Those working in criminal justice settings are often inadequately trained in identification, assessment, diagnosis, treatment, and supervision of individuals with co-occurring disorders. For example, screenings are often conducted by staff who lack considerable training or experience related to mental or substance use disorders and who may be unfamiliar with related treatment services for these disorders. In recent years, a specialized base of knowledge and set of skills have been developed for working with justice-involved individuals who have co-occurring disorders. Training in these areas should be provided for all staff who are involved in screening and assessing for co-occurring disorders in the justice system.
Specialized training in criminal justice settings should be considered in each of the following areas:
Prevalence, course, signs, and symptoms of co-occurring disorders Interaction of symptoms of mental and substance use disorders
Strategies for enhancing accuracy of screening and assessment information among those who have co-occurring disorders
Use of specialized screening and assessment instruments
Integrated treatment approaches and other evidence-based practices Supervision and sanction approaches for individuals with co-occurring disorders
Specialized services available in the community for justice-involved individuals with co-occurring disorders, and procedures for initiating referrals for assessment and treatment services.
Summary
An increasing number of individuals with co-occurring mental and substance use disorders are found in the justice system. These individuals are characterized by diversity in symptoms, level of functional impairment and life skills, behaviors exhibited before and after involvement in the justice system, and in their response to treatment. Co-occurring disorders are often undetected in the justice system due to the absence of effective screening and assessment procedures, the complicated set of symptoms presented, and by lack of training in co-occurring disorders among criminal justice and treatment staff. Non-detection of co-occurring disorders in the justice system can lead to elevated risk for suicide, worsening of mental health and related behavior problems, placement in inappropriate treatment, poor outcomes in treatment, rearrest, and reincarceration.
Given the high prevalence of mental and substance use disorders in criminal justice settings, screening and assessment approaches should be guided by the understanding that co-occurring disorders are to be anticipated. As a result, routine screening and assessment services to detect both mental and substance use disorders should be established in all criminal justice settings. Criminal justice and treatment staff should actively collaborate to share information and to provide a coordinated response in identification, treatment, and management of these disorders. Offender screening and follow-up assessment for co-occurring disorders should be provided on an ongoing basis, and at different transition points (e.g., arrest, jail booking, prison reception) throughout the system. Detection of a single disorder (i.e., either mental or substance use) during screening or assessment should immediately trigger examination for the other type of disorder. It may be useful to delay diagnosis until offenders have attained sobriety to determine the validity of symptoms related to mental and substance use disorders.
Several new instruments are available that examine both sets of disorders, and it is also quite feasible to create an integrated screening or assessment protocol by pairing instruments that address single disorders. Use of self-report instruments should be supplemented whenever possible by drug testing, examination of archival records, and review of information compiled from collateral sources.
The range of available drug testing options has expanded in recent years to include urine testing, hair testing, saliva and sweat testing, blood testing, and breathalyzers. These options vary considerably in their cost, detection time, and intrusiveness. Examination of suicide risk, trauma/abuse history, and motivation and readiness for treatment should also be included whenever feasible during the processes of screening and assessment.
A number of screening instruments have been validated for use in examining mental and substance use disorders, and are recommended for use in criminal justice settings. These include the Global Appraisal of Individual Needs–Short Screener (GAIN-SS) and the Mental Health Screening Form–III (MHSF-III) that address mental disorders, and the Simple Screening Instrument (SSI) and the
Texas Christian University Drug Screen–II (TCUDS-II) that address substance use disorders. One of these mental health screens and one of these substance abuse screens can be combined to provide a quick, effective, and economically attractive screen for co-occurring disorders in the justice system. Other specialized screens for co-occurring disorders such as the BASIS-24 and CAMH-CDS (see Appendix F) have been developed recently and appear promising for use in criminal justice settings. In addition, more focused instruments are available to screen for trauma/
PTSD, suicide risk, and motivation and readiness for treatment. Screening instruments implemented in the criminal justice system should be reliable; valid in detecting mental health, substance abuse, and other related problems; and optimally should have a proven record of use with offenders.
Options for assessment of co-occurring disorders in the justice system include the Psychiatric Research Interview for Substance and Mental Disorders (PRISM), a structured interview assessment instrument for co-occurring disorders, or a combination assessment approach that includes a mental health instrument (e.g., the MMPI-II, the MCMI-III, or the PAI) and a substance abuse assessment instrument (e.g., the ASI-V5). Several structured instruments are available that can provide a more detailed and lengthy diagnostic assessment, including the DIS-IV or the SCID-IV. Other specialized instruments can help to determine the chronological pattern of substance abuse and to identify the most appropriate level of treatment services for offenders who have varying degrees of substance abuse and mental health problems. In addition to reviewing areas covered in screening of co-occurring disorders (e.g., current mental health and substance abuse problems, trauma/PTSD, suicide risk, motivation and readiness for
treatment), a comprehensive assessment should examine the history of mental and substance use disorders, the pattern of interaction among the disorders, cultural and linguistic needs, individual strengths, and environmental supports.
Ongoing training should be provided for staff involved in screening and assessment of co-occurring disorders in the justice system. Training should be provided
in detecting signs and symptoms of co-occurring disorders, understanding the complicated symptom presentation (e.g., mimicking, masking), use of integrated screening and assessment instruments, strategies to enhance accuracy during interviews, drug testing, differential diagnosis, and initiating referral for assessment and treatment.