 items)—drug and alcohol Pre-contemplation and Determination stage questionnaire for significant others of (Napper et al., 2008) males ■ In a sample of nonviolent offenders Positive Features who had committed drug crimes, the ■ The instrument is brief to administer and is SOCRATES Recognition scale predicted easily scored arrests within the past 12 months, and both the Ambivalence and Taking Steps scales ■ The SOCRATES has been used with a predicted drug arrests during the past 12 range of offender populations (Brocato months (Prendergast et al., 2009) & Wagner, 2008; Evans, Huang, & Hser, 2011; Morris & Moore, 2009; Prendergast ■ Among offenders with alcohol use et al., 2009; Vanderburg, 2003) and people problems, those who received a with substance use disorders (Gossop, motivational interviewing intervention Stewart, & Marsden, 2007; Kelly, Finney, scored higher on the Recognition scale of & Moos, 2005; Napper et al., 2008; Zhang, the SOCRATES, in addition to change from Harmon, Werkner, & McCormick, 2004) the Pre-contemplation to Contemplation and is commonly used with offenders stage of change, as measured by the to assess readiness for change (Gunter, University of Rhode Island Change Antoniak, 2010) Assessment Scale (URICA) and RCQ, supporting the convergent validity of the

140 Instruments for Screening and Assessing Co-Occurring Disorders

SOCRATES 19-item instrument (Mann, ■ The SOCRATES Recognition scale has Ginsburg, & Weekes, 2002) moderately good sensitivity and specificity ■ In a study of offenders who were court- in identifying substance-dependent mandated to substance use treatment, offenders (Peters & Greenbaum, 1996) those who remained longer in treatment Concerns had significantly higher total scores on the SOCRATES compared to dropouts, ■ The validity of the SOCRATES has not supporting the validity of the measure been widely examined among individuals (Brocato & Wagner, 2008). The with CODs SOCRATES total score also predicted ■ The SOCRATES may contain some length of treatment stay, and the confusing and ambiguous language, which Recognition scale predicted therapeutic can detract from effective assignment of alliance and length of treatment stay across individuals to different stages of change. groups differing by race/ethnicity and type The determination of stages of change by of primary drug use the SOCRATES is not always consistent ■ The SOCRATES ambivalence scale with stages of change determined by other shows reliable and clinically significant measures, such as by the RCQ (Burrowes change from pre to post-treatment among & Needs, 2009; Lechner, Brug, De Vries, offenders, supporting its ability to assess van Assesma, & Muddle, 1998; Littell & change in motivation over time (Morris & Girvin, 2002; Williamson, Day, Howells, Moore, 2009) Bubner, & Jauncey, 2003) ■ In a sample of substance-involved military ■ The SOCRATES may not be able to clearly personnel, the SOCRATES Ambivalence, distinguish among the five stages of change Recognition, and Taking Steps scales (DiClemente, Schlundt, & Gemmell, 2004) are related to commitment to abstinence, ■ Although a study conducted by Nochajski disease attribution, and powerlessness, and Stasiewicz (2005) did not support the as measured by the Addiction Treatment use of the SOCRATES with DUI offenders, Attitude Questionnaire (ATAQ; Mitchell & the Ambivalence and Recognition subscales Angelone, 2006). The same study found were found to be associated with binge that the SOCRATES Ambivalence scale is drinking related to treatment completion, supporting ■ The SOCRATES 19-item version may the concurrent validity of the measure not detect changes in motivation among ■ Internal consistency coefficients for the drug-involved offenders who received a SOCRATES are quite good, with alphas motivational interviewing intervention, as ranging .81.–93 for the Recognition well as the RCQ (Vanderburg, 2003) scale, .84–88 for Taking Steps, and .71 ■ Not all subscales of the SOCRATES may for Ambivalence (Gossop et al., 2007; be useful in predicting treatment retention. Mitchell, Francis, & Tafrate, 2005; Brocato For example, the Ambivalence and Taking & Wagner, 2008) Steps scales were not found to predict ■ The test-retest reliability of the SOCRATES length of stay in treatment among offenders is quite high among correctional (Brocato & Wagner, 2008) populations (Peters & Greenbaum, 1996). ■ The SOCRATES may be more useful when Test-retest reliability (Miller & Tonigan, used in combination with the URICA to 1996) of the SOCRATES over a 2-day assess readiness to change (DiClemente et interval is also quite good across different al., 2004) scales, including Ambivalence (r score ■ In a review of the existing literature, = .83), Recognition (r score = .99), and DiClemente, Schlundt, and Gemmell Taking Steps (r score = .93)

141 Screening and Assessment of Co-Occurring Disorders in the Justice System

(2004) found only modest support for the treatment. The TCU MOTForm can be used prior predictive validity of the SOCRATES to treatment to examine motivation and readiness ■ Research provides support for both for change and as a repeated measure to monitor two- and three-factor structures for the change over time. It was developed for criminal SOCRATES (Demmel, Beck, Richter, & justice settings. Reker 2004; Figlie, Dunn, & Laranjeira, 2005; Mitchell et al., 2005) and indicates Positive Features that the number of items could be reduced ■ The TCU MOTForm is brief to administer, ■ The internal consistency of the SOCRATES score, and interpret is low when used to determine readiness ■ The TCU MOTForm was developed for use for change via stages of change (Hodgins, in criminal justice settings 2001) that include Pre-contemplation, ■ A greater desire for help (DH) as measured Contemplation, Determination, and by the TCU MOTForm is related to greater Maintenance, with alphas < .61 (Napper et treatment participation (Joe, Simpson, al., 2008) Greener, & Rowan-Szal, 1999) ■ Internal consistency of the Ambivalence ■ Treatment readiness (TR) as measured by scale is low (alpha = .38; Gossop et al., the TCU MOTForm is related to improved 2007) post-treatment outcomes (Joe, Simpson, ■ The SOCRATES exhibits low agreement Greener et al., 1999; Simpson, Joe, with other validated measures of readiness Greener, & Rowan-Szal, 2000) to change, such as the URICA and RCQ, ■ Among offender and community-based across the various stages of change (<40 treatment samples, the TCU MOTForm percent agreement; Napper et al., 2008) scales of PR, DH, and TR are correlated with treatment engagement, satisfaction, Availability and Cost counselor rapport, and peer support (Joe, The SOCRATES is available free of charge at Simpson, & Broom, 1999; Pankow et al., the following site: http://casaa.unm.edu/inst/ 2012; Simpson et al., 2000; Simpson et al., socratesv8.pdf 2012). The DH, TR, and TN scales also predict significant variance in treatment participation, supporting the predictive Texas Christian University Motivation validity of the scales (Simpson et al., 2012) Form (TCU MOTForm) ■ Across gender groups among offender The TCU MOTForm is a 36-item instrument samples, people with higher scores on that examines not only readiness for change but the TCU MOTForm have higher levels also motivation and readiness for treatment. of treatment participation, supporting the Items are worded specifically for drug-involved validity of the measure (Simpson et al., populations. The instrument includes five scales, 2012) including Problem Recognition (PR), Desire for ■ Across prison and community-based Help (DH), Treatment Readiness (TR), Pressures treatment settings, the TCU MOTForm for Treatment (PT), Treatment Needs (TN), and scales are related to scales from the Accuracy (Attentiveness). Accuracy is a single Addiction Severity Index (ASI). item that identifies whether the respondent is Specifically, the PR, DH, and TN scales paying attention while completing the measure. are positively related to higher scores Respondents indicate how strongly they agree or on the psychiatric, medical, legal, drug, disagree with the statement on a one (disagree alcohol, and employment scales of the ASI, strongly) to five (agree strongly) scale. Higher supporting the concurrent validity of the TCU MOTForm (Pankow et al., 2012) scores indicate higher levels of motivation for

142 Instruments for Screening and Assessing Co-Occurring Disorders

■ Among offenders, higher scores on the Availability & Cost TCU MOTForm (particularly the DH, TR, The TCU MOTForm is available in the public and TN scales) are negatively correlated domain, and the instrument along with materials with criminal thinking scales such as power related to scoring and interpretation can be found orientation, coldheartedness, criminal at the following site: http://ibr.tcu.edu/forms/ rationalization, and entitlement (Garner, Knight, Flynn, Morey, & Simpson, 2007), treatment-motivation-scales/ supporting the concurrent validity of the TCU MOTForm University of Rhode Island Change ■ An exploratory factor analysis of the Assessment Scale (URICA) MOTForm instrument shows a good fit for each scale, as evidenced by a single factor The URICA (DiClemente & Hughes, 1990; structure for each subscale (Simpson et al., McConnaughy, Prochaska, & Velicer, 1983) 2012) includes 24-, 28-, and 32-item versions of the self-report questionnaire examining motivation ■ The TCU MOTForm has good internal and readiness for treatment. The 32-item consistency for each scale, PR (alpha = .87–.90), DH (alpha = .66–.81), TR (alpha URICA consists of four scales made up of 8 = .75–.84), and TN (alpha = .64), in both items each, while the 28-item and the 24-item community and criminal justice settings versions have four scales consisting of 7 and (Garner et al., 2007; Simpson et al., 2012; 6 items, respectively. The 24-item version has Simpson & Joe, 1993) been adapted to those with CODs (URICA-M). The URICA-M uses simpler language, defines ■ The test-retest reliability of the TCU MOTForm is quite high over a 2-week problems identified by the instrument with interval (r scores range .74–.88) the respondent, and can be administered as an interview for those who have problems related to Concerns literacy or sight. A 12-item version of the URICA ■ Additional research is needed regarding the is available that examines readiness to change predictive validity of the TCU MOTForm drinking behaviors and includes four scales. The in criminal justice and community settings four scales were developed to examine each of the and with populations who have CODs theoretical stages of change (Pre-contemplation, ■ The TCU MOTForm scales of TN and DH Contemplation, Action, and Maintenance) may have lower internal consistency (alpha related to individual motivation for treatment = .64–.67) in comparison to the other scales (DiClemente & Prochaska 1982, 1985; Prochaska (Garner et al., 2007; Simpson et al., 2012) & DiClemente, 1992). ■ A confirmatory factor analysis provides The URICA appears to identify two distinctive inconsistent results to support a single factor structure for each scale, and some subtypes: pre-contemplation and contemplation/ scales may be multidimensional in nature. action (Blanchard, Morgenstern, Morgan, The authors of the MOTForm report that Labouvie, & Bux, 2003; Edens & Willoughby, these results may be due to combining 1999, 2000). Readiness to change (RTC) can results obtained prior to treatment with be calculated from the URICA instrument by those obtained during the course of subtracting mean Pre-contemplation scores treatment, at which time the meaning from Contemplation, Action, and Maintenance of motivation and readiness may have scores (Connors et al., 2000; Project MATCH changed with treatment progress (Garner et Research Group, 1997). A Contemplative Action al., 2007; Simpson et al., 2012) score (CA) can be calculated by subtracting mean Contemplation scores from Action scores

143 Screening and Assessment of Co-Occurring Disorders in the Justice System

(Pantalon, Nich, Frankforter, & Carroll, 2002). 2008) such that those determined to be in later stages of change (higher scores on The following cut-off scores may be appropriate contemplation, action and maintenance) for the general population: < 8 to be classified report less psychological aggression against as “Pre-contemplators,” 8–11 to be classified their partner during the previous 6 months as “Contemplators,” and 11–14 to be classified as “Preparators into Action Takers.” URICA ■ The URICA’s validity in assessing readiness for change is demonstrated scale scores may vary across different settings in outpatient substance use treatment and stages of change in the particular settings. settings (Field, Duncan, Washington, & Thus, use of the URICA to classify individuals Adinoff, 2007), where RTC scores are to various stages of change should consider correlated with increased anger problems profiles generated from the particular setting that and experience of recent life stressors, correspond with stages of change in that setting. suggesting that RTC reflects the desire to The URICA differs from the SOCRATES and change and seek help. In these settings, several other motivational screens in that it does CA scores are negatively correlated with not directly ask about motivation for alcohol or alcohol problems and anxiety, indicating drug treatment but instead presents questions in that CA may reflect commitment to a more general manner. The URICA does not change substance use behaviors. Three require clinical training to administer or score. studies involving outpatient substance use treatment participants (Budney et al., Positive Features 2000; Budney et al., 2006; Jungerman et ■ The URICA is brief to administer and score al., 2007) found that URICA scores were negatively correlated with marijuana use ■ The URICA has been used with offender and related problems after treatment, populations (Alexander & Morris, 2008; supporting the concurrent validity of the Brodeur, Rondeau, Brochu, Lindsay, & URICA (Callaghan et al., 2008) Phelps 2008; Levesque, Gelles, & Velicer, 2000; Polaschek, Anstiss, & Wilson, 2010; ■ Support for the convergent and concurrent Tierney & McCabe, 2004), people with validity of the URICA has been shown substance use disorders (Callaghan et al., in outpatient treatment settings, in which 2008; Budney, Higgins, Radnovich, & higher RTC scores are correlated with more Novy, 2000; Budney, Moore, Rocha, & severe drug and alcohol problems (Field Higgins, 2006; Field, Adinoff, Harris, Ball, et al., 2009), while higher CA scores are & Carroll, 2009; Jungerman, Andreoni, associated with less severe alcohol and & Laranjeira, 2007), and those with drug use problems and less severe familial CODs (Bellack et al., 2006; Kinnaman, and medical problems (Field et al., 2009) Bellack, Brown, & Yang, 2007; Nidecker, ■ The validity of the URICA has also been DiClemente, Bennett, & Bellack, 2008) demonstrated among people with CODs. ■ The URICA has been adapted for domestic Among this population, higher psychiatric violence offenders (URICA-DV), and the distress is correlated with endorsement of instrument properties are consistent with negative aspects of drinking and higher the original URICA four-scale model. The scores on the Maintenance scale of the URICA-DV shows good psychometric URICA, indicating greater difficulties in properties and is correlated with domestic attempts to maintain sobriety (Velasquez, violence behaviors such as history of Carbonari, & DiClemente, 1999) violence, blame, and changing violent ■ In support of the convergent validity of the behaviors (Levesque et al., 2000) URICA among people who have CODs, ■ The URICA-DV demonstrates good the URICA-M is correlated with other concurrent validity (Alexander & Morris, measures of change, such as the Process

144 Instruments for Screening and Assessing Co-Occurring Disorders

of Change Scale (POC; DiClemente, Tierney & McCabe, 2004). Internal Carbonari, Addy, & Velazquez, 1996) consistency of the URICA is also good and its subscales and the “cons” of drug when applied to changing substance use use from the Decisional Balance Scale behaviors, for scales of Pre-contemplation (DBS; Velicer, DiClemente, Prochaska, (alphas range .73–.80), Contemplation & Brandenburg, 1985). The relationship (alphas range .72–.90), Action (alphas between the POC and the URICA-M are range .71–.81), and Maintenance (alphas strongest among depressed individuals range .67–.74; Field et al., 2009; Nidecker (Nidecker et al., 2008) et al., 2008) ■ The URICA is able to discriminate between ■ The URICA has good reliability, with readiness to change among people who are estimates ranging .79–.88 (Carey, Purine, alcohol dependent, with and without co- Maisto, & Carey, 1999). Reliability occurring depression (Shields & Hufford, estimates for the URICA are .68–.85 among 2005) alcohol, opiate, cocaine, and nicotine- ■ The concurrent and convergent validity of dependent individuals (Blanchard et al., the URICA in predicting change in criminal 2003) behaviors among offenders is supported Concerns by high correlations (r score = .80) with the Criminogenic Needs Inventory (CNI; ■ Additional research is needed to establish Coebergh, Bakker, Anstiss, Maynard, & the validity of the URICA with offenders Percy, 2001) and low correlations (r score ■ Among people with CODs, the URICA = -.42) with an inventory of deceptive may not predict levels of treatment behaviors, the Balanced Inventory of participation, treatment retention, dropout, Desirable Responding (BIDR; Paulhus, or other treatment outcomes (Bellack et al., 1998; Polaschek et al., 2010) 2006; Kinnaman et al., 2007) ■ The URICA has good psychometric ■ Research examining the validity of the properties in predicting change in criminal URICA has yielded mixed results. Studies behaviors (Field et al.,2009; Tierney & involving people with alcohol user McCabe, 2004; Polaschek et al., 2010) disorders and psychotherapy clients provide ■ The URICA-M demonstrates good support for the validity of the URICA’s four psychometric properties as a unitary scale scales, but studies involving people with among those with CODs (Nidecker et al., other drug use disorders do not provide 2008), as the Pre-contemplation scale is similarly strong support (Carey et al., 1999; negatively correlated with other scales DiClemente et al., 2004) (-.25 to -.30), while Contemplation, Action, ■ Although good concurrent validity was and Maintenance scales are positively found for the four URICA scales and for correlated with each other (r scores range the overall score, one study found that .48–.80) neither the scales, nor the overall score ■ The URICA has good internal consistency successfully predicted treatment outcome among people with CODs (Pantalon (Blanchard et al., 2003) & Swanson, 2003). When applied to ■ The URICA produces scores related to changing criminal behavior among four stages of change. However, these offenders, internal consistency is acceptable aren’t precisely aligned with the most for the 32-item URICA (alpha = .82) and recent transtheoretical model of change across scales of Pre-contemplation (alpha = (Prochaska et al., 1992), in which the .75–.83), Contemplation (alpha = .60–90), Preparation stage has been eliminated due Action (alpha =.81–.93), and Maintenance to poor fit with the instrument’s underlying (alpha =.89–.90; Polaschek et al., 2010; factor structure (Polaschek et al., 2010)

145 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ When applied to changing criminal (or) behavior, the four-factor structure of the URICA may be more accurately 2. The University of Rhode Island Change represented by deletion of items 2, 8, and Assessment Scale (URICA), which provides 24, based on findings of improved internal efficient identification of readiness to change consistency and fit across the various scales and directly maps onto four out of the five (Polaschek et al., 2010). The internal transtheoretical stages of change. The consistency of the Contemplation scale URICA-M is specifically designed for people may also be low among offenders when with CODs and provides simpler language applied to changing criminal behaviors and a shorter administration time. (alpha = .90; Polaschek et al., 2010) Both of these instruments have been examined in Availability and Cost the criminal justice system and/or among people The URICA is available free of charge. The with CODs. The URICA is recommended for URICA instruments and materials describing settings in which it is important to determine scoring and interpretative guidelines can be found readiness to change, while the TCU-MOTForm at the following site: http://habitslab.umbc.edu/ can also be used to assess issues related to urica/ treatment engagement. Each of these measures requires approximately 10–15 minutes to Recommendations for Motivational administer and score. Screening Instruments Information regarding motivational screening Assessment Instruments for instruments is based on a critical evaluation of Substance Use and Treatment the literature, including comparative research Matching Approaches examining the efficacy of these instruments. Important factors in determining the utility of The use of assessment to match justice-involved motivational screens include empirical evidence individuals to appropriate levels of behavioral supporting the reliability and validity of the health services has been recognized as among the instruments, cost of the instruments, and ease of most fundamental of evidence-based approaches administration and scoring within the criminal (CSAT, 2005b). The goal of treatment matching justice settings. Motivation can also be focused on is to provide an individualized examination of a variety of domains (e.g., substance use, mental a range of mental and substance use disorders health, criminal justice involvement). Specific to and other related psychosocial problems to assist the area of motivational screening, instruments in matching offenders to appropriate levels recommended are those that closely align with of services. Triage to appropriate services is the transtheoretical model (TTM) and stages particularly important among offenders who of change and that have demonstrated validity have CODs, as mental and/or substance use within the criminal justice system. The following disorders often go undetected, and this population instruments are recommended: is often mismatched to less intensive services than are needed. This section describes several 1. The Texas Christian University Motivation treatment matching approaches, as well as specific Form (TCU-MOTForm). This instrument assessment instruments to assist in matching is unique in identifying not only readiness offenders with CODs to specific services. to change but also variables related to Matching approaches include the Risk-Need- motivation and treatment engagement, Responsivity model and the American Society of including problem recognition, desire for Addiction Medicine’s Patient Placement Criteria help and treatment readiness. (ASAM PPC). Both of these approaches provide

146 Instruments for Screening and Assessing Co-Occurring Disorders detailed frameworks for assessing substance sample. Results indicated that approximately use disorders, mental disorders, and other areas a third of male and female prisoners needed related to placement in treatment and supervision residential treatment, and approximately 16–18 services. Assessment instruments and treatment percent needed outpatient treatment. A survey matching approaches should be administered of correctional institutions revealed that only by mental health professionals with advanced 19 percent of males and 23 percent of females clinical training related to mental and substance actually received substance use treatment, use disorders, diagnosis, referral to treatment, and and of those receiving treatment, about a third treatment planning. Several of the structured and received only drug education or self-help standardized self-report assessment instruments groups (e.g., AA/NA). These findings highlight described in this section can be administered the importance of using a formal assessment by nonclinicians, although staff should be approach to identify needs of offenders and to knowledgeable about appropriate referral sources. provide matching to specific levels of treatment services, and challenges in treatment matching Specific assessment instruments described in within an environment that often includes scarce this section include the Addiction Severity Index treatment resources and with a population that has (ASI), the Timeline Followback (TLFB), and the pronounced treatment needs (e.g., offenders with TCU Correctional Justice instruments (TCU CJ). CODs).

Identifying Gaps in Offender Services Treatment Matching Approaches Despite the availability of several treatment Risk-Need-Responsivity Model matching approaches and instruments, there are significant challenges in matching offenders who The Risk-Need-Responsivity (RNR) model have CODs to appropriate levels of care, due to identifies the importance of identifying the lack of available treatment and supervision “criminogenic needs” of offenders that are related services in many jurisdictions. Belenko & Peugh to recidivism and using this information to match (2005) developed a protocol to identify gaps in offenders to different levels of treatment and treatment services (primarily substance misuse supervision (Andrews & Bonta, 2010b). The “risk services) within correctional systems. In order principle” encourages assessment of criminal risk to identify offenders’ treatment needs, guidelines to ensure that intensive resources (e.g., CODs were developed to assess substance use severity, treatment, substance use treatment) are reserved recency of substance use problems, consequences for offenders who are at moderate to high risk of substance use, and other psychosocial and levels. Key predictors of criminal risk include health problems. The second step involved “static” or unchanging factors (e.g., age, age at surveying available correctional treatment first arrest, number of prior arrests/convictions) resources and categorizing them according to the and “dynamic” or changeable factors, such as following schema: (1) no treatment (low level criminal attitudes and beliefs, criminal peers, of drug use, no drug related consequences), (2) substance use problems, employment, education, short-term intervention (self-help, motivational family problems, and lack of prosocial leisure interviewing), (3) outpatient treatment (individual skills. or group counseling), and (4) residential treatment The most important predictors of criminal risk are (separate housing, long-term intensive treatment past criminal behavior and antisocial attitudes, for those with several drug related consequences beliefs, and peers, although substance use and frequent drug use). Using this protocol, they problems also represents an important risk factor. compared offenders’ treatment needs with actual Although mental illness is not an independent treatment received within a large correctional risk factor for recidivism, offenders who have

147 Screening and Assessment of Co-Occurring Disorders in the Justice System mental disorders are at elevated criminal risk provides a very useful framework for matching due to having high levels of criminogenic needs offenders to different types and intensity of (e.g., ingrained criminal belief systems, poor treatment and supervision. Appropriate matching employment history, lack of education). Offenders based on these principles leads to reductions in who have CODs are at particularly high risk for recidivism and other positive outcomes in offender recidivism and should be a priority population for programs (Andrews et al., 2006). In summary, programming and specialized supervision (Drake, offenders who are assessed to be at higher risk 2011). A range of risk assessment instruments should be prioritized for intensive services, has been developed that examines both static and these services should target criminogenic and dynamic risk factors and provides overall needs and responsivity factors in order to reduce criminal risk scores and recommendations for recidivism and improve outcomes in treatment placement in different levels of treatment and and supervision. Lower risk offenders do not supervision. Various risk assessment instruments require the same services or intensity of services are described in the "Risk Assessment" section of to achieve comparable outcomes (Thanner & this monograph. Taxman, 2003).

The RNR model asserts that dynamic risk factors (“criminogenic needs”) should be Risk-Needs-Responsivity (RNR) targeted in individualized assessment and Simulation Tool offender programming to most effectively reduce Crites & Taxman (2013) have developed a web- recidivism. Many offender programs, including based Risk-Needs-Responsivity (RNR) Simulation those providing treatment for CODs, do not Tool that categorizes community treatment address a range of these criminogenic needs, and programs according to their focus on evidence- as a result, are less likely to reduce recidivism based practices related to criminogenic needs and (Lowenkamp & Latessa, 2005). Research matches offenders to their particular level of risk indicates that there is a cumulative effect in and needs. The RNR Simulation Tool is based addressing criminogenic needs, resulting in a on the ASAM PPC model and a similar treatment linear relationship between the number of needs matching model, Level of Care Utilization System addressed in offender treatment and supervision (LOCUS), developed by the American Association and positive outcomes related to recidivism (Bonta of Community Psychiatrists (2009). The RNR & Andrews, 2010; Carey & Waller, 2011). Simulation Tool classifies offender programs The RNR model also indicates the need to address by assessing several domains: target, content, “responsivity” in offender programs, referring to dosage, and implementation quality. These factors that influence the offender’s engagement domains are linked to increased effectiveness of in evidence-based treatment (e.g., services that offender programs (Andrews & Dowden, 2005). address dynamic risk factors/criminogenic Information from each domain is then used needs). Responsivity factors include mental to match offenders to specific programs. The health problems, need for gender-specific services, following types of information are compiled for history of trauma/PTSD, need for culturally each domain: sensitive programming, and various disabilities. If ■ Target addresses the behavior(s) that are the unaddressed, responsivity factors can undermine focus of the particular treatment program. engagement, retention, and outcomes in offender These include reducing the severity treatment and supervision. of substance use problems, cognitive restructuring of criminal thinking and Consideration of the three components of the RNR reducing criminal peers, self-improvement model (risk, criminogenic needs, responsivity) and self-management strategies (e.g.,

148 Instruments for Screening and Assessing Co-Occurring Disorders

improving social skills, problem services, certification in administration of solving, self-control), improving social/ treatment protocols, supervision of staff interpersonal skills, identifying deficits who implement treatment protocols, use of in physical/life needs (e.g., employment, quality assurance measures, and adequate education, housing), and implementing a staff communication regarding participants’ sanctions-only approach for those who are treatment progress at low risk. As noted previously, effective “targets” for offender treatment programs A second part of the RNR Simulation Tool are those that address criminogenic needs involves profiling of offenders, based on offenders’ that are linked to reducing recidivism risk level for recidivism. Risk level is composed (Andrews, 2012; Andrews & Bonta, 2010a, of factors related to criminal history (leading to 2010b) classification as “low,” “moderate,” or “high-risk” ■ Content addresses the therapeutic offenders), primary needs (e.g., substance use orientation of treatment programs, disorders, criminal thinking), clinical destabilizers including the main area of treatment focus, (e.g., presence of mental disorders), lifestyle services provided, and reinforcement of destabilizers (e.g., poor social supports, lack of treatment skills. The content of offender education, unemployment, lack of stable housing), programs should be a CBT skills-based and stabilizers (i.e., opposite of destabilizing approach to address factors such as factors, such as educational achievement, antisocial behaviors, thinking, and peers, in stable housing, social support). Programs are addition to substance use disorders (Lipsey, categorized according to these features and placed Landenberger, & Wilson, 2007). Other key in one of six groups (Crites & Taxman, 2013) content includes social restrictiveness or that are differentiated by recidivism risk level, supervision (e.g., curfews, probation visits, primary needs, responsivity (appropriate match and mandatory daily program attendance), between individual’s needs and program services), which can reduce recidivism (Drake, Aos, dosage, program integrity (factors associated with & Miller, 2009) implementation fidelity), and social restrictiveness. ■ Dosage addresses the amount (total number of hours), duration (number of Summary of Key Issues weeks or months), frequency (number of ■ The Risk-Needs-Responsivity (RNR) times per week), and quantity (number Simulation Tool uses a series of algorithms of hours per week) of services provided generated from the Bureau of Justice by treatment programs. Dosage serves to Assistance, Survey of Inmates data set to moderate the risk for recidivism (Lipsey match offenders with appropriate programs & Landenberger, 2005). Moreover, risk level determines the appropriate dosage ■ The tool also helps to identify gaps between necessary, with high-risk offenders offenders’ needs and the existing program generally requiring at least 300 hours of resources in a particular community (Crites cognitive-behavioral treatment (CBT) and & Taxman, 2013) related services, moderate-risk offenders ■ The RNR model provides a useful requiring approximately 200 hours of CBT framework to identify and address and related services; and low-risk offenders criminogenic needs and responsivity factors requiring approximately 100 hours of that influence treatment outcomes among services (Bourgon & Armstrong, 2005) offenders with CODs, including relapse and recidivism ■ Implementation Quality addresses whether programs are implemented as designed. ■ The RNR Simulation Tool is based on an Key factors include adherence to treatment empirically derived theoretical approach to protocols, proper staff training in delivering identify the appropriate level of treatment

149 Screening and Assessment of Co-Occurring Disorders in the Justice System

and supervision services that are needed Fishman, Gastfriend, & Griffith, 2001). The to promote positive outcomes among most recent revision, ASAM Criteria-Treatment offenders who have substance use problems Criteria for Addictive, Substance Related, and and CODs Co-occurring Conditions (Mee-Lee, 2013), reflects changes to the DSM-5 diagnostic criteria. Concerns ■ Although the RNR Simulation Tool is Underlying concepts of the ASAM PPC (Mee- based on a sound theoretical model to Lee & Shulman, 2003) include the following: (1) determine treatment matching for those the biopsychosocial perspective of addiction that involved in the justice system, it is a new encompasses etiology, expression, and treatment approach and requires application and of addiction, allowing for a more comprehensive testing to assess its validity, including its assessment and treatment approach; (2) effectiveness in reducing recidivism individualized treatment that provides a patient- ■ Several other assessment tools are available driven approach; (3) multidimensional assessment to examine offenders’ risk and needs (see the six domains below) that determines for psychosocial interventions. These level of services needed; (4) treatment matching include the Addiction Severity Index that integrates all six domains (described in (ASI; McLellan et al., 1985), the Global the following section) and addresses issues of Assessment of Individual Needs (Dennis, motivation to change, management of social/ Titus, White, Unsicker, & Hodgkins, 2003), occupational risk factors, medication management the Level of Service Inventory-Revised (e.g., detoxification, craving management), and (Andrews & Bonta, 1995), and a range of other risk assessment instruments other services (e.g., self-help/12-step groups, such as NA and Dual Recovery Anonymous); Availability and Cost and (5) monitoring of care that includes relapse Information regarding the RNR Simulation Tool is prevention, treatment engagement and retention, available at the following site: http://www.gmuace. and other important social/occupational factors. org/tools/. Direct link to the RNR Simulation The ASAM PPC provide separate guidelines Tool: http://www.gmuace.org/tools/program-tool for placement in adolescent and adult treatment services. The ASAM PPC-2R guidelines American Society of Addiction Medicine- operationalize six assessment dimensions that Patient Placement Criteria (ASAM PPC) define biopsychosocial severity within the context of behavioral health services: (1) acute The ASAM PPC is a widely used assessment and intoxication and/or withdrawal potential; (2) triage approach that employs patient placement biomedical conditions and complications; (3) criteria to identify appropriate levels of care for emotional, behavioral, or cognitive conditions people who have substance use disorders and and complications; (4) readiness to change; (5) CODs. The ASAM PPC for the Treatment of relapse, continued use, or continued problem Psychoactive Substance Use Disorders (Hoffman, potential; and (6) recovery/living environment. Halikas, Mee-Lee, & Weedman, 1991) were Criteria described for each of the six dimensions developed through a consensus process, and are then used to guide placement in one of this approach has subsequently been used in a five levels of treatment services, which vary number of states and increasingly by managed by the intensity of services provided: (1) level care organizations to modify treatment matching 0.5—Early intervention, (2) level I—Outpatient approaches for use in the behavioral health field. treatment, (3) level II—Intensive outpatient/ The ASAM PPC were revised in 1996 and again partial hospitalization treatment, (4) level III— in 2001 (ASAM PPC-2R; Mee-Lee, Shulman,

150 Instruments for Screening and Assessing Co-Occurring Disorders

Residential/inpatient treatment, and (5) level IV— distance learning are also provided to help train Medically managed intensive inpatient treatment. individuals in proper assessment and appropriate treatment placement. The instrument also employs The ASAM PPC-2R (2001) were the first to automated software that utilizes an algorithm identify the need for substance use programs to (Turner, Turner, Reif, Gutowksi, & Gastfriend, provide integrated services for CODs. The ASAM 1999) for matching individuals with appropriate PPC-2R supplement also reviews issues related treatment programs. This software application to medically assisted treatment for alcohol use demonstrates good concurrent validity with other disorders (AUDs), detoxification, and relapse standardized assessments, such as the Addiction prevention. The ASAM PPC-2R guidelines Severity Index (ASI), and predicts treatment recognize that for people with CODs, whichever outcomes for those who are appropriately matched disorder causes the most functional impairment (Magura et al., 2003; Sharon et al., 2003). should be considered in making the placement to a particular type of treatment setting. Treatment One caveat to these research findings is that many programs described in the PPC-2R may be either individuals were mismatched for treatment or “dual diagnosis capable” or “dual diagnosis did not show up to treatment and thus were not enhanced,” to address people with CODs who included in these results (Angarita et al., 2007; demonstrate a wide range of psychopathology. Gastfriend & Mee-Lee, 2011). In a study of Specifically, dual-diagnosis capable programs alcohol users, those who were mismatched to are those that address the comorbidity between more intensive levels of treatment did not show substance use disorders and more stable mental greater improvement in treatment outcomes than health problems, where the co-occurring mental those who were correctly matched to treatment. health problems do not interfere with engagement However, people mismatched to less intensive and progress in addiction treatment. Policies levels of treatment showed poorer treatment and procedures address dual diagnoses and outcomes (Magura et al., 2003). Another study allow for collaboration with mental health indicated that those who needed higher levels of services to appropriately handle CODs and care did not receive it (e.g., residential treatment provide psychopharmacological monitoring/ Level III versus hospitalization Level IV) and assessment both on site and via coordinated off- were in treatment significantly longer than those site services. Dual diagnosis enhanced programs who were matched to the correct level of care accept individuals who have CODs and more (Sharon et al., 2003). unstable mental disorders. These programs allow for mental health problems to be managed Difficulty in treatment matching may be due in simultaneously with addictions, providing part to substantial disagreement (81 percent) continuity in the overall treatment approach. between computerized algorithm results and Policies and procedures include more stringent clinician recommendations (Sharon et al., monitoring of participants and integration of 2003). Clinicians may judge the algorithm’s mental health treatment with addictions treatment, matching recommendations as too restrictive. The which allows for treatment continuity for both algorithm may classify individuals into higher disorders. For each level of treatment, criteria levels of treatment based on one item in the PPC are specified (within dimensions 2–6) for dual- criteria rather than considering other items that diagnosis capable and enhanced programs. provide more relevant coverage of that particular dimension. For example, concerns related to ASAM developers provide a range of information emotion/behavioral functioning may lead to to aid in standardizing clinical assessment and matching people to Level IV, but these people may placement, in addition to materials to encourage be just as well suited as people matched to Level individualized treatment planning. Tutorials and III to complete the treatment program successfully.

151 Screening and Assessment of Co-Occurring Disorders in the Justice System

Challenges in Applying the ASAM Criteria in available rather than on individualized needs for Justice Settings treatment. As a result, offenders may not receive a Although the ASAM criteria have been commonly comprehensive assessment or the optimal services used in community-based settings to guide that are needed. Another consideration is that the treatment matching, they have only recently been recent emphasis on risk assessment procedures in implemented in the justice system. For example, justice settings may result in offenders receiving only about a third of drug court survey respondents treatment and supervision that is focused primarily indicated the use of the ASAM PPC (American on antisocial behaviors, attitudes, and peers, University, 2001). Several states now use the without considering the importance of other ASAM criteria to place individuals convicted of factors, such as co-occurring mental disorders DUI/DWI offenses in different types of treatment and substance use issues, employment, education, programs. The ASAM PPC or similar approaches and family services, that also influence criminal provide a structured approach to potentially match involvement and recovery. justice-involved individuals more effectively to Finally, the ASAM PPC are based on a medical different levels of treatment intensity, structure, model of substance use treatment that includes an and supervision (CSAT, 2005b). emphasis on individual counseling and oversight There are several challenges in implementing the provided by medical personnel, whereas group ASAM criteria in justice settings (Mee-Lee, 2013). counseling is the preferred approach for offenders First, specific to readiness to change, there may (including those with substance use disorders), be an unreasonable expectation, particularly in and oversight is typically provided by justice the first few months of treatment, that offenders or substance use treatment personnel. A related are in the “action stage” of recovery and are concern is that the ASAM PPC do not currently able to comply with justice system mandates provide a “dimension” that addresses risk for for abstinence from drugs and alcohol and fully criminal recidivism, nor does the PPC provide engage with treatment services. In addition, some recommendations for how to modify “levels” of treatment programs that are mandated by the treatment to address the unique resources and courts may be too short in duration for participants limitations related to drug courts, day treatment, to reach the “action stage” of recovery and to other community correctional treatment programs, maintain healthy and prosocial behaviors. or jail and prison-based programs.

Some judges or community supervision officers Summary of Key Issues may also place offenders in mandated treatment ■ Implementation of the ASAM PPC-2R based on their own view of what level of care criteria includes the use of standardized is needed rather than by conducting a formal assessment tools and computerized assessment to identify treatment needs and match software, which can improve accuracy people to appropriate services. In contrast, some in matching individuals to appropriate treatment programs (Baker & Gastfriend, courts may recommend treatments that seem more 2003; Gastfriend & Mee-Lee, 2011) “restrictive” such as residential programs, in part because the proxy of confinement gives a sense of ■ A study involving outpatient treatment comfort related to criminal recidivism potential or programs provides support for the ASAM violence risk reduction. This can be problematic model in treatment matching and indicates that programs using standardized ASAM if the treatment needs are not as intensive as the PPC assessment tools are more likely to treatment that falls under a court order. provide both counseling and other support In other justice settings, offenders are placed services that follow practice guidelines in treatment based on the resources that are

152 Instruments for Screening and Assessing Co-Occurring Disorders

developed by ASAM or CSAT (Rieckmann, PPC treatment placements generated by Fuller, Saedi, & McCarty, 2010) the computerized algorithm and clinician- ■ The Addiction Severity Index (ASI) is a recommended treatment placements. It common standardized assessment tool used is important to consider factors that may in ASAM implementation in outpatient contribute to these disparities, including settings and criminal justice settings the emphasis placed on certain dimensional (Cohen, Mankey, & Wendt, 2003; Koob, criteria by the computerized algorithm. Brocato, & Kleinpeter, 2011; Magura et al., Further research is needed to examine 2003; Marlowe, Festinger, Dugosh, Arabia, treatment outcomes among people who & Kirby, 2008; Rieckmann et al., 2010) are mismatched to treatment based on the ASAM PPC computerized algorithm, ■ The Global Assessment of Functioning and to identify strategies to reduce these (GAF) and Structured Clinical Interview mismatches for Diagnostic Statistical Manual (SCID) are commonly used for mental health ■ The ASAM PPC materials are somewhat assessment and diagnosis in treatment costly to purchase settings that use the ASAM criteria Availability and Cost (Kosanke, Magura, Staines, Foote, & DeLuca, 2002; Magura et al., 2003; The most recent version of the ASAM PPC, The Rieckmann et al., 2010) ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-occurring Conditions Concerns and the ASAM PPC supplement can be purchased ■ Challenges in implementing the ASAM from the American Society of Addiction Medicine PPC criteria in justice settings include the at the following site: http://www.asam.org/ need to address criminal risk as it affects publications/the-asam-criteria placement in various levels of treatment and supervision, matching to specialized The cost of the ASAM PPC is $95 ($85 for offender programs (e.g., drug courts), members of ASAM), and the supplement costs $65 the need to triage offenders to programs and is available for the Kindle. that provide group treatment services, and the need to integrate specialized ASAM recommends a set of assessment and CODs treatment services with intensive placement instruments that adhere to ASAM supervision and court monitoring criteria, and these are available for purchase. ■ Further research is needed to establish the Assessment and placement instruments cost validity of the ASAM PPC in improving between $50 and $80, and each instrument treatment outcomes among offenders who contains 25 copies. Instruments can be obtained have substance use disorders and CODs at the following site: http://changecompanies.net/ asamcriteria/assessments.php ■ Although the ASAM PPC computerized software helps to predict treatment outcomes among people matched to Substance Use Assessment various levels of treatment, studies Instruments and Treatment Matching examining placement outcomes using Several assessment instruments have been the ASAM PPC criteria generally do not developed for treatment matching as part of the include people who were mismatched RNR Simulation Model and the ASAM PPC, to treatment and who did not attend as described in previous sections. A number of treatment. Many individuals who are risk assessment instruments are also available to mismatched to treatment show poorer assist in matching to treatment and supervision, treatment outcomes. In addition, there is as described in the "Risk Assessment" section significant disagreement between ASAM

153 Screening and Assessment of Co-Occurring Disorders in the Justice System

of this monograph. Several other substance use ASI are highly correlated (.91), indicating high assessment instruments are frequently used in reliability between the different versions of the treatment matching in behavioral health settings instrument (Brodey et al., 2004). and are described in this section. These include the Addiction Severity Index (ASI), the Texas The ASI includes seven domains of functioning Christian University intake and assessment forms/ commonly affected by substance use, including instruments, and the Timeline Followback (TLFB). drug and alcohol use (separate sections), legal status, family and social relationships, Addiction Severity Index-Fifth Version employment and support status, medical status, (ASI-5/ASI-6) and psychiatric status. The ASI examines the severity of problems in each of these domains over The ASI (McLellan et al., 1992; McLellan, the past month and the need for treatment. The Luborsky, Woody, & O’Brien, 1980) is one of instrument also reviews indicators of emotional, the most widely used instruments for screening, physical, and sexual abuse. Although the ASI assessment, and treatment planning related to measures frequency of use, it does not address substance use disorders. The 155-item instrument quantity of use, as quantity may be underestimated was designed as a structured interview to examine and frequency is easier to recall (McLellan et al., symptoms, frequency of substance use, and other 1992). The ASI-5 includes interviewer severity psychosocial areas that are frequently affected by ratings (ISR) that combine current and lifetime substance use. The ASI requires 45–60 minutes to symptoms within each domain to help assess the administer and 10–20 minutes to score. Additional need for treatment. The ASI composite summary versions of the instrument have been developed for scores (CS) are generated for each domain clinical and training purposes (ASI-CTV), and a and assess the current severity of symptoms. brief version is available that takes approximately Evaluation factors (EF) are available for five 30 minutes to administer (ASI-Lite). The ASI-Lite of the domains, and clinical factors (CF) are has been adapted for use in the VA system (ASI-L- included for all seven domains. CFs measure VA). current and lifetime functioning scores that reflect a global severity rating. EFs measure individual Self-report and clinician administered functioning during the past month. computerized versions of the ASI are available (ASI-Net and CA ASI-Net), as are versions Many offender programs have developed designed for interactive voice response (ASI- modified versions of the ASI for use in substance IVR) and automated telephone administration use screening. A sixth edition of the ASI is (Brodey et al., 2004; Rosen et al., 2000). The now available. Revisions to the ASI-6 include ASI-Multimedia Version (ASI-MV; Butler et al., replacement of the ISR ratings with clinical 2001) is a computerized form of the instrument, indices of lifetime functioning (CIs). An and was designed to reduce burden on treatment interval of 6 months has been added in addition counselors. The instrument provides virtual to past month and lifetime ratings. The ASI-6 simulation of a clinician-administered interview includes “skip-out” questions that can reduce and includes audio and video presentations as well administration time to approximately 1 hour, and as “skip-logic.” The instrument has been found the instrument provides more specific wording of to be reliable and valid (Butler et al., 2001) and questions to increase reliability. Item Response generates two summary scores: (1) composite Theory (IRT) analysis indicates that in comparison scores for each ASI domain, and (2) severity to previous versions, the ASI-6 is better able to ratings by domain for problems occurring during address changes in substance use problems and the past month. The composite scores generated treatment needs of diverse populations (e.g., by the interview and automated versions of the welfare clients, drug court participants, individuals

154 Instruments for Screening and Assessing Co-Occurring Disorders who are homeless) and has improved psychometric ASI-6 domains are significantly correlated properties across the seven domains. The ASI-6 with scales from other TCU instruments. consists of nine summary scores (“Recent Status For example, the ASI-6 is significantly Scores” or RSS) that map to the seven Composite correlated with the TCU psychological Scores in the ASI-5, with two additional summary functioning (PSYForm)–self-esteem scores that address family/social support and child scale; the TCU social functioning problems (McLellan, Cacciola, Alterman, Rikoon, (SOCForm) scales of social desirability, social functioning, and hostility; the Carise, 2006; Denis, Cacciola, Alterman, 2013). psychological functioning scales of The ASI-6 also contains a follow-up interview anxiety/depression; and the TCU criminal that addresses change in symptoms over time. thinking scales (CTS; Pankow et al., 2012). Items from the ASI-6 differentiate between current The ASI-6 (Pankow et al., 2012) is also symptoms (past 30 days) and those experienced significantly correlated with other validated since the last administration of the ASI interview. psychological measures, such as the K10 (Kessler et al., 2003) and the PTSD Positive Features Checklist (PCL; Weathers et al., 1993) ■ The ASI-6 has been translated into Spanish ■ ASI normative data is available for criminal and several other languages justice populations (McLellan et al., 1992) ■ The ASI is a public domain instrument and ■ The ASI is highly correlated with objective is available at no cost indicators of addiction severity (McLellan ■ The ASI describes recent and long-term et al., 1980, 1985; Searles et al., 1990) and patterns of substance use and examines with alcohol use disorder and substance a range of different legal and illegal use disorder diagnoses (Rikoon, Cacciola, substances. The ASI can also be used to Carise, Alterman, & McLellan, 2006). The screen for trauma and PTSD (Cacciola et ASI-Drug Use section was one of three al., 2007; Najavits et al., 1998). The ASI- sets of screening instruments found to be 6 provides more structure than previous the most effective in identifying substance- versions of the instrument and enhanced dependent offenders (Peters et al., 2000) ability to identify drug, alcohol, and mental ■ Among people seeking substance use health problems (Cacciola, Alterman, treatment, the ASI-6 domains/scales show Habing, & McLellan, 2011) good concurrent validity with other related ■ Recent validity studies indicate measures and are correlated with measures improvement of several scales on the ASI-6 of the following: (1) medical problems in comparison to the ASI-5 (Denis et al., and physical health, as measured by the 2013) Short Form Mental Health Survey (SF-12, ■ Many criminal justice agencies have used r score = -.64); (2) family/social support, sections of the ASI-6 for substance use as measured by the Social Readjustment screening (McLellan et al., 1985; Peters Scale Self-Report, SAS-SR-social (r score et al., 2000), as well as the full ASI-6 for = -.34); (3) family and social problems, as assessment purposes (Eriksson et al., 2013; measured by the SAS-SR social (r score Ettner et al., 2006; Pankow et al., 2012; = .40); (4) employment, as measured by Proctor, 2012; Serowik & Yanos, 2013) the SAS-SR Work, (r score = .76), (5) ■ Among offenders, the ASI-6 (McLellan et alcohol problems, as measured by the Short al., 2006) shows good concurrent validity, Index of Problems (SIP-Alcohol, r score including significant correlations with the = .68; Alterman, Cacciola, Ivey, Habing, Texas Christian University Drug Screen & Lynch, 2009); (6) drug problems, as II (TCUDS-II), a validated substance measured by the SIP-Drugs (r score = .61; use screening measure. Scores from the Alterman et al., 2009); (7) legal problems,

155 Screening and Assessment of Co-Occurring Disorders in the Justice System

as measured by prior arrests (r score = internal consistency across the same .15); and (8) mental health problems, summary scales (Cacciola et al., 2007) as measured by the Symptom Checklist ■ Research indicates that the ASI is reliable Revised (SCL-10R, r score = .68; Cacciola and valid for use with people who have Alterman, Habing, & McLellan, 2011) CODs (Carey, 1997) ■ Among people with substance use ■ In comparison to the ASI-MV, the ASI-5 disorders, the ASI-5 domains/scales also demonstrated no significant differences demonstrate good concurrent validity with in responses for particular domains such other related measures of physical health, as employment, and items specific to current/lifetime alcohol problems, recent/ alcohol use (Butler, Villapiano, & Malinow, lifetime drug problems, legal problems, and 2009). Areas of significant differences family/social problems (Alterman et al., that were found could be due to higher 2009). The ASI-6 domains may provide rates of disclosure by participants on the better coverage than the original ASI-5 computerized interview as compared to domains, particularly the family/social area face-to-face interviews (Butler et al., 2009; and its subscales (Denis et al., 2013). The Garb, 2007) ASI-6 also demonstrates higher correlations than the ASI-5 with concurrent validity Concerns measures in five of the seven original ■ The ASI-6 is still in the process of domains (employment, psychiatric, family/ development and is not as widely used as social, legal, and drug; Denis et al., 2013) the ASI-5 ■ The ASI-6 has good internal consistency ■ The ASI requires approximately 45–90 across all domains, the summary scales, minutes to administer, although the alcohol and across different race/ethnicity groups and drug sections can be completed in (alphas range .73–.94; Cacciola et al., significantly less time 2011). Most of the ASI-6 RSS domains are ■ Substantial training is needed to administer highly correlated with the ASI-5 CS scales and score the ASI (Denis et al., 2013) ■ The ASI-6 Spanish version demonstrates ■ When administered over a 2–3 day period variable psychometric properties, including to a treatment-seeking sample, the ASI-5 poor to good internal consistency (alphas has good interrater reliability for agreement range .47–.95; Díaz-Mesa et al., 2010) with the ASI-L-VA on most ISR ratings and and poor to excellent test-retest reliability scores for CS, CF, and EF, across domains (.36–1.0; Díaz-Mesa et al., 2010) of alcohol, drugs, and psychiatric problems (ICCs range .62–.89; Cacciola et al., 2007). ■ The ASI-5 legal scales may be more valid Similarly, the ASI-5 has adequate test-retest than those of the ASI-6 (Denis et al., 2013). reliability for most ISRs ratings and CS, For example, ASI-5 arrest results from CF, and EF scores, when readministered the ASI-5 legal domain are more highly after short intervals (Cacciola et al., 2007) correlated with the history of arrest than the ASI-6 (Denis et al., 2013) ■ The seven domains of the ASI-5 have good internal consistency (alphas range .73–.92) ■ Among those seeking substance use for both current and lifetime problems treatment, the ASI-5 has lower interrater (Alterman, Cacciola, Habing, & Lynch, reliability for agreement ISR ratings in 2007) domains of employment and family-social problems and lower EFs, CFs, and CSs for ■ The ASI-5 has acceptable internal family-social problems when compared to consistency for most summary scales (CFs, the ASI-L-VA (ICCs < .60; Cacciola et al., CSs, Efs; alphas range .72–.89; Cacciola et al., 2007). The ASI-L-VA has acceptable

156 Instruments for Screening and Assessing Co-Occurring Disorders

2007), indicating that these domains may Texas Christian University (TCU) Intake generate inconsistent or inaccurate ratings and Assessment Instruments ■ The ASI-5 may have poor test-retest reliability for EF, CS, and ISR ratings The TCU intake and assessment instruments related to the family/social domain (ICCs < (Simpson & Knight, 1998) are available in the .60; Cacciola et al., 2007) public domain and include versions tailored specifically for criminal justice and community ■ The ASI-5 may have lower internal treatment settings. The instruments assess a broad consistency for certain summary scales, such as drug (CS) and legal problems (CS/ range of psychosocial issues, including drug, CF; alphas <.70; Cacciola et al., 2007). alcohol, and mental health problems, as well as The ASI-L-VA also exhibits lower internal other social, occupational, and treatment areas. consistency on these scales (Cacciola et al., TCU instruments described here include both 2007) interviewer administered and self-report scales. Instruments developed for justice settings are ■ Results from the ASI-MV (Butler et al., 2001) and face-to-face interview versions referred to as the Criminal Justice treatment forms of the ASI may be inconsistent, as (TCU CJ) and contain an interviewer-administered differences in scores were obtained in the CJ Comprehensive Intake (TCU CJ CI), and a self- following domains: drug, alcohol, legal, report CJ Client Evaluation of Self and Treatment family, and psychiatric problems (Butler et (TCU CJ CEST-intake). Instruments developed al., 2009) for community treatment settings include an ■ The ASI may have reduced reliability and interviewer-administered Brief Intake (TCU BI), a validity for people who have significant Comprehensive Intake (TCU CI), and a self-report substance use problems and co-occurring Client Evaluation of Self and Treatment, Intake mental disorders (Carey, 1997; Corse, version (TCU CEST-Intake). Hirschinger, & Zanis, 1995; McLellan, Cacciola, & Alterman, 2004; Zanis, The self-report CEST forms for both criminal McLellan, & Corse, 1997) justice and community settings contain several sections, or short forms, that can be administered Availability and Cost separately. A follow-up CEST form is also The ASI is a public domain instrument that available for both community and justice settings was developed by the Treatment Research and can be used to evaluate treatment progress Institute, 600 Public Ledger Building, 150 South over time. Other self-report instruments can Independence Mall West, Philadelphia, PA 19106, be combined with both the criminal justice and (215) 399-0980. The instrument is available at community CEST forms, including the TCU the following site: http://www.tresearch.org/index. Drug Screen V (TCUDS V), the TCU Criminal php/tools/download-asi-instruments-manuals/ Thinking Scales (TCU CTS), and other mental health scales that integrate components of the This site also provides several manuals that K6 and K10 instruments (Kessler et al., 2003). include information on administration, scoring, Several TCU short forms are based on sections and interpreting the ASI. contained in the original interviewer-administered The ASI-6 is available at no charge on a case-by- intake instrument. These include the global risk case basis. Additional information regarding the assessment (TCU RSKForm), the Family and ASI-6 can be obtained by emailing the help desk Friends assessment (TCU FMFRForm), the mental at [email protected] health and PTSD screen (TCU TRMAForm), and physical and mental health screens (TCU HTLHForm). The TCU HTLHForm contains items from the K10 and is designed to examine

157 Screening and Assessment of Co-Occurring Disorders in the Justice System psychological distress. The short forms provide a Rowan-Szal, & Simpson, 2002; Knight, vehicle for individualized assessment to address Simpson, & Morey, 2002) is a self-report CODs relevant to involvement in treatment. instrument for use with offenders. The instrument examines treatment motivation Criminal Justice Instruments: and a range of other psychosocial factors ■ The TCU CJ Comprehensive Intake (TCU affecting treatment. The TCU CJ CEST CJ CI) is administered 1 to 3 weeks after reviews the following domains: program entry and queries about the » Treatment motivation, with subscales past month or the past 6 months prior to of problem recognition (PR), desire for incarceration. The TCU CJ CI contains help (DH), treatment readiness (TR), sections assessing the following domains: and pressure for treatment index (PT) » Sociodemographic background » Psychological functioning, with » Family background, including quality subscales of self-esteem (SE), of relationships with family members depression (DP), anxiety (AX), and » Peer relations, including quality of decision making (DM) relationships with friends and gang » Social functioning, with subscales of affiliations childhood problems (CP), hostility » Criminal history, including prior (HS), and risk taking (RT) arrests, involvement in illegal A scoring guide is provided to help interpret activities, and legal status results from the instrument. Each of the TCU CJ » Health and psychological status, CEST domains can be administered as separate including physical and mental health one-page forms, in combination with each other, (e.g., anxiety, depression), and history with other scales (TCU CTS, TCUDS V, K6/K10), of hospitalization or with other short forms, as described previously, » Drug history, including frequency of to provide a more individualized assessment alcohol and drug use over the past approach. The short forms and scales are designed month and past 6 months and prior to supplement intake assessments that are used treatment history. Alcohol use is by different justice programs. Individual scoring assessed in more detail, including manuals are provided for each of the short forms. quantity and patterns of drinking over The follow-up version of the CEST also contains the past month. Problems caused by a “treatment progress domain” that provides drug and alcohol use are based on subscales related to treatment participation DSM-IV criteria (TP), treatment satisfaction (TP), counseling AIDS risk assessment, including risky » rapport (CR), peer support (PS), and social behaviors support (SS). The treatment progress domain The TCU CJ CI requires approximately 90 can also be administered as a separate one-page minutes to administer. Instructions are provided form. A follow-up version of the CEST can be to the interviewer to read aloud to the participant administered over the course of treatment to assess explaining the purpose of the assessment, in change over time for each of the domains and to addition to answer cards to help guide the format examine engagement and retention, as indicated by of participants’ responses. “Skip logic” items the treatment progress domain. are provided that can reduce the duration of Community Treatment Forms: administration. The TCU community treatment instruments are ■ The TCU CJ Client Evaluation of Self and similar to the criminal justice instruments but are Treatment (TCU CJ CEST; Joe, Broome,

158 Instruments for Screening and Assessing Co-Occurring Disorders designed primarily for outpatient and residential social functioning. As with the TCU CJ treatment settings. CEST, each domain of the TCU CEST- Intake can function as a stand-alone ■ The Brief Intake interview (TCU instrument or be combined with other short BI) contains sections similar to the CJ forms. Unique to the TCU CEST-Intake Comprehensive Intake but is significantly is a self-efficacy scale (Pearlin Mastery shorter. The instrument includes the Scale (Pearlin & Schooler, 1978) that is following sections: embedded in the psychological functioning » Background information domain. A social consciousness scale is » Psychosocial functioning during the also included in the social functioning past 6 months domain and examines social values. The follow-up CEST-Intake is identical Drug use background, including » to the CJ CEST version in coverage information describing substance use of domains and analysis of treatment in the past 6 months and during the engagement, retention, and progress. A lifetime manual is provided to assist in scoring and » Drug use problems in the past year, interpretation of the CEST-Intake. including areas addressed by the DSM criteria for substance use disorders Positive Features ■ The Comprehensive Intake Interview ■ The TCU intake and assessment (TCU CI) is similar to the TCU CJ CI instruments have been used in a wide interview but is geared towards those variety of offender settings (Farabee, receiving treatment in the community and Prendergast, & Cartier, 2002; Czuchry includes special instructions for those & Dansereau, 2000; Joe, Rowan-Szal, entering treatment from jail or prison. Greener, Simpson, & Vance, 2010; Pankow Domains of the TCU CI are similar to & Knight, 2012) those in the TCU CJ CI, but there are ■ The TCU CJ CEST and community several differences in the item structure and CEST instruments include norms for wording of individual items. For example, both offender and community treatment the sociodemographic background section populations provides detailed information about ■ The TCU intake and assessment childhood history. The drug history instruments provide two sets of forms that section includes questions addressing are tailored for offender and community treatment support from family and friends treatment settings and problems related to gambling. An additional section is provided to record ■ Each of the TCU intake and assessment interviewer comments about the quality instruments is fully structured and of participant responses. The TCU CI addresses multiple domains, including requires approximately 90 minutes to diagnostic criteria for various disorders. administer, and like the TCU CJ CI, The instruments can be administered by includes answer cards and instructions for nonclinicians and include a straightforward administration. set of items/questions ■ The Client Evaluation of Self and ■ The self-report CEST forms can Treatment Intake Version (TCU CEST- be administered as short, one-page Intake) is a self-report instrument that assessments or can be combined to provide is similar to the TCU CJ CEST and that a more comprehensive assessment, thus includes similar domains addressing allowing programs flexibility to tailor their treatment motivation, psychological approach to the needs of participants and functioning, treatment motivation, and to the needs of the program. For example,

159 Screening and Assessment of Co-Occurring Disorders in the Justice System

several short forms are available to assess Simpson, Knight, Dansereau, 2004) and mental health, social functioning and for the specific domains that can be used as other related domains, and these can be independent assessment instruments (e.g., administered individually or in combination TCU psychological functioning and TCU with CEST forms social functioning domains; Rowan-Szal et ■ The assessment forms examine DSM al., 2012; Simpson et al., 2012) criteria for drug and alcohol use disorders. ■ TCU CJ CEST subscales of social The self-report TCU CJ CEST can be functioning and psychological functioning combined with other forms, such as the represent unitary dimensions, as indicated TCU CTS, to assess risk for recidivism by confirmatory factor analyses (Garner et and to provide a more comprehensive al., 2007; Simpson et al., 2012) assessment. Criminal thinking as measured ■ The CJ CEST domains have good test- by the TCU CTS is correlated with lower retest reliability across subscales (Garner et treatment motivation/engagement and al., 2007) poorer psychological and social functioning ■ The TCU CEST Community Treatment (Garner et al., 2007) forms demonstrate good internal ■ TCU CJ CEST motivation scales are consistency for domains of treatment correlated with treatment engagement motivation (alphas range .88–.90), social among offenders (Pankow et al., 2012; functioning (.71–.90), and psychological Simpson et al., 2012) functioning (.80–.91; Joe et al., 2002; ■ The TCU CJ CEST domains of Simpson, 2004) psychological functioning, social ■ The TCU TRMAForm, TCU HLTHForm, functioning, and motivation are related to and their subscales show good internal relevant domains on the Addiction Severity consistency among female offenders Index, supporting the convergent validity (alphas range .75–.94; Rowan-Szal et al., of the CEST instrument. For example, 2012) treatment motivation and psychological and social functioning are correlated with ASI Concerns measures of legal status, drug problems, ■ Further study is needed to determine the and psychiatric problems (Pankow et al., validity and reliability of both the TCU 2012) intake and assessment forms in detecting ■ Among female offenders, the TCU the severity and scope of substance use TRMAForm and TCU HLTHForm are disorders, mental disorders, and related highly correlated with the psychological psychosocial problems functioning scales/domains of anxiety and ■ Many of the existing studies of the TCU depression in addition to social functioning intake and assessment forms in justice scales/domains of hostility and risk taking, settings have been conducted by the supporting the concurrent validity of these developers of the instruments. Studies measures (Rowan-Szal et al., 2012) conducted by other research teams are ■ The TCU CJ CEST shows acceptable needed to confirm these results internal consistency in justice settings ■ The criminal justice and community across domains of treatment motivation treatment intake and assessment forms do (alphas range .60–.80), psychological not include a module to detect psychosis functioning (alphas range .71–.74), and ■ The TCU CEST does not address antisocial social functioning (alphas range .71–.80; behaviors Garner et al., 2007). Other studies provide support for the internal consistency of the ■ The domain of treatment motivation and entire CEST instrument (Simpson, 2004; its subscales appear to have relatively

160 Instruments for Screening and Assessing Co-Occurring Disorders

low internal consistency, particularly the individuals identify and note memorable occasions subscales related to desire for help (alpha over these time intervals (e.g., the past 30 days) to = .67) and treatment needs (alpha = .60). aid in the recall of daily patterns of substance use Results of confirmatory factors analyses and nicotine use. Common variables computed indicate that the four treatment motivation for alcohol use include the number of drinking subscales may lack structural integrity days, average drinks, total drinks per month, and may not represent unitary dimensions and maximum drinks consumed during one (Garner et al., 2007) occasion (Pedersen & LaBrie, 2006). For drug Availability and Cost use, variables calculated include the number of days of use, the longest period of use, and the Each of the TCU intake and assessment longest period of abstinence; however, this varies instruments is available at no cost. The across drug class. For example, the quantity of community treatment forms, including scoring marijuana use can be more accurately assessed in interpretation and norms can be found at the terms of frequency (number of joints; Robinson, following site: http://ibr.tcu.edu/forms/tcu-core- Sobell, Sobell, & Leo, 2012). The TLFB approach forms/ provides a more accurate and comprehensive Criminal justice treatment forms including assessment of individual drinking and drug use scoring, interpretation and norms can be found at patterns compared with typical quantity and the following sites: frequency measures that may underestimate substance use behavior (Sobell et al., 2003). The http://ibr.tcu.edu/forms/forms-archives/cj-forms- TLFB protocol requires approximately 10–30 correctional-residential-treatment/ minutes to complete and is available in several languages. http://ibr.tcu.edu/forms/forms-archives/cj-forms- correctional-outpatient-treatment/ Positive Features The individual CEST domains as one-page forms ■ The TLFB measure can be administered via and a scoring guide for the implementation of the interview or computer. The computerized CEST can be obtained from the following site: version provides detailed instructions for self-administration and allows http://ibr.tcu.edu/forms/client-evaluation-of-self- measurement of time intervals up to 12 and-treatment-cest/ months. The computerized version of the Other TCU forms can be found at the following TLFB requires the same amount of time to site, which links the user to archives containing administer as the interview version various forms and descriptions of each form: ■ The TLFB has been used successfully http://ibr.tcu.edu/forms/forms-archives/ with justice populations (Broner, Mayrl, & Landsberg, 2005; Easton et al., 2007), including DUI/DWI offenders (Brown et Timeline Followback (TLFB) al., 2008; Fridell, Hesse, & Billsten, 2007; The Timeline Followback (TLFB) protocol Palmer, Ball, Rounsaville & O’Malley, provides a detailed daily history of alcohol and 2007) other substance use over a specific period of time ■ In a meta-analysis of drug-involved (from 7 days to 2 years) but is employed most populations (Hjorthøj, Hjorthøj, & frequently to examine substance use within the Nordentoft, 2012), agreement between previous 3 months. The TLFB involves using a biological assessment (e.g., urine drug blank calendar to help produce a detailed pattern tests) and the self-report TLFB is quite good across drug classes (79–94 percent). of substance use and nicotine use over specified Agreement between biological measures time intervals. The calendar is used to help

161 Screening and Assessment of Co-Occurring Disorders in the Justice System

and the self-report TLFB is quite good (r scores range .52–.62) in both samples across different time periods assessed by (DeMarce et al., 2007) the TLFB. For example, with a period ■ The TLFB is highly correlated with self- of less than 30 days, TLFB agreement report measures of drug use frequency ranges 81–85 percent, and for over 30 (DUF) over the previous 6 months across days, agreement ranges 87–93 percent. all drug classes (O’Farrell, Fals-Stewart, The TLFB produces few false negative Murphy, & Murphy, 2003; r scores range errors for most categories of drugs when .83–.96). Very high rates of agreement compared to urinalysis (Westerberg, have also been found between the TLFB Tonigan, & Miller, 1998) and DUF on use versus non-use across ■ In comparing biological assays and the all drug classes (r scores range .97–1.00; TLFB for specific drug classes during the O’Farrell et al., 2003) past 60 days, agreement was 86–92 percent ■ The TLFB is highly correlated with for cocaine and 84–87 percent for cannabis measures of general life functioning (r (Stasiewicz et al., 2008). Agreement scores = .62–.99; Westerberg et al., 1998) across multiple substances during the past ■ The test-retest reliability of the TLFB over 6 months is also high (kappas = .74–.94; 1–2 weeks is quite good among people with Morgenstern, Hogue, Dauber, Dasaro, & substance use disorders seeking treatment, McKay, 2009), providing support for the for percent of days abstinent, longest period reliability and validity of the TLFB over of use, and longest period of abstinence time over 30, 60, and 360 days, for both cocaine ■ Comparisons between the TLFB and (ICCs range .74–.90; r scores range .75– ASI for people with CODs have found .91) and marijuana (ICCs range 89–.96; r high rates of agreement between the two scores range .81– 96). Test-retest reliability instruments (kappa = .79; Carey, 1997). was also quite good for the total number However, the TLFB may yield higher of marijuana joints used (ICC = .78–.94; r estimates of drinking than the ASI over a scores range .79–95) and number of joints 30-day interval used per day (ICCs = .85–.93, r scores ■ In support of the concurrent validity of the range .80–.94; Robinson et al., 2012) TLFB among those enrolled in residential ■ The TLFB has very good test-retest substance use treatment, the TLFB shows reliability for drinking, illicit drug use, and adequate agreement with the ASI (past psychosocial functioning (r score > .90; 30 days) for reported alcohol use among Tonigan, Miller, & Brown, 1997). The people with substance use disorders TLFB shows good test-retest reliability (SUDs) only and for people who have over 5 days among substance-involved CODs (91–93 percent agreement, kappas outpatients and for 30, 60, and 90 days range .60–.70). Agreement is also high across a range of drinking variables (Carey, for drug use (82–87 percent, kappas range Carey, Maisto, & Henson, 2004; Pedersen .63–.70; DeMarce et al., 2007) & LaBrie, 2006) ■ For samples with either SUDs or CODs, the TLFB demonstrates good agreement Concerns with collateral reports of alcohol use ■ Completion time for the TLFB depends on (90-91 percent; kappas range .50–.61) the time period covered and the individual and with drug use (77–81 percent: kappas pattern of consumption range .45–.62). Good agreement was also ■ There are lower agreement rates on the found between the TLFB and frequency of TLFB for shorter recall periods (e.g., drinking days, as measured by the ASI (r shorter number of days assessed; Hjorthøj scores range .70–.78) and collateral reports et al., 2012)

162 Instruments for Screening and Assessing Co-Occurring Disorders

■ The quantity of drug use may not be as articulated by the RNR theoretical model. adequately assessed for drugs such as Recommendations for substance use and treatment cocaine and amphetamines. A related matching instruments in the justice system include concern to cannabis/marijuana is that the the following: type of measurement used (e.g., number of joints) may not adequately assess the 1. The TCU short forms (e.g., TCUDS V, TCU amount consumed CEST, TCU TRMA, TCU HLTH). These forms address key criminogenic needs and Availability and Cost psychosocial factors related to treatment The TLFB instrument is available online at no intake and matching, and can be tailored charge from the Nova Southeastern University, according to the specific resources and Center for Psychological Studies at the following assessment needs of a particular justice site: http://www.nova.edu/gsc/online_files.html program or setting.

Calendars, instructions, and method manuals for (and/or) alcohol, drugs, and nicotine can be downloaded at no cost. The Timeline Followback-User’s Guide is 2. The TCU Criminal Justice Comprehensive available for $29.95 from the Centre for Addiction Intake (TCU CJ CI), which can be used and Mental Health at the following site: http:// in settings that do not currently utilize a www.camhx.ca/Publications/CAMH_Publications/ standardized intake instrument. The TCU CJ timeline_followbk_usersgd.html CI intake can be combined with other short forms to provide a full assessment and to Recommendations for Assessment assist in treatment matching. of Substance Use and Treatment The TCU short forms each take approximately Matching 5–10 minutes to administer and score and can be Information in this section provides a critical administered by nonclinicians who are trained in review of treatment matching approaches and scoring and administration procedures and aware a description of specific instruments that can of appropriate referral procedures. The TCU CJ be used for assessing and matching offenders CI takes approximately 90 minutes to administer who have CODs to appropriate services. The and score and should be conducted by a trained assessment instruments described in this section and licensed/certified clinician. vary considerably in the level of detail provided for mental disorders and CODs. This analysis Assessment Instruments for Mental is based on a review of research examining the Disorders reliability and validity of these approaches and instruments, the relative cost of instruments, ease The assessment instruments described below of administration of instruments, and potential for require significant training in administration, application within the justice system. Although scoring, and interpretation. As a result, these summaries of instruments are based on DSM-IV instruments should be administered by trained criteria, instrument recommendations are based mental health staff who are licensed, certified, or on the potential for alignment with the DSM-5 otherwise credentialed in assessing and diagnosing criteria to allow for a more seamless transition mental disorders and related psychosocial to the newly implemented DSM-5 diagnostic problems. classification system. Recommendations for assessment of substance use and treatment matching instruments include those that address criminogenic needs (i.e., “dynamic risk factors”)

163 Screening and Assessment of Co-Occurring Disorders in the Justice System

Minnesota Multiphasic Personality MMPI-2RF include improvement in the validity Inventory-2 (MMPI-2/MMPI-2 RF) scales for nonresponding, inconsistent responding, overreporting, and underreporting of symptoms. The MMPI (Hathaway & McKinley, 1951; The “?” or “cannot say” scale (CNS) has not been Hathaway & McKinley, 1967; Hathaway & altered from the MMPI-2. McKinley, 1989) is one of the most widely used instruments for assessment of mental disorders. The MMPI-2 RF features revised versions of the The MMPI has been used in correctional MMPI-2 validity scales, including the following: settings since 1945 to classify individuals and Variable Response Inconsistency (VRIN-r) and to predict behaviors while incarcerated and True Response Inconsistency (TRIN-r); the Lie after release (Megargee et al., 1979; Megargee scale, which is now Uncommon Virtues (L-r); & Carbonell, 1995). The MMPI-2 replaced the and the K-Scale (Correction Scale), now referred MMPI (Butcher, Dahlstrom, Graham, Tellegen, to as Adjustment Validity (K-r). The latter two & Kaemmer, 1989) following several rounds of scales address underreporting of symptoms. The scale revisions. The instrument is a self-report other four validity scales address overreporting of measure with 567 items and 10 main clinical symptoms and improve upon three of the MMPI- scales, including Hypochondriasis, Depression, 2 scales of Infrequent Response (F-r), Infrequent Hysteria, Psychopathic Deviancy, Masculinity- Psychopathology Responses (Fp-r), and Symptom Femininity, Paranoia, Psychasthenia (obsessive- Validity (FBS-r, previously Fake Bad Scale; Ben- compulsive features), Schizophrenia, Hypomania, Porath, Tellegen, & Graham, 2008). An additional and Social Introversion. The MMPI provides 15 scale, the Infrequency Somatic Response (Fs) supplementary content scales that address internal was added to identify overreporting of somatic traits, external traits, and general problems. complaints. The final scale, the Response Bias In addition, the MMPI contains six validity Scale (RBS; Gervais, Ben-Porath, Wygant, & scales that examine response sets, including Green, 2007), identifies overreporting in personal unanswered items, endorsement of uncommon injury or medical disability settings and negative items, inconsistent responding, malingering, response bias in forensic settings. overreporting of symptoms, and faking good. All revised scales are shorter than the original An abbreviated version of the MMPI-2 includes validity scales and feature improved psychometric 370 items, but scores obtained are not as methods for testing the validity of these scales comprehensive as the original 567-item version in detecting inconsistent responding and (Butcher & Hostetler, 1990). The MMPI-2 underreporting or overreporting of symptoms. The Restructured Clinical (RC) scales (Tellegen et al., MMPI-RF T scores are not K-corrected (correction 2003) are revised versions of the original clinical used to represent the accuracy of scores and to scales and improve upon the overlapping item compensate for faking good or faking bad) nor content and high correlations between scales. are they gender specific. This allows for clinician The most recent version of the instrument is judgment when examining differences between the MMPI-2 Restructured Form (MMPI-2 RF; the non-K corrected clinical scale T scores and Ben-Porath & Tellegen, 2008), which is based the K-corrected clinical scale T scores because on norms from the MMPI-2 and retains the previous research indicates that the K-corrected same RC scales. The MMPI-2 RF has 338 items scales have poor validity. The RC (Restructured and 51 scales. These scales include Validity Clinical) scales are the same as those in the scales, Higher-Order scales (HO), RC scales, MMPI-2. Somatic/Cognitive, Internalizing, Externalizing, The MacAndrew Alcoholism Scale-Revised Interpersonal, Interest, and Personality (MAC-R) was developed to differentiate Psychopathology Five (PSY-5). Changes to the

164 Instruments for Screening and Assessing Co-Occurring Disorders alcoholic from nonalcoholic psychiatric & Lillenfeld, 2012; Mattson, Powers, patients. This supplementary scale on the Halfaker, Akeson, & Ben-Porath, 2012; MMPI-2 includes 49 items that provide a subtle Wilson, 2012) screening measure to differentiate alcoholics ■ The MMPI-2 is available in several from nonalcoholics (Searles et al., 1990). A 13- languages and can be administered using item Addiction Acknowledgment Scale (Weed, a paper and pencil format, by audio Butcher, McKenna, & Ben-Porath, 1992) was recording, or via a computerized version of developed using items in the MMPI-2 whose the instrument content is clearly related to substance use. The ■ The MMPI-2 is well validated in a variety Addiction Potential Scale was also developed, of settings and has good psychometric which included heterogeneous items related to properties (Butcher, Graham, Ben-Porath, extroversion, excitement seeking, risk taking, and Tellegen, & Dahlstrom, 2001; Graham, lack of self-efficacy. 2000; Greene, 2000) ■ A derived MMPI-RF measure of The MMPI-2 Criminal Justice and Correctional psychopathy corresponds well with other Report was developed for use in justice settings. validated measures (e.g., Psychopathic This report assists in determining diagnoses and Personality Inventory; Lilienfeld & analyzing the MMPI-2 validity, clinical, content Andrews, 1996) and traits (antisocial scales, and supplementary scales. The report behaviors, narcissism; Phillips, Sellbom, provides information relevant to assessment, risk Ben-Porath, & Patrick, 2014; Sellbom, assessment, and treatment and program planning Ben-Porath, Lilienfeld, Patrick & Graham, for individuals involved with the justice system. 2005; Sellbom et al., 2012) The report contains several behavioral dimensions ■ The MMPI-2 RC scales demonstrate that examine the need for further mental health concurrent validity with other similar assessment, conflict with authorities, extroversion, substantive measures (Tellegen, Ben- likelihood of favorable response to academic Porath, & Sellbom, 2009). For example, or vocational programming, and hostile peer RC2-low positive emotion is correlated relations. Several potential problem areas are with depressive mood symptoms (Arbisi, also identified, related to alcohol or substance Sellbom, & Ben-Porath, 2008; Forbey use, manipulation of others, hostility, and anger & Ben-Porath, 2007; Handel & Archer, control. 2008) and social anxiety (Forbey & Ben- Porath, 2008), and RC1-somatic symptoms Positive Features are correlated with somatoform problems (Arbisi et al., 2008; Forbey & Ben-Porath, ■ Only a sixth-grade reading level is required 2007, 2008) ■ The MMPI-2 was normed using a large sample that was representative of the U.S. ■ The MMPI-2 RC scales indicate high population internal consistency across gender groups in clinical representative samples (alphas ■ A specialized interpretive report is range .78–.95; Rogers, Sewell, Harrison, available for justice-involved individuals & Jordan, 2006). The RC scales show ■ Scales and profile configurations, which improvement over the clinical scale in indicate personality profiles, have similar reducing interscale correlations (Rogers, correlates in forensic settings as in other Gillard, Berry, & Granacher, 2011; Tellegen settings (Graham, 2006) et al., 2003) ■ The MMPI-2 has been used extensively ■ Several studies support the validity of the with justice-involved individuals (Claes, revised or added RF validity scales for the Tavernier, Roose, Bijttebier, Smith, MMPI-2RF. The VRIN-r, TRIN-r, L-r, and

165 Screening and Assessment of Co-Occurring Disorders in the Justice System

K-r are useful in identifying underreporting ■ Clinical elevations on the RC scales among both clinical and nonclinical are difficult to interpret when used in samples (Sellbom & Bagby, 2008). The combination, as scales can provide Fp-R indicates incremental utility in contradictory information. For example, detecting overreporting of psychopathology RC1 demonstrates clinical elevations (Tellegen & Ben-Porath, 2008. The Fs in over 60 percent of cases (somatic scale also provides incremental utility in complaints), but these profiles were identifying exaggerated or “faked” somatic classified as within normal limits. The complaints (Wygant et al., 2007). The RCd, which reflects general psychiatric FBS-r, F-r, and F-s are able to identify distress, shows no elevation for those who neurocognitive, emotional, and somatic endorsed persecutory ideation on RC6 complaints (Wygant et al., 2010). Among (Rogers et al., 2011) offenders, the F-r and Fp-r were able to ■ Although the RBS scale improves identify malingering of psychopathology identification of symptom validity, (Sellbom, Toomey, Wygant, Kurcharski, other symptom validity tests are still & Duncan, 2010; Wygant et al., 2011), recommended during the assessment and these scales have been shown to be process (Heilbronner et al., 2009) effective when compared to the Structured ■ The FBS-r and Fs may not perform well in Interview of Reported Symptoms (SIRS; detecting malingering, as they are focused Rogers, Bagby, & Dickens, 1992) more on somatic and cognitive deficit ■ The Response Bias Scale (RBS; Gervais complaints (Sellbom et al., 2010) et al., 2007) is able to identify the validity ■ Many of the studies that validate scales of of reported symptoms in forensic settings the MMPI-2 RF use archival data sets that as demonstrated by its discriminatory have previously been used in validating ability to distinguish between those who the MMPI-2 and thus employ convenience pass or fail the symptom validity tests sampling rather than replication in diverse (Word Memory Test: Green, 2003; Test of samples Memory Malingering: Tombaugh, 1996). The RBS scale is also associated with other ■ Since the MMPI-2 is based on symptom validity scales such as the F-r, psychological constructs developed in Fp-r, and Fs. Combinations of these scales the 1940s, both the content and clinical can improve the specificity of overreported scales are somewhat heterogeneous. As psychopathology and somatic complaints such, there is some overlap among scales, (Wygant et al., 2010) which lessens the discriminant validity of this measure. For example, while it is Concerns possible to differentiate between bipolar ■ The MMPI-2 requires somewhat more time disorder and schizophrenia using the to administer than the PAI Depression (Dep) content scale, no clinical or content scales on the MMPI-2 are able ■ The MMPI-2 RF does not include updated to differentiate between bipolar depression norms and is based on norms from the and unipolar depression (Bagby et al., MMPI-2. Many validation studies of the 2005) MMPI-2RF employ the original validation data for the MMPI-2, and few studies have ■ The K correction scale does not have been conducted by those other than the empirical support in many populations instrument developers (Barthlow, Graham, Ben-Porath, Tellegen, & McNulty, 2002), and there is some ■ The MMPI-2 RC scales provide poor disagreement regarding the cut-off scores convergent validity for related areas of to use for different validity scales to detect psychopathology (Rogers et al., 2011)

166 Instruments for Screening and Assessing Co-Occurring Disorders

malingering (Meyers, Millis, & Volkert, Inventory consists of 14 Personality Disorder 2002) Scales and 10 Clinical Syndrome Scales, ■ Hispanic respondents produce higher both of which include separate Moderate and scores on the Lie scale, and culturally Severe Syndrome Scales. In addition, there specific norms or corrections have not been are Correction Scales that help detect random developed for this scale responding and consist of three modifying indices ■ The MMPI-2 scale names do not reflect the (disclosure, desirability, and debasement) and domains that are measured one validity index. The MCMI-III contains three ■ The MMPI was developed using an Facet Scales for each MCMI-III Personality Scale. empirical approach with the goal of The Facet Scales were developed using factor discriminating between individuals with analytic techniques and are included to guide psychiatric diagnoses and individuals clinicians in the interpretation of the Clinical without any diagnosis. However, items Personality Patterns and the Severe Personality were not selected based on theory or Pathology Scales. The scales aid in identifying psychopathology research specific personality processes (e.g., self-image, ■ The MAC-R scale does not have good interpersonal conduct, cognitive style) that internal consistency (.56 for men and .45 contribute to overall scale elevations. Base rates for women; Butcher, Dahlstrom, Graham, of disorders in the specific population are used Tellegen, & Kaemmer, 1989). In addition, as cut-off scores to indicate clinically significant several studies have urged caution when levels of severity (i.e., > 75 percent = moderate using the MAC-R scale with African level, > 85 percent = severe level; Millon, 1997). Americans (Graham, 2006) Two of the Moderate Syndrome Scales of the Availability and Cost MCMI-III address substance use (B-Alcohol Information describing the MMPI-2 RF can be Dependence, T-Drug Dependence). The MCMI- found at the following location, including scales, III is well suited for use in correctional settings. A frequently asked questions, references, and an separate Correctional Summary includes the use of interpretation guide: http://www.upress.umn.edu/ special correctional norms for certain scales and a test-division/MMPI-2-RF/mmpi-2-rf-publications one-page summary of likely needs and behaviors relevant to corrections settings, including the need The MMPI-2 RF manual, scoring sheets, and for mental health and substance use treatment. scoring/interpretive software can be purchased at The report classifies a justice-involved individual’s the following location and are quite costly: http:// probable needs as low, medium, or high in the psychcorp.pearsonassessments.com/HAIWEB/ areas of mental health intervention, substance Cultures/en-us/Productdetail.htm?Pid=PAg523 use treatment, and anger management services. In addition, escape risk, reaction to authority, Millon Clinical Multiaxial Inventory-III disposition to malinger, and suicidal tendencies are (MCMI-III) evaluated.

The MCMI-III (Millon, 1983, 1997) is an Positive Features objective, self-report psychological assessment ■ The MCMI-III is brief to administer, measure consisting of 175 true/false items. The requiring approximately 25 minutes to MCMI is designed to assess DSM-IV Axis complete II (personality) disorders and related clinical ■ The MCMI-III provides an interpretive syndromes (Axis I) and is particularly useful report that describes potential DSM-IV in identifying personality disorders that may diagnoses that may apply affect involvement in treatment. The Personality

167 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ The instrument can be administered scales on the MCMI I and MCMI II (Craig, via paper and pencil, audiotape, CD, or 1997) computer ■ The MCMI-III disclosure, desirability, and ■ The instrument is available in English and debasement validity scales are effective Spanish in detecting malingering among traumatic ■ The measure was normed with adult brain injury patients (Aguerrevere, Greve, inpatient and outpatient clinical samples Bianchini, & Ord, 2011) and with individuals in jail and prison Concerns ■ The MCMI-III has been used in justice/ ■ Little research has been conducted to forensic settings (Bow, Flens, & Gould, examine the cultural sensitivity of the 2010; Ferragut, Ortiz-Tallo, Loinaz, 2012; MCMI-III Morgan, Fisher, Duan, Mandracchia, & Murray, 2010; Young, Wells, & ■ An eighth-grade reading level is required, Gudjonsson, 2011) which may be problematic in some justice settings ■ The AUC, sensitivity, and specificity are acceptable for the MCMI-III as determined ■ AUCs for the MCMI-III anxiety and by comparison with clinician-rated DSM- dysthymia scales are quite poor in detecting IV diagnoses (Millon, 1997) DSM-IV anxiety disorders or dysthymia (Hsu, 2002) ■ AUCs (> .70) for the MCMI-III scales are adequate for alcohol, drug, psychotic ■ An international study found poor (MCMI-III delusions scale only), and major agreement between the MCMI-III and the depressive disorders when compared to MINI in diagnosing treatment-seeking DSM-IV diagnoses (Hsu, 2002) people with substance use disorders (Hesse et al., 2012) ■ The MCMI-III personality disorder scales show relatively good convergent validity ■ Another international study of a mental with the MMPI scales for most disorders health treatment-seeking population (Rossi, Hauben, Van den Brande, & Sloore, indicated poor sensitivity for the MCMI-II 2003) in detecting anxiety disorders, dysthymia, and major depressive disorder and poor ■ The MCMI-III demonstrates adequate specificity for anxiety disorders and diagnostic accuracy for Axis I disorders dysthymia, as indexed by the MINI clinical in international settings when compared interview (Saulsman, 2011). The MCMI- with results from the Mini International III also did not adequately distinguish Neuropsychiatric Interview (MINI; AUCs between anxiety disorders and depressive > .70), with the exception of psychotic disorders disorders (Hesse, Guldager, & Holm Linneberg, 2012). This same study ■ Several studies examining the validity supports the convergent validity of MCMI- of the MCMI-III (Millon, 1994; Millon, III scales with other measures, such as the 1997) indicate significant differences Beck Anxiety Inventory and the MINI in diagnostic accuracy and raise methodological concerns (Hsu, 2002; ■ Another international study indicates Millon, 1994; Millon, 1997; Retzlaff 1996) acceptable sensitivity for the anxiety scale related to the impact of varying levels of of the MCMI-III (73 percent), as identified clinician skills and uneven interviewing by diagnoses obtained from the MINI procedures (Saulsman, 2011) ■ Some MCMI-III scales do not perform ■ The sensitivity and specificity of MCMI- better than chance in detecting mental III Scales B (alcohol) and T (drug) are disorders and may not adequately significantly improved from equivalent

168 Instruments for Screening and Assessing Co-Occurring Disorders

discriminate between diagnoses (Hsu, based on a construct-validation framework that 2002) emphasized a rational and quantitative method ■ The MCMI-III thought disorder scale (SS) of scale development. A strong emphasis is may reflect general psychiatric distress, and placed on a theoretically informed approach to it is correlated with measures such as the the development and selection of items (Morey, Beck Anxiety Inventory and Montgomery 1998). Key areas examined by the PAI include Asberg Depression Rating Scale (MADRS; response styles, clinical syndromes, interpersonal Hesse et al., 2012) style, treatment complications, and subject’s ■ Based on the MCMI-III manual, environment. approximately 13 percent of people who randomly respond on the instrument The PAI instrument includes 344 items and 22 have invalid and noninterpretable results nonoverlapping full scales, with 4 validity scales, (Charter & Lopez, 2002). This study 11 clinical scales, 4 treatment consideration scales, also indicates that too few items may and 2 interpersonal scales. Validity scales include be contained in the validity scale of the inconsistent responding (ICN), infrequency of MCMI-III endorsed response (INF), negative impression ■ The MCMI-III may underreport management (NIM), and positive impression personality disorders among justice- management (PIM). Clinical scales include involved individuals (Retzlaff, Stoner, & separate measures for alcohol problems (ALC), Kleinsasser, 2002) drug problems (DRG), somatic complaints (SOM), ■ In prior versions of the MCMI, the Drug anxiety (ANX), anxiety-related disorders (ARD), Abuse Scale was found to have poor depression (DEP), mania (MAN), paranoia (PAR), sensitivity (39 percent) but high specificity schizophrenia (SCZ), borderline personality (88 percent) in identifying people with disorder (BOR), and antisocial personality substance use disorders (Calsyn, Saxon, & disorder (ANT). Treatment consideration scales Daisy, 1990) include aggression (AGG), suicide ideation (SUI), stress (STR), nonsupport or lack of social Availability and Cost support (NON), and treatment rejection (RxR). The MCMI, manual, and hand-scoring guide Interpersonal scales include dominance (DOM) can be purchased at the following site: http:// and warmth (WRM). A T score ≥ 70 on the psychcorp.pearsonassessments.com/HAIWEB/ clinical scales, treatment scales, and interpersonal Cultures/en-us/Productdetail.htm?Pid=PAg505 scales indicates clinically significant problems. There are 27 critical items that indicate acute Costs for the MCMI vary depending on the desired problems (e.g., suicidal ideation) for which follow- format. Scoring software is available that provides up with the client should be provided. The PAI interpretive reports. requires approximately 50 minutes to complete (Morey, 2007). Personality Assessment Inventory (PAI) Positive Features The PAI is a self-administered objective test of ■ The PAI was standardized on a sample that personality and psychopathology developed to matched the 1995 census on gender, race, provide information related to treatment planning and age (Morey, 1998) and evaluation. Although the instrument was ■ PAI test items and scales were empirically introduced more recently than the MMPI and the derived and are based on clinical research MCMI, it has received considerable attention by and personality theory (Morey, 1991) clinicians and researchers because of its rigorous ■ A Spanish version of the PAI is available methodology. The development of the PAI was

169 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ Additional software for justice settings is ■ The ANT scale contains subscales available that is geared towards assessment examining aggression, dominance, of risk, psychological needs, and and violence potential and provides an rehabilitation assessment of risk factors that predict ■ Validity scales allow the clinician to detect recidivism and violence in offenders whether items are left unanswered, answers (Boccaccini et al., 2010; Morey, Warner, & are inconsistent, infrequent items are Hopwood, 2007) endorsed, and whether attempts are made ■ The ANT, AGG, and DRG scales have been to provide an overly negative or positive found to predict prison infractions in an impression international offender sample, including ■ Information regarding symptom severity violent, nonviolent, and drug-related is provided, which helps in developing infractions and recidivism (Newberry & assessment and treatment recommendations Shuker, 2012), as indexed by the Offender Group Reconviction Scale (OGRS, Copas ■ The PAI includes 27 critical items, chosen & Marshall, 1998) based on their importance as indicators of potential crisis situations. These items ■ Incremental validity for the PAI-ANT facilitate follow-up probes to examine the scale has been found in predicting need for crisis or other clinical services disciplinary problems, verbal and physical aggression, and recidivism (Buffington- ■ An interpretative profile is provided Vollum, Edens, Johnson, & Johnson, 2002; with each report to guide the clinician in Walters & Duncan, 2005; Walters et al., developing treatment approaches 2003) in comparison to clinical measures ■ The PAI is widely used in justice settings such as the PCL-R (Hare & Vertommen, and substance use settings (Boccaccini, 2003). The scale performs as well as the Murrie, Hawes, Simpler, & Johnson, Static-99 (Hanson & Thornton, 1999) and 2010; Boccaccini, Rufino, Jackson, & Minnesota Sex Offender Screening Tool- Murrie, 2013; Magyar et al., 2012; Patry, Revised (Epperson, Kaul, Hesselton, 1998) Magaletta, Diamond, & Weinman, 2011; in predicting recidivism among sexual Ruiz et al., 2012; Salekin, 2008; Walters, offenders (Boccaccini et al., 2010) Duncan, & Geyer, 2003) ■ In an offender sample, incremental validity ■ The PAI is used in the criminal sentencing has been found for the AGG scale in process, including cases involving capital predicting noncompliance (e.g., gambling, sentencing (Mullen & Edens, 2008) stealing) and aggressive behaviors (both ■ The PAI-ANT scale is related to other verbal and physical) above and beyond measures of antisocial behaviors and scales such as ANT and BOR. Overall, criminal thinking (Bradley et al., 2007; AGG, BOR, and ANT scales have been Douglas et al., 2007; Walters & Geyer, found to predict aggressive or disruptive 2005), such as the Shedler-Westen behaviors (Magyar et al., 2012) Assessment Procedure (SWAP-200; Westen ■ The concurrent validity of the PAI & Shedler, 1999a,1999b), and measures of with offenders is supported by findings psychopathy (Douglas, Guy, Edens, Boer, indicating that the DRG and ALC scales & Hamilton, 2007; Patrick, Poythress, are correlated with other indices of Edens, Lilienfeld, & Benning, 2006; Edens alcohol use and drug use from the Federal & Ruiz, 2005), such as the Psychopathy Bureau of Prisons mental health data base, Checklist-Revised (PCL-R; Hare & psychological intake questionnaire, and Vertommen, 2003) and the Psychopathic presentencing reports (Patry et al., 2011) Personality Inventory (PPI; Lilienfeld & ■ In support of the PAI’s external validity Andrews, 1996) among offenders who are court mandated

170 Instruments for Screening and Assessing Co-Occurring Disorders

to substance use treatment, higher scores on ■ The Spanish version of the PAI may not the AGG scale are correlated with a history provide psychometric properties that of assault. Similarly, higher ANT scale are equivalent to the English version scores are related to rule-breaking while (Fernandez, Boccaccini, & Noland, 2008; in treatment, particularly among offenders Rogers, Flores, Ustad, & Sewell, 1995) who have higher scores on the DRG scale. ■ Several unique issues should be considered The SUI scale accurately identifies those in interpreting the PAI’s validity scales who have a history of suicide attempts in justice and treatment settings. For (Hopwood, Baker, & Morey, 2008) example, people seeking treatment may ■ Also supporting external validity of the have higher NIM scale scores as they may PAI with both psychiatric inpatients and exaggerate symptoms to secure treatment. outpatients, the PAI clinical scales show PIM scores may also be elevated in justice moderate to strong correlations with life settings as a result of attempts to deny events that are relevant to PAI scales. potential problems, such as substance use For example, the ANT scale is correlated (Douglas et al., 2007; Morey & Quigley, with history of arrest, alcohol, and drug 2002; Newberry & Shuker, 2012). INF problems, and lower education level. and ICN scores may also be inflated Similarly, the DRG, ALC, BOR, and AGG among offenders, who tend to respond scales are correlated with the history of inconsistently and to endorse items with arrest. The ARD scale is also correlated to low base rates (Douglas et al., 2007; trauma and prior history of hospitalization, Newberry & Shuker, 2012). However, and the DEP scale is correlated with prior scale scores may be affected by poor hospitalization (Slavin-Mulford et al., reading abilities (Nikolova, Hendry, 2012) Douglas, Edens, & Lilienfeld, 2012) ■ Within offender samples, the PAI clinical ■ Inappropriate use of cut-off scores with scales may reflect a two-dimensional offenders may lead to misclassification in structure of “internalizing” and determining “risk” level and in assignment “externalizing” tendencies, as indicated to services (Edens, Poythress, & Watkins- by statistical taxometric procedures and Clay, 2007) confirmatory factor analysis (Ruiz & ■ For offenders with high PIM scale scores Edens, 2008) (T scores ≥ 57), the violence potential ■ The overall psychometric properties of index (composed of items from different the PAI are quite favorable (Morey, 1991; PAI scales, including drug use, aggression, Morey, 2007) and include high internal and antisocial behaviors) and the SUI and consistency of scales (Magyar et al., 2012) STR scales may not be useful in assessing ■ Full-scale reliability estimates for the PAI risk, and ANT scale scores may not as are high, averaging .82 (Boone, 1998) effectively predict problem behaviors (Walters, 2007) Concerns ■ The PAI’s alcohol and drug scales are ■ The PAI is a commercially available susceptible to denial since the item content instrument is not subtle ■ Only trained mental health professionals Availability and Cost can administer and interpret the PAI The PAI is available at cost from Psychological ■ The PAI may be lengthy to administer, Assessment Resources at the following site: http:// typically requiring an hour but sometimes requiring up to 2.5 hours to complete www4.parinc.com/Search.aspx?q=PAI

171 Screening and Assessment of Co-Occurring Disorders in the Justice System

There are numerous PAI resources available, be administered and interpreted by a trained and including the instrument, scoring sheets, an licensed/certified mental health professional. interpretive guide, a user manual, and scoring software that generates interpretive reports. Assessment and Diagnostic Supplementary software is also available Instruments for Co-occurring Mental that generates interpretive reports geared for correctional settings. and Substance Use Disorders This section reviews instruments that are used to A PAI kit can be purchased for $315 and includes diagnose or assess CODs. Included are assessment the professional manual, answer booklets, the instruments that examine other biopsychosocial instrument, and materials for hand scoring (e.g., domains related to CODs. Diagnostic instruments profile forms). include those that evaluate DSM or ICD disorders Recommendations for Assessment of and provide a diagnosis for a range of mental Mental Disorders and substance use disorders. Some instruments, such as the GAIN and MINI, which include Information describing assessment instruments multiple versions (e.g., screening, assessment) are for mental disorders is based on a critical described in this and other sections. In contrast evaluation of the research examining the efficacy to instruments described in screening sections, of these instruments. Important indicators used assessment instruments described in this section in evaluating instruments include the following: require more time to administer; provide more empirical evidence supporting both the reliability detailed and comprehensive coverage of issues and validity of the instrument, ability to assess related to the various disorders; and are designed multiple mental health problems/disorders, to yield formal diagnoses and treatment plan the relative cost of the instrument, ease of recommendations, including levels and types of administration and interpretation, and previous use services that are needed. The assessment and within justice settings. Although the assessment diagnostic instruments described below require instruments provide information that addresses the significant training in administration, scoring range of mental disorders described in the DSM- and interpretation. As a result, these instruments IV, it is highly desirable for these instruments to be should be administered by trained clinicians who closely aligned with the newly implemented DSM- are licensed, certified, or otherwise credentialed in 5 criteria to allow for a seamless transition from assessing and diagnosing mental and substance use the DSM-IV to DSM-5 diagnostic classification disorders and related psychosocial problems. systems. Based on these considerations, the following instrument is recommended for use in Assessment Instruments for Co- assessing mental disorders for people with co- occurring Mental and Substance Use occurring disorders in the justice system: Disorders ■ The Personality Assessment Inventory (PAI) Alcohol Use Disorders and Associated Disabilities Interview (AUDADIS-IV) The PAI assesses personality traits, mental health problems/disorders, and other treatment-related The AUDADIS-IV (Grant & Dawson, 2000) is problems and requires approximately 45–60 both an assessment and diagnostic instrument, minutes to administer and 25–30 minutes to and is a fully structured clinical interview that is score and interpret. The PAI provides several based on the DSM-IV and ICD-10 criteria. The validity indices and facilitates clinician follow- AUDADIS-IV assesses alcohol, drug, and nicotine up to individual item responses. The PAI should use disorders. It also assesses mental disorders,

172 Instruments for Screening and Assessing Co-Occurring Disorders

including mood disorders, anxiety disorders, and ■ The AUDADIS-IV has been used with DSM-IV personality disorders, in addition to the offenders to study antisocial behaviors family history of mental disorders. The instrument and their correlates (e.g. drug use, low is standardized to diminish the unreliability that income,) in a large national epidemiological is often found in other structured interviews and survey (Gelhorn, Sakai, Kato Price, & navigates complex diagnostic criteria by use of Crowley, 2007; Hoertel, Le Strat, Schuster, multiple short questions. If the respondent meets & Limosin, 2012; Vaughn et al., 2011; Vaughn et al., 2010) criteria for a particular diagnosis, all questions in the module are asked to provide a more complete ■ The AUDADIS-IV has also been used dimensional assessment of related problems. as a diagnostic/assessment tool in justice The instrument requires approximately 1 hour settings (Kerridge, 2009) to administer and provides both lifetime (prior ■ The concurrent validity of the AUDADIS- to past 12 months) and current diagnoses (past IV is supported by findings of high 12 months). The AUDADIS-IV examines the comorbidity of nicotine disorders with onset of disorders; duration of symptoms of each other substance use disorders and is disorder; the presence of co-occurring disorders; correlated with mental health scores on the SF-12; (Short Form Health Survey, severity and impairment of symptoms, including Compton, Thomas, Stinson, & Grant, 2007; “rule out” causes of symptoms (e.g., use of Gandek et al., 1998; Grant et al., 2004; medication or drugs); frequency of substance use, Hasin, Stinson, Ogburn, & Grant, 2007; patterns of use; and quantity of use. The most Kessler et al., 1994) recent version of the AUDADIS-IV includes ■ The concurrent validity of the AUDADIS- additional risk factor scales related to social and IV is also supported by findings from a occupational functioning, such as the self-reported large epidemiological study that yielded discrimination scales (e.g., reported bias against high rates of co-occurring substance use, race, weight, ethnicity, culture). The instrument anxiety, and mood disorders (Grant et al., also examines stressful life events and perceived 2004). This same study indicated that stress. personality disorders were associated with lower mental health scores as measured by Positive Features the SF-12 (Grant et al., 2004). Borderline ■ The AUDADIS-IV is fully structured and personality disorder was associated with translates DSM-IV criteria into simpler increased mental and social difficulties, language and thus can be administered by which is consistent with findings from nonclinicians other studies (Grant et al., 2008) ■ The AUDADIS-IV has been translated into ■ Concurrent validity is also supported by Spanish findings of high rates of co-occurring ■ The AUDADIS-IV was designed to depression among offenders who have comprehensively assess for CODs among substance use disorders (Kerridge, 2009) people who have substance use disorders ■ In large representative samples, interrater ■ The AUDADIS-IV provides adequate reliability for drinking and tobacco use coverage of quantity, frequency, and frequency and quantity were quite good duration of substance use disorders over an average 10-week period, with ICCs ■ The AUDADIS-IV provides improved ranging .69–.84 (Grant, Dawson, Stinson, coverage of the chronology of symptoms Chou, Kay, & Pickering, 2003). Interrater and disorders in comparison to other reliability for current and lifetime alcohol structured assessment interview instruments use disorders is also quite good (kappas (Grant et al., 2003) range .70–.74; Grant et al., 2003)

173 Screening and Assessment of Co-Occurring Disorders in the Justice System

■ Interrater reliability for depressive The Composite International Diagnostic disorders is acceptable (kappas range .59– Interview (CIDI) .65), and reliability for severe anxiety is quite good (ICCs range .71–.86). Interrater The CIDI is a structured comprehensive interview reliability for adult ADHD and current/ developed by WHO to assess mental disorders lifetime PTSD is adequate (kappas range according to the definitions and criteria of the .63–.77; Ruan et al., 2008) International Classification of Disease (ICD, ■ The Spanish version of the AUDADIS- ICD-10) and the DSM (DSM-IV). The CIDI IV demonstrates good psychometric is one of the most widely used structured properties, including test-retest reliability diagnostic interviews internationally, as it was and interrater reliability for agreement on developed specifically for use among different diagnoses (Mestre, Rossi, & Torrens, 2013) cultures and settings. The instrument was ■ Internal consistency of the additional risk derived from the Diagnostic Interview Schedule factor scales related to perceived stress and (DIS; Robins, Helzer, Croughan, & Ratcliff, stressful life events are good (alphas range 1981) and accommodates diagnoses based on .82–.94), and discrimination for current/ the definitions and criteria of both the ICD and lifetime symptoms is acceptable (alphas DSM. The CIDI was first used in 1990 and range .59–.78; Ruan et al., 2008) was revised and expanded in 1998 by the WHO World Mental Health (WMH) initiative to address Concerns subthreshold impairment, symptom severity and ■ The AUDADIS-IV was developed in the persistence, risk factors, internal and external general population and would benefit from (global) impairment, consequences, patterns of further validation in clinical, criminal treatment, and treatment adequacy, in addition to justice, and substance use settings diagnosis of mental disorders (Kessler & Üstün, ■ Further validation is needed for AUDADIS- 2004). The WMH-CIDI contains 22 diagnostic IV modules examining PTSD and DSM-IV sections, including anxiety, mood, eating, tobacco, personality disorders and substance use disorders, attention deficit ■ The AUDADIS-IV does not assess for hyperactivity disorder (ADHD), conduct disorder, psychosis other than inquiring about psychosis, and personality disorders. There are lifetime diagnosis of schizophrenia and four sections assessing functioning and physical assessment of schizoid personality disorder comorbidity, two sections assessing treatment, (Grant et al., 2003) seven sections assessing sociodemographics, and ■ The AUDADIS-IV may not effectively two sections assessing methodological factors diagnose current/lifetime anxiety disorders (e.g., interviewer observations). The CIDI-SAM (ICCs range .40–.52, Grant et al., 2003) (Substance Abuse Module) can be used separately, ■ The discrimination scales indicate if desired, to diagnose substance use disorders. relatively low internal reliability across current and lifetime time periods (Ruan et Positive Features al., 2008) ■ Administration of the CIDI does not require use of mental health professionals or Availability and Cost significant clinical training to administer The AUDADIS-IV is available free of charge and ■ The CIDI provides both ICD-10 and DSM- can be obtained by contacting Dr. Bridget Grant at IV diagnoses [email protected] ■ A diverse sample was used to develop the instrument, including individuals with a broad range of alcohol and drug use severity

174 Instruments for Screening and Assessing Co-Occurring Disorders

■ The WMH-CIDI has been translated into ■ The WMH-CIDI demonstrates good several languages using the standard WHO sensitivity, specificity, positive predictive translation and back-translation protocol values, and negative predictive values ■ A computerized version of the CIDI across different mental disorders and severe is available, which contains a scoring substance use disorders (Kessler et al., algorithm to provide a diagnosis. The 1998), although the reliability of substance computerized version has the ability to use diagnoses have been less than adequate handle more elaborate “skip” patterns, in several studies (Kessler et al., 1998; while covering the same information as the Üstün et al., 1997) paper and pencil version (WHO, 2004) ■ The WMH-CIDI provides adequate ■ The CIDI has been used to diagnose agreement with the SCID-I for substance disorders among people with intoxicated use diagnoses (Haro et al., 2006) driving charges (Lapham, Baca, McMillan, Concerns & Lapidus, 2006; Shaffer et al., 2007), prisoners (Brinded, Simpson, Laidlaw, ■ The CIDI is quite lengthy and requires an Fairley, & Malcolm, 2001), and juvenile average of 2 hours to administer offenders (Steinberg, Blatt-Eisengart, & ■ Use of the WMH-CIDI requires completion Cauffman, 2006) of a training program that reviews ■ The CIDI-SAM shows acceptable interviewing techniques and field quality agreement with the Schedules for Clinical control Assessment in Neuropsychiatry (SCAN; ■ In a large U.S. survey, the WMH-CIDI Wing et al., 1990) in diagnosing alcohol exhibited low accuracy in identifying use disorders (kappa = .69) and cocaine use substance use disorders and a range of disorders (.61; Compton, Cottler, Dorsey, mental disorders when compared with the Spitznagel, & Mager, 1996). A nationally SCID-I (Haro et al., 2006) representative U.S. survey also indicates ■ Little data is available regarding the CIDI’s positive findings for the AUC for the effectiveness in justice settings WMH-CIDI for substance use disorders (AUC = .72–.99), anxiety disorders Availability and Cost (AUC = .74–93), mood disorders (AUC Both printable to paper and computerized versions = .87–.97), and “any” disorder (AUC = of the CIDI can be obtained free of charge from .76; Haro et al., 2006). According to this the World Health Organization at the following same survey, the CIDI-SAM demonstrates site: https://www.hcp.med.harvard.edu/wmhcidi/ good test-retest reliability for substance use disorders over a 1-week period (kappas download-the-who-wmh-cidi-instruments/ range 63–.80; Horton, Compton, & Cottler, Information regarding training in use of the CIDI 2000) can be found at the following site: https://www. ■ The CIDI has good sensitivity (74 percent) hcp.med.harvard.edu/wmhcidi/who-wmh-cidi- and specificity (98 percent) for any training/ substance use diagnosis (Haro et al., 2006) and has adequate sensitivity for anxiety disorders (84 percent), mood disorders (69 Global Appraisal of Needs (GAIN) percent), or “any” disorder (78 percent). The GAIN (Dennis, Titus, White, Unsicker, & The CIDI has excellent specificity (93 Hodgkins, 2006) includes a set of instruments percent, 97 percent, and 91 percent for each developed to provide screening and assessment of these respective disorders; Haro et al., 2006), and good positive predictive values of psychosocial issues related to mental and and negative predictive values substance use disorders. A more detailed

175 Screening and Assessment of Co-Occurring Disorders in the Justice System description of the GAIN family of instruments items needed for diagnosis, and the American is provided in the section entitled, “Screening Society of Addiction Medicine (ASAM) placement Instruments for Co-occurring Mental and criteria for treatment planning and referral. The Substance Use Disorders.” The GAIN instruments GAIN-I Core is used when the GAIN-Initial can be administered via interview or self- cannot be administered and contains less detailed administered by paper and pencil or by computer. information examining service utilization and A wide variety of software is available to score treatment history. The GAIN-I core requires and interpret results of the GAIN instruments. 60–75 minutes to administer. The GAIN-M90 The Quick version of the GAIN (GAIN-Q3) monitors treatment progress and is administered at requires 25–35 minutes to administer and includes 6, 9, and 12 months following treatment initiation; assessment of nine individual sections related it requires approximately 60 minutes to administer. to a wide range of psychosocial and behavioral health issues in adults and adolescents. The Positive Features GAIN examines areas such as substance use, ■ The GAIN-Q and GAIN-I is designed mental health status, physical health, stress, work for use in justice settings, primary care problems, life satisfaction, behavioral problems, settings, substance use treatment programs, and service utilization in the past 90 days. The and other social service programs GAIN instrument can also be used as a follow-up ■ Norms for the GAIN have been developed tool to assess and monitor progress. The GAIN-Q for adults and adolescents and for different provides a recommended cut-off score of ≥ 3 for levels of care. Additional norms are being both adults and adolescents in identifying people developed by gender, race/ethnicity, CODs, with a mental disorder (Dennis et al., 2006). and for juvenile and adult offenders Other versions of the instrument include the ■ Scoring software is available to interpret GAIN-Q3-Lite, which consists of nine individual scores for purposes of diagnosis and screeners and requires approximately 25 minutes treatment planning. Personal feedback to administer. The GAIN-Q3-MI (motivational reports (PFR) are also available interviewing) includes information regarding ■ Computerized versions of the GAIN are readiness for treatment and change. available that provide interpretation of assessment and validity reports to identify The GAIN-Initial requires approximately erroneous or missing data. A wide variety 120 minutes to administer and provides a full of support services are available through assessment of psychosocial issues related to the GAIN Coordinating Center substance use treatment, as well as internalizing ■ The GAIN has been used to assess and externalizing disorders and problems related mental disorders among juvenile and to crime and violence. The GAIN-Initial is useful adult offenders (Belenko, 2006; Hussey, for diagnostic purposes, treatment planning, Drinkard, & Flannery, 2007; Sacks et al placement in different levels of treatment 2007b, Ramchand, Morral, & Becker, services, and monitoring offender and/or program 2009) outcomes. Several versions of the GAIN-Initial ■ The GAIN has been widely used to assess have been developed for various programs, mental health problems among adolescents primarily those funded by CSAT and by the Robert and adults enrolled in substance use Wood Johnson Foundation. Several follow-up treatment (Chan, Dennis, & Funk, 2008; forms are available to examine change over time Dennis, White, & Ives, 2009; Shinn et al., in psychosocial areas related to treatment. The 2007) GAIN-I Lite is shorter to administer, requiring ■ Among adults, the GAIN-I demonstrates approximately 60 minutes, but is not as detailed as good predictive utility related to recidivism the full version. It contains the GAIN-Q3, other

176 Instruments for Screening and Assessing Co-Occurring Disorders

and relapse (Dennis, Scott, & Funk, 2003; ■ Among adolescents, the GAIN-I shows Dennis et al., 2006) good agreement with diagnoses of ■ The GAIN-I–Substance Problem Scale ADHD, mood disorders, conduct disorder/ is correlated with increased risk of oppositional defiant disorder, and internalizing and externalizing disorders and distinguishes among adults. The Behavior Complexity between co-occurring psychopathology Scale is correlated with severity of (kappas range .65–1.00; Shane, Jasiukaitis substance use problems, and the Crime/ & Green, 2003) Violence Scale is correlated with future ■ Among adolescents, the GAIN-I has good criminal behavior (Dennis et al., 2006) internal consistency for three subscales ■ A confirmatory factor analysis supports of internal mental distress, behavior the factor structure of the GAIN in adults, complexity, and crime/violence (Dennis including its use as a unidimensional et al., 2006; Titus et al, 2008). Original measure (total score) and use of the scales were highly correlated with individual subscales (Dennis et al., 2006) shortened subscales among both adults and adolescents (Titus et al., 2008) ■ The GAIN-I and its subscales have good internal consistency for use with adults, Concerns with alphas ranging .71–.96 (Dennis et ■ Training is strongly recommended before al., 2006). Studies examining concurrent administering the GAIN. The GAIN validity have been conducted primarily training is costly and includes separate with adolescents, but are quite promising trainings to administer the instrument and (Dennis et al., 2006) to train others on how to use the measure ■ The GAIN-Q and its subscales have ■ The GAIN is a copyrighted instrument, and adequate internal consistency among adults there are separate costs to purchase the set (GAIN Coordinating Center, 2013) of instruments and for the software ■ The GAIN-I demonstrates good internal ■ License agreement paperwork and a consistency for three comorbidity subscales separate user agreement are required at cost related to internal mental distress, behavior complexity, and crime/violence, with ■ Further validation among offender alphas ranging .78–.96. The condensed populations is needed to examine versions of these scales, the internal the GAIN’s psychometric properties, behavior scale, and the external behavior including predictive utility of diagnoses scale also demonstrate good internal and diagnostic impressions. Self-reported consistency, with alphas ranging .69–.90 substance use on the GAIN is only (Titus, Dennis, Lennox, & Scott, 2008). moderately correlated with drug testing and The GAIN original scales are highly other collateral information (Dennis et al., correlated with the subscales for adults 2006) ■ The GAIN-I has good test-retest reliability ■ Item response theory (IRT) analyses show for the main subscales (internal mental that the crime/violence scale on the GAIN distress, behavior complexity scale, may be less reliable for adults, particularly substance problem scale, crime/violence among adult females, potentially leading to scale), with r score = .70 and kappas = .60. errors in clinical diagnoses (Conrad et al., The GAIN-I also has good agreement with 2010) timeline followback, urinalysis, treatment, Availability and Cost and other measures of substance use disorders (r score ≥ .70 and kappa ≥ .60; Scoring and diagnostic interpretation using the Dennis et al., 2006) paper version of the GAIN-I and GAIN-Q are

177 Screening and Assessment of Co-Occurring Disorders in the Justice System described in the GAIN manual. Using the hand- purposes (Blouin, Perez, & Blouin, 1988; Robins scored approach requires substantially more et al., 1981) and has been updated to coincide time than automated scoring provided using the with revisions to diagnostic categories in the web version. The various GAIN manuals and DSM. Revised versions of the DIS have improved information describing administration, scoring, accuracy in identifying a range of mental and norms can be found at the following locations: disorders. A self-administered computerized version of the DIS is available (C-DIS), although GAIN-I: https://chestnut.app.box.com/v/GAIN-I- staff must be present to address respondents’ Materials questions. Administration of the DIS does not GAIN-Q: https://chestnut.box.com/v/GAIN-Q3- require clinical experience. The DIS-IV has Materials 19 diagnostic modules covering over 30 Axis I disorders, which include demographic and The GAIN-ABS (Assessment Building System) risk factors, sequencing of comorbid disorders, is an online system that provides administration, observations of psychotic symptoms or other scoring, and interpretative reports for the GAIN-I problems during the interview, and a range of and GAIN-Q3. This version requires the license individual modules examining different types agreement as noted above, in addition to separate of disorders related to mood, anxiety, eating, user agreements. Interpretative reports are only schizophrenia spectrum, somatization, substance available using the web version of the GAIN. use disorders, antisocial personality disorder, Costs for utilizing the GAIN depend on the ADHD, , and gambling. The DIS number of users within an agency accessing the provides information regarding both current and cloud-based system, a one-time set up fee, and lifetime diagnoses of common mental disorders. the annual user fee for each authorized user. A quote based on project needs can be requested Positive Features by email at [email protected] or by calling ■ The DIS can be administered by (309) 451-7900. Administration training costs nonclinicians, requires minimal training, range from $500 to $1,800. Different training is and has been translated into many provided to administer the GAIN-I and GAIN-Q3. languages Training recipients are not authorized to train ■ The DIS has been used to diagnose mental others on how to administer the instrument. Local disorders among offenders (Lo & Stephens, training certification is provided for those who 2000; Teplin et al.,1996; Wiesner, Kim, & would like to train other users. These certificates Capaldi, 2005) and people with substance cost between $1,500 and $2,400 for the GAIN-I use disorders (Havassy, Alvidrez, & Owen, and GAIN-Q3. Each type of training is available 2004; Horton, Compton, & Cottler, 1998) online; however, there are designated time limits ■ In addition to detecting the presence of in which the training must be completed (i.e., 3–6 mental disorders in the justice system, the months). DIS has been used to refer offenders to treatment (Lo, 2004; Teplin, 1990) Diagnostic Instruments for Co- ■ The DIS includes an antisocial personality occurring Mental Health and Substance disorder (ASPD) module. DIS-IV Use Disorders diagnoses of ASPD are correlated with substance use and chronic patterns of offending (Wiesner et al., 2005) Diagnostic Interview Schedule–Fourth Edition (DIS-IV) ■ The DIS has good agreement with the MAST (.79) in detecting alcohol disorders The DIS-IV is a fully structured diagnostic among individuals treated for mental interview instrument designed for research disorders (Goethe & Fisher, 1995).

178 Instruments for Screening and Assessing Co-Occurring Disorders

Reliability of DIS diagnoses is quite good ■ There is poor agreement between the DIS because interview questions, probes, and and the Schedule for Affective Disorders coding procedures are carefully described and Schizophrenia- Lifetime (SADS-L) in (Compton & Cottler, 2004) diagnosing depression among individuals ■ The DIS has adequate agreement with who have CODs (Hasin & Grant, 1987) the SCAN for diagnosis of substance use ■ The DIS may be overly sensitive in disorders and for depression (Compton & diagnosing major depressive disorder Cottler, 2004) and has excellent specificity (Helzer et al., 1985) (90 percent) in detecting depression (Eaton Neufeld, Chen, & Cai, 2000) ■ The DIS has low agreement with the SCAN for diagnosis of depression (Eaton et al., ■ The DIS demonstrates adequate agreement 2000) with medical chart diagnoses (Robins, Helzer, Ratcliff, & Seyfried, 1982) ■ The DIS may not accurately diagnose anxiety disorders (e.g., panic, social ■ The DIS diagnoses provide adequate phobia) or schizophrenia (Anthony et agreement with most lifetime disorders, al., 1985; Cooney, Kadden, & Litt, 1990; as determined by the DSM-III-R among Erdman et al., 1987; Summerfeldt & psychiatric patients (kappas ≥ .5; Robins et Antony, 2002) al., & Ratcliff, 1981; Robins et al., 1982). Similarly, in college students, interrater ■ Caution is urged when using the DIS as agreement for both current and lifetime a primary diagnostic tool, as agreement disorders on the DIS is acceptable (median between the DIS and clinician diagnosis kappas range .43–.46; Vandiver & Sher, has sometimes been poor in comparison 1991) to that of the SCID (Blanchard & Brown, 1998) ■ Wittchen et al. (1989) found good agreement (kappas range .50–.70) between ■ The C-DIS provides poor to moderately the clinician-administered and nonclinician- good (-.05–.70) test-retest reliability in administered interviews for the DIS, as diagnosing CODs, depending on the type of well as good test-retest reliability between mental disorder (Ross, Swinson, Doumani, administrations of the DIS (kappa > .6). & Larkin, 1995) ■ ■ The DIS has good test-retest reliability (95 The DIS is not sensitive to response styles percent agreement for severe disorders) in and does not provide methods for detecting diagnosing men who are incarcerated in jail dissimulation (Alterman et al., 1996) (Abram & Teplin, 1991) Availability and Cost Concerns A copy and license for the use of the DIS ■ The DIS is quite lengthy, requiring 90–120 (computerized version) may be purchased at the minutes to administer. However, it is following site: http://epidemiology.phhp.ufl.edu/ possible to omit sections of the DIS that are assessments/c-dis-iv/brochure/ not of interest The cost for licensing ranges from $1,000 to ■ Further validation of DIS diagnoses is $2,000. needed with offenders ■ Structured instruments such as the DIS may fail to detect 25 percent of those abusing The Mini International Neuropsychiatric alcohol (Drake et al., 1990) and possibly Interview (MINI) a higher proportion who are abusing illicit The MINI (Sheehan et al., 1998) is a 120-question substances (Stone, Greenstein, Gamble, & structured diagnostic interview used to evaluate McLellan, 1993) DSM and ICD Axis I mental disorders (although

179 Screening and Assessment of Co-Occurring Disorders in the Justice System the DSM-5 does not have axes, some of these Loveless, Allen, & Sieleni, 2010). In frameworks are built around DSM-IV and earlier a study of the MINI-Plus with a prison versions), including substance use disorders. The sample (Black et al., 2004), the measure instrument was designed as a brief diagnostic was easily administered by correctional screen and has been used in numerous research staff, well received by prisoners, and it and clinical settings. The MINI provides a family accurately assessed mental disorders in this of structured interviews, which includes the MINI, population MINI-Kid, MINI-Plus, and MINI-Screen. Another ■ The MINI clinician-administered interview section, “Screening Instruments for Co-occurring demonstrates good sensitivity (62–96 Mental and Substance Use Disorders,” provides a percent) and specificity (86–100 percent) more detailed description of the MINI screening across almost all current/lifetime Axis I tool. The MINI-Plus is a fully structured disorders as determined by the SCID-I patient clinical interview (Sheehan et instrument that assesses the presence of 23 al., 1998). Similarly, the MINI patient DSM-IV-TR Axis I disorders, including attention rated self-report instrument has adequate deficit hyperactivity disorder (ADHD) and one sensitivity (60–89 percent) and good Axis II disorder (antisocial personality disorder), specificity (74–99 percent) for many of chronology of disorders, and rule-out questions the current/lifetime Axis-I diagnoses. The to accurately identify the presence of comorbid MINI also has good sensitivity (67–89 disorders. The Mini-Kid screens for common percent) and specificity (72–97 percent) childhood and adolescent psychopathology, for many CIDI (Composite International including mood disorders, anxiety disorders, Diagnostic Interview) DSM-III-R substance use disorders, externalizing disorders, disorders. Overall specificity is good for and developmental disorders. Other MINI the MINI as compared to other structured instruments have been developed to examine clinical interviews (Sheehan et al, 1998) bipolar and psychotic disorders and suicidality. ■ Agreement between MINI clinician-rated The most recent version of the MINI, MINI 7.0.2, and CIDI diagnoses for psychotic disorders is also available for administration by computer. is adequate (kappas range .68–.82), as are those between the MINI and SCID–I Positive Features diagnoses (Sheehan et al., 1998) ■ Only brief training is required to use the ■ Interrater reliability estimates for the instrument clinician-administered version of the MINI ■ The MINI provides a diagnostic impression ranges .79–1.00 for all subscales. Fourteen for major “Axis I disorders” and examines of the 23 test-retest reliability values are a broad range of symptoms. The greater than .75 (range = .35–1.00, and only instrument requires approximately 20 one is below .50; Sheehan et al., 1998) minutes to administer to individuals who ■ The MINI shows good concordance with do not have a mental disorder SCID DSM-IV diagnoses (kappas range ■ The MINI has been translated into many .90–1.0; Sheehan et al., 1998) languages and includes norms for several ■ The MINI-Kid shows good sensitivity subpopulations (Sheehan et al., 1998) (71–100 percent) and specificity (74–99 ■ The MINI-Plus has been used with percent) in identifying mental disorders as offenders to assess current and lifetime determined by the K-SADS-PL (Schedule mental and substance use disorders (Black for Affective Disorders and Schizophrenia et al., 2007; Cuomo, Sarchiapone, Di for School-Aged Children; Kaufman et al., Giannantonio, Mancini, & Roy, 2008; 1997). For individual diagnosis, sensitivity Gunter et al., 2008), including antisocial is adequate (67–100 percent) and personality disorder (Black, Gunter, specificity (73–99 percent) is good across

180 Instruments for Screening and Assessing Co-Occurring Disorders

most disorders (Sheehan et al., 2010). ■ Agreement between the clinician Interrater reliability for the MINI-Kid is administered MINI and CIDI was low also good (Sheehan et al., 2010) for many anxiety disorders, bulimia, and ■ Test-retest reliability for the MINI-Kid current/lifetime manic diagnoses (kappas is good for any disorder and .75–1.00 range 43–68 percent; Sheehan et al., 1998) for individual disorders over 1–5 days ■ The MINI-Kid has poor sensitivity for (Sheehan et al., 2010) current/lifetime psychotic disorder, major depressive disorder, dysthymia and panic Concerns disorders (43–64 percent; Sheehan et al., ■ Further validation is needed of the MINI- 2010), as determined by the K-SADS-PL Screen with offender populations Availability and Cost ■ The MINI does not consider symptom severity, and thus may generate The MINI is available in paper and computerized unnecessary referrals for treatment. The versions. The paper form may be downloaded MINI does not assess cognitive impairment twice for $10; however, a download is not a ■ The MINI-Plus requires an average of 41 license agreement for use. A computerized version minutes to administer to offenders, which may be ordered for $295 or more, depending may inhibit broad use of the instrument upon the version. The following website can be with this population (Black et al., 2004) accessed to contact the author for permission to ■ Although malingering, denial of symptoms, use the MINI or to obtain more information about and other response sets are common the MINI 7.0.2, eMINI 6.0 (computerized version) problems in justice settings, the MINI is and Dolphin EDC (MINI administered via internet not able to detect the presence of these browser): http://harmresearch.org/index.php/mini- response sets international-neuropsychiatric-interview-mini/ ■ The psychosis and major depression The MINI Plus 7 can be downloaded at the modules of the MINI-Plus can be following location: http://harmresearch.org/index. somewhat difficult and confusing to php/mini-international-neuropsychiatric-interview- administer (Black et al., 2004) mini/ ■ The MINI-Plus clinician-administered interview exhibits lower sensitivity for substance use disorder and dysthmia (42– Psychiatric Research Interview for 52 percent), as determined by the SCID-I Substance and Mental Disorders patient version. Further, MINI patient rated (PRISM) self-report diagnoses for many anxiety The PRISM is a semi-structured interview disorders, bulimia, and current/lifetime mania have low sensitivity (17–55 percent). designed to diagnose psychopathology among Low sensitivity for the MINI clinician- substance-involved people. The instrument administered interview was found for requires approximately 90 minutes to administer. agoraphobia, simple phobia, and lifetime As a result of the increasing recognition of bulimia (46–63 percent), as determined by the relevance of CODs, DSM-IV and DSM- the CIDI 5 emphasize the importance of distinguishing ■ Agreement between the clinician between substance-induced psychiatric symptoms administered MINI and the SCID-I was low related to active use and withdrawal and “primary” for many current/lifetime anxiety disorders, mental disorders (Samet, Nunes, & Hasin, 2004). current psychotic disorders, current/lifetime Since specific guidelines for these diagnostic substance use disorder, and dysthymia decisions did not exist prior to DSM-IV, in the (kappas range 43–67 percent) past there have been problems with the reliability

181 Screening and Assessment of Co-Occurring Disorders in the Justice System

and validity of mental health diagnoses among ■ The PRISM-CV has been widely used in people with substance use disorders. The PRISM both mental health and general medical examines current and lifetime substance use, settings mental disorders, and borderline and antisocial ■ Severity measures, consisting of a personality disorders. The substance use sections continuous rating of the number of are presented prior to other diagnostic sections. symptoms present, are provided for some Therefore, the interviewer has the substance use mental disorders, such as major depressive history information available when assessing disorder and substance use disorders mental disorders. ■ The PRISM has been used with several populations that have CODs (Coombes & A computerized version of the PRISM (PRISM- Wratten, 2007; Hasin et al., 2002; Vergara- CV-IV) is also available. The PRISM-CV- Moragues et al., 2012), with individuals IV reviews the consistency of respondents’ who are homeless (Caton et al., 2005), and answers, and incorporates skip logic, reducing with offenders (Kravitz, Cavanaugh, & administration time to approximately 70 minutes Rigsbee, 2002) (Hasin, Samet, Nunes, Mateseoane, & Waxman, ■ Among substance-involved populations, 2006). A diagnostic report is produced to assist the PRISM exhibits good agreement with with scoring and interpretation. Differences DSM-IV diagnoses for current and lifetime between the paper and computerized version diagnoses (kappas range .62–.82; Hasin et of the PRISM include use of a question format al., 2006) (e.g., multiple questions in the paper version ■ Among people with substance use are presented as individual questions in the disorders, the PRISM demonstrates good computerized version). The order of modules reliability for agreement in severity across is also different in the paper and computerized most types of disorders, including both versions. Additional modules in the computerized current and lifetime disorders (Hasin et al., version include nicotine use, suicidality 2006) assessment, ADHD, and Pathological Gambling. ■ Among people with substance use The PRISM paper version is no longer supported disorders, the PRISM shows adequate by the PRISM website. agreement with DSM-IV diagnoses of current and lifetime major depressive Positive Features disorder and manic episodes, psychotic ■ The instrument distinguishes between disorders, eating disorders, and personality primary and substance-induced disorders disorders (Hasin et al., 2006) ■ The PRISM was developed using a racially/ ■ The PRISM has excellent reliability in ethnically diverse sample diagnosing major depression (Hasin, ■ A Spanish version of the PRISM is Samet, Nunes, Mateseoane, & Waxman, available and appears to have some 2006) advantages over the Spanish version of the Concerns SCID in diagnosing major depression and ■ The PRISM interview must be administered borderline personality disorders among by a trained clinician substance-involved people (Torrens, Serrano, Astals, Pérez-Domínguez, & ■ The PRISM website no longer supports Martín-Santos, 2004) the paper instrument services, such as data entry or diagnostic programs for scoring ■ The PRISM addresses the problem of and interpretation diagnosing depression among people with substance use disorders ■ The PRISM has not been widely used or tested in criminal justice populations

182 Instruments for Screening and Assessing Co-Occurring Disorders

■ Agreement with DSM-IV diagnoses of Training and certification for administration of the many substance use disorders has been PRISM-CV-IV is available. The cost of training found to be low in some samples (Hasin et workshops is $3,000 and certification costs are al., 2006) $200. ■ Reliability for the PRISM severity of stimulant disorder is low, as determined by Paper instruments including the training manual symptoms counts on the DSM-IV for both for scoring and interpretation are available upon current and lifetime disorder (ICCs range request by sending email correspondence to the .55–.64; Hasin et al., 2006) following address: [email protected] ■ The PRISM’s anxiety disorders module does not have good reliability for primary Psychiatric Diagnostic Screening or substance-induced anxiety disorders Questionnaire (PDSQ) (kappa = .57), nor dysthymic disorder (kappa = .36; Hasin et al., 2006) The PDSQ (Zimmerman & Mattia 2001b) is a 126-item self-administered instrument that Availability and Cost assesses 13 of the most common DSM-IV mental The author of the PRISM maintains a website disorders in outpatient mental health settings. (http://www.columbia.edu/~dsh2/prism/) The instrument was designed to assess current containing information regarding computer and recent symptomatology and to provide software related to the instrument. The site also background information prior to providing a contains information regarding the PRISM’s more extensive diagnostic evaluation. The PDSQ psychometric properties and available training. examines five areas, including eating disorders, mood disorders, anxiety disorders, substance use The training manual for the PRISM is available disorders, and somatoform disorders. The PDSQ at the following location: http://www.columbia. also includes a six-item screen for psychosis. The edu/~dsh2/prism/files/PRISMman266.pdf instrument has undergone several iterations to The PRISM-CV-IV is available for purchase and enhance the reliability and validity, and indices includes all software required for administration, of mania, dysthymic disorder, and anorexia scoring, and interpretation. PRISM administration were eliminated from the instrument due to poor does not require the software, but it is psychometric features. At recommended cut-off recommended that a license be purchased from scores, the PDSQ has sensitivity of greater than 90 Blaise ® Licensing. Information including percent for major depressive disorder, obsessive- cost (approximately $200) can be obtained compulsive disorder, PTSD, generalized anxiety by requesting a software quote through the disorder (GAD), panic/agoraphobia/social phobia, following site: https://www.westat.com/our-work/ alcohol use disorders, and bulimia or somatoform information-systems/blaise percentC2 percentAE- disorders (Zimmerman, 2002; Zimmerman & distribution-training/blaise-licensing-ordering Mattia, 2001a).

The PRISM-CV-IV software package includes Positive Features the interview protocol, a codebook that defines ■ The PDSQ requires only 15 minutes to interview questions and diagnostic variables, a administer, yet reviews a range of mental manual that provides diagnostic information for disorders scoring and interpretation of interviews, a user ■ The PDSQ was developed to be aligned guide, and information on how to export data to with DSM diagnostic classifications other statistical software programs. The cost of ■ The PDSQ has been used extensively with this package is $1,800. populations that have CODs and may

183 Screening and Assessment of Co-Occurring Disorders in the Justice System

assist in detecting disorders that are missed ■ The PDSQ has good to excellent internal during unstructured clinical evaluations consistency (alphas ≥ .80 for 12 out of 13 ■ Cut-off scores were chosen to optimize subscales); test-retest reliability over two sensitivity (> 90 percent; Zimmerman & weeks (r score ≥ .80 for nine subscales, Mattia, 2001a) mean r score = .83); and discriminant, convergent, and concurrent validity ■ The PDSQ has been used to diagnose (Zimmerman & Mattia, 2001a) mental disorders in justice settings (Stuart, Moore, Gordon, Ramsey, & Kahler, 2006; Concerns Swogger, Walsh, Houston, Cashman- ■ The validity of the PDSQ has not been Brown, & Connor, 2010; Weitzel, widely studied in justice-involved Nochajski, Coffey, & Farrell, 2007) and populations for the diagnosis of mental among people with substance use disorders disorders (Simmons, Lehmann, & Cobb, 2008; Weitzel et al., 2007) ■ Various cut-off scores are recommended to achieve optimal sensitivity for mental ■ PDSQ subscales related to depression are disorders, which may lead to difficulties in correlated with victimization of women and scoring and interpreting results PTSD among women who are arrested for domestic violence (Stuart et al., 2006) ■ The PDSQ’s alcohol and drug subscales do not distinguish between levels of substance ■ Among offenders, the PDSQ subscales use severity (Stuart et al., 2006) of GAD and PTSD are correlated with impulsive aggression (Swogger et al., ■ The PDSQ has low specificity for 2010) generalized , obsessive- compulsive disorder, social phobia, and ■ The PDSQ results in a 42 percent rate of PTSD among people who are diagnosed referral for further mental health evaluation with substance use disorders, as determined among drug offenders, a rate similar to by the SCID-I (Zimmerman, 2008; those referred for evaluation in other Zimmerman et al., 2004) substance-involved populations (Harris & Edlund, 2005; Watkins et al., 2004; Weitzel ■ Positive predictive values for the PDSQ et al., 2007) vary widely across mental disorders, indicating that some individuals may not ■ The PDSQ has a low false positive rate in be correctly diagnosed as having a disorder identifying Axis I disorders (30 percent; (Zimmerman, 2008; Zimmerman & Zimmerman & Chelminski, 2006). Among Chelminski, 2006) psychiatric outpatients, the AUC for the PDSQ is good for those with and without ■ The sensitivity of the PDSQ’s psychosis diagnosed substance use disorders (.83 subscale is not particularly high and .86 respectively) as determined by (Zimmerman, 2008; Zimmerman & the SCID-I, across a range of disorders Chelminksi, 2006; Zimmerman & Mattia, (Zimmerman, 2008; Zimmerman, Sheeran, 2001a) Chelminski, & Young, 2004) ■ No current PDSQ validity indices are ■ Among psychiatric outpatients with available for mania, dysthymic disorder, or substance use disorders, the PDSQ has anorexia good sensitivity (92 percent) and adequate Availability and Cost specificity (63 percent) in identifying co- occurring mental disorders (Zimmerman, The PDSQ can be purchased at the following 2008; Zimmerman & Chelminski, 2006; site: http://www.wpspublish.com/store/p/2901/ Zimmerman et al., 2004) psychiatric-diagnostic-screening-questionnaire- pdsq

184 Instruments for Screening and Assessing Co-Occurring Disorders

The cost to purchase the PDSQ is $130 for 25 ■ The SADS has been used in justice settings test booklets, 25 summary sheets, an instruction to diagnose mental disorders (Blackburn & manual, and a CD containing 13 follow-up Coid, 1998; Hodgins, Lapalme, & Toupin, interview guides (one for each of 13 disorders). 1999) and has been found to be effective in these settings (Rogers, Sewell, Ustad, Reinhardt, & Edwards, 1995; Rogers, Schedule of Affective Disorders and Jackson, Salekin, & Neumann, 2003) Schizophrenia–Third Edition (SADS) ■ The SADS is useful in inpatient, outpatient, The SADS is a semi-structured interview designed and primary health care settings for for use by trained clinicians to evaluate current diagnosing CODs and providing referral to and lifetime affective and psychotic disorders services (Rogers, Jackson & Cashel, 2004) (Endicott & Spitzer, 1978). The instrument ■ The SADS has adequate concurrent validity predates the SCID and offers specified probes for mental disorders when compared with for diagnostic criteria. The SADS includes other diagnostic interview instruments Part I (Current) and Part II (Lifetime). Part (Farmer et al., 1993; Rogers et al., 2004; I assesses current episodes, particularly the Hesselbrock, Stabenau, Hesselbrock, most severe period of the current episode. The Mirkin, & Meyer, 1982) SADS also examines six graduated levels of ■ The SADS-C has good reliability in symptoms experienced, ranging from “not at diagnosing mental disorders (McDonald- all” to “extreme.” Part II of the SADS reviews Scott & Endicott, 1984) lifetime history of symptoms and episodes of the ■ The SADS-C subscales of schizophrenia, disorders and features two graduated levels of depression, and bipolar disorder are symptoms experienced (“presence” or “absence”). significantly correlated with similar scales Several alternate versions of the SADS have also on the Referral Decision Scale (Rogers, been developed. For example, the SADS-L is Sewell et al., 1995), and other studies similar to Part II of the SADS in that it provides provide evidence of concurrent validity of a description of lifetime symptoms and dedicates the SADS-C (Johnson, Magaro, & Stern, 1986) very little time to current symptoms. The 45-item SADS-C examines current symptoms and changes ■ Within justice settings, the SADS-C shows in these symptoms. The global assessment scale good interrater reliability for symptoms of the SADS-I describes symptoms experienced and subscales (ICC = .92, range .94–.97; Rogers et al., 2003) in both treatment over particular intervals of time following the seeking and emergency care settings initial SADS-L interview. ■ Across multiple studies, the SADS exhibits Positive Features good interrater reliability for symptom ■ The SADS has been found to be more ratings and diagnosis (Andreasen et al., effective than the DIS in diagnosing 1982; Endicott, & Spitzer, 1978; Keller et depressive disorders (Hasin & Grant, 1987) al., 1981; Rogers, Sewell et al., 1995) ■ Interrater reliability is excellent for current ■ The SADS’s test-retest reliability is disorders and is good for past disorders moderate to high (McDonald-Scott & Endicott, 1984; Rapp, Parisi, Walsh, & ■ The SADS has been translated into several Wallace,1988) when the elapsed time languages between administrations is less than 6 ■ The instrument examines symptom severity months and ancillary symptoms that are related to, but not part of, formal diagnostic criteria

185 Screening and Assessment of Co-Occurring Disorders in the Justice System

Concerns Structured Clinical Interview for DSM-IV ■ The SADS was developed concurrently (SCID-IV) with the DSM-III and does not use DSM- The SCID is a semi-structured psychological IV or DSM-5 terminology or classification systems assessment interview developed for administration by trained clinicians (First, Spitzer, Gibbon, & ■ There is poor agreement between the SADS Williams, 1996). The SCID-I is one of the most and the DIS in diagnosing depression widely used structured interview instruments among individuals with substance use developed to diagnose DSM disorders and is problems (Hasin & Grant, 1987) considered to be the “gold standard” for diagnostic ■ The SADS does not adequately address all assessment (Shear et al., 2000). The SCID-I substance use disorders, and thus, other obtains diagnoses for all mental disorders, using interviews such as SCID may be preferred the DSM criteria. Standard threshold questions (Rogers, 2001) are provided and the administrator may reword ■ The SADS has not been used extensively in questions to clarify them, as needed. The justice settings Substance Use Disorders module identifies ■ The SADS is rather lengthy and complex to lifetime and past 30-day diagnoses for alcohol administer and requires clinical judgment and other drugs. The SCID-IV also differentiates ■ Significant training is required for between different levels of severity of substance administration and scoring of the SADS use disorders. A separate instrument (SCID-II) ■ The instrument is not very sensitive to examines Axis II Personality Disorders and is response styles, and participants can fake published separately. positive symptoms of disorders. Research has examined the potential use of some Both research (SCID-RV) and clinical versions SADS-C subscales to detect malingering (SCID-CV) of the SCID-I and II are available. (Rogers et al., 2003) The clinical version is shorter (45–90 minutes) and examines disorders frequently seen in clinical ■ The SADS provides limited breadth of coverage, with a focus on evidence of settings (First, Spitzer, Gibbon, & Williams, 2001), affective and psychotic disorders while excluding most of the subtypes, severity, and course specifiers included in the research version. ■ The SADS is not recommended for assessment of personality disorders Some disorders are not fully evaluated but instead (Rogers, 2001) are assessed briefly at the end of the SCID administration (e.g., social and , Availability and Cost generalized anxiety disorder, eating disorders, A description of the SADS can be found in the hypochondriasis). The full SCID-I Research following article: Endicott, J., & Spitzer, R. L. Version examines the mental disorders. The (1978). A diagnostic interview: The Schedule of Research Version requires approximately 1.5–2 Affective Disorders and Schizophrenia. Archives hours to administer and 10 minutes to score. of General Psychiatry, 35, 837–844. The SCID-RV and SCID-CV for DSM-5 are now This instrument is no longer in print and thus available, in addition to user guides for these copies of the instrument may be difficult to obtain. instruments. These instruments are available from the American Psychiatric Publishing Inc. (see "Availability and Cost"). Revisions are also underway for the SCID-II, which will be renamed the “SCID for Personality Disorders” (SCID-PD).

186 Instruments for Screening and Assessing Co-Occurring Disorders

Positive Features moderately high for alcohol disorders ■ Diagnoses are made according to DSM-IV, (current diagnosis, .80; lifetime diagnosis, DSM-IV TR, or DSM-5 criteria .78) and varied considerably for drug use disorders (current diagnosis, .48–1.00; ■ The SCID has been translated into several lifetime diagnosis, .04–1.00), although languages. Several foreign language these were generally quite high versions have been shown to have good psychometric properties (Lobbestael, ■ The SCID shows good interrater reliability Leurgans & Arntz, 2011; Schneider et al., in people receiving outpatient treatment 2004) across mental disorders (Zimmerman & Mattia, 1999a) and for both lifetime and ■ Computer-assisted interview versions of the past month alcohol and drug disorders SCID (SCID-CV) are available, including among offenders (Peters et al., 2000) the research version. A shorter, computer- administered self-report screening version ■ The internal consistency of the SCID-II is of the SCID is also available. However, good, with alphas ranging .71–.94 (Maffei this latter version does not yield definitive et al., 1997) diagnoses but rather diagnostic impressions that should be confirmed through use of a Concerns SCID interview or full clinical evaluation ■ The SCID was designed for use by a ■ The instrument has been used with trained clinician at the masters or doctoral psychiatric, medical, nonsymptomatic level, although in research settings, it adults in the community and justice has also been used by bachelors-level populations (Cohen et al., 2002; Dolan & technicians with extensive training. Blackburn, 2006; Morgan, Fisher, Duan, Significant training is required for both Mandracchia, & Murray, 2010; First et al., administration and scoring of the SCID 2001; Peters. Greenbaum, Edens, Carter, ■ Administration of the SCID I and II and Ortiz, 1998; Peters et al., 2000) may each require more than 2 hours for ■ SCID diagnoses have been found to be individuals who have multiple diagnoses. more accurate and more comprehensive The Psychoactive Substance Use Disorders than unstructured clinical interviews (Basco module requires 30–60 minutes, when et al., 2000; Kranzler et al., 1995) administered separately ■ The SCID has been used to assess CODs, ■ For people with cognitive impairment or including treatment-seeking individuals psychotic symptoms, the SCID may need to who have substance use disorders (Kidorf be administered across several sessions et al., 2004) ■ Clinical judgment is required to determine ■ In a community sample, the SCID for whether symptoms are present for a Axis II disorders shows adequate interrater particular disorder reliability for diagnoses (kappas range ■ An eighth-grade reading level is required .85–.95) in addition to adequate agreement for the SCID for the presence of individual traits related ■ The SCID provides a dichotomous decision to mental disorders (ICCs range .87–.99). (yes/no) regarding diagnoses, and it does The self-report SCID-II demonstrates good not provide subthreshold diagnoses or interrater reliability for the diagnosis of take into account symptoms that may be the personality disorders (kappas range experienced along a continuum .66–.99; Farmer & Chapman, 2002) ■ The SCID is quite costly to purchase ■ Peters et al. (1998) examined the use of the SCID among correctional populations Availability and Cost using DSM-IV guidelines. Kappas were The SCID is available for purchase from American Psychiatric Publishing, Inc., 1400

187 Screening and Assessment of Co-Occurring Disorders in the Justice System

Street, N.W., Washington, DC 20005, at the personality disorders and psychosocial risk following site: http://www.appi.org/home/search- factors. results?FindMeThis=SCID (or) Available materials include SCID user’s guides, administration booklets, and score sheets. The 2. The Mini International Neuropsychiatric Research Version of the SCID can be obtained by Interview (MINI) or the Structured Clinical contacting Biometrics Research at (212) 960-5524. Interview (SCID), which address a full range of co-occurring mental health and substance The user’s guide and administration booklet use disorders and provide a diagnostic cost approximately $80 for either the SCID-I or impression of multiple disorders. SCID-II. A packet of SCID score sheets costs approximately $80. Each instrument requires between 45-120 minutes to administer, dependent on the symptom The SCID-5 products can be purchased at the presentation and particular problems that are following site: https://www.appi.org/products/ selected for assessment. The measures can structured-clinical-interview-for-dsm-5-scid-5 be administered in their entirety, or specific modules can be administered that are tailored Recommendations for Assessment and to the individual’s assessment needs and set of Diagnosis of CODs symptoms. The different options provided here Information describing assessment and diagnostic for assessment and diagnosis of co-occurring instruments related to co-occurring mental disorders may be appealing dependent on the and substance use disorders is based on a specific needs in a particular justice setting. The critical review of the instruments and research MINI and SCID provide diagnosis of the full examining their efficacy. Key considerations set of disorders, while the AUDADIS provides a in recommending instruments are based upon comprehensive assessment of the disorders and empirical evidence supporting both the reliability a review of related biopsychosocial problems. and validity of the instrument, relative cost of These instruments should be administered by the instrument, ease of administration, and use trained clinicians who are licensed, certified, or within justice settings. Although summaries otherwise credentialed in assessing and diagnosing of instruments are based on DSM-IV criteria, CODs and related psychosocial problems. instruments recommendations are those that align more closely with DSM-5, allowing for a more seamless transition from DSM-IV to DSM-5. Recommendations for assessment and diagnosis of co-occurring mental and substance use disorders include instruments that provide comprehensive examination of multiple disorders and related biopsychosocial problems. The following instruments are recommended:

1. The Alcohol Use Disorders and Associated Disabilities Interview (AUDADIS-IV), which provides a comprehensive assessment and examines a range of co-occurring substance use and mental health problems, including

188 Suggested Reading

Improving Cultural Competence: Treatment Improvement Protocol Series No. 59 Source: Substance Abuse and Mental Health Services Administration Availability: http://store.samhsa.gov/product/TIP-59-Improving-Cultural-Competence/SMA14- 4849 Description: Assists professional care practitioners and administrators in understanding the role of culture in the delivery of substance use and mental health services. Discusses racial, ethnic, and cultural considerations and the core elements of cultural competence. Appendix D briefly reviews a selection of screening and assessment instruments, noting their utility with specific racial and ethnic groups.

Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide Source: National Institutes of Health Availability: http://www.drugabuse.gov/publications/principles-drug-abuse-treatment-criminal- justice-populations/principles Description: Describes the treatment principles and research findings that have particular relevance to the criminal justice community and to treatment professionals working with substance abusing offenders.

Screening, Assessment, and Treatment Planning for Persons with Co-Occurring Disorders: Overview Paper 2 Source: Substance Abuse and Mental Health Services Administration Availability: http://store.samhsa.gov/product/Screening-Assessment-and-Treatment-Planning-for- Persons-With-Co-Occurring-Disorders/PHD1131 Description: Gives an overview of integrated screening, assessment, and treatment planning for people with co-occurring disorders of substance use and mental illness. Discusses staffing, protocols, methods, systems issues, financing, and client-centered services.

Substance Abuse Treatment for Persons with Co-Occurring Disorders: Treatment Improvement Protocol Series No. 42 Source: Substance Abuse and Mental Health Services Administration Availability: http://store.samhsa.gov/product/TIP-42-Substance-Abuse-Treatment-for-Persons- With-Co-Occurring-Disorders/SMA13-3992 Description: Provides substance use treatment and service practitioners with updated information on co-occurring substance use and mental disorders and advances in treatment for people with co- occurring disorders. Discusses terminology, assessment, and treatment strategies and models.

189 Screening and Assessment of Co-Occurring Disorders in the Justice System

Trauma-Informed Care in Behavioral Health Services: Treatment Improvement Protocol Series No. 57 Source: Substance Abuse and Mental Health Services Administration Availability: http://store.samhsa.gov/product/TIP-57-Trauma-Informed-Care-in-Behavioral- Health-Services/SMA14-4816 Description: Assists behavioral health professionals in understanding the impact and consequences for those who experience trauma. Discusses patient assessment, treatment planning strategies that support recovery, and building a trauma-informed care workforce. Chapter 4 addresses screening and assessment.

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256 Contributors

This report was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) by Policy Research Associates, Inc. under SAMHSA IDIQ Prime Contract #HHSS283200700036I, Task Order #HHSS28342003T with SAMHSA, U.S. Department of Health and Human Services (HHS). David Morrissette, Ph.D., served as the Contracting Officer’s Representative. Numerous people contributed to the development of this publication, and SAMHSA would like to acknowledge the individuals below.

Policy Research Associates Henry J. Steadman, PhD Chanson D. Noether, MA

University of South Florida Louis de la Parte Florida Mental Health Institute Roger H. Peters, PhD Elizabeth Rojas, MA Marla G. Bartoi, PhD

Massachusetts Department of Mental Health University of Massachusetts Medical School Debra A. Pinals, MD

Substance Abuse and Mental Health Services Administration David Morrissette, PhD, LCSW Kenneth W. Robertson

257

PEP19-SCREEN-CODJS Originally printed in 2015 Revised June 2019