Screening, Assessment, & Treatment

Screening

• Screening is the application of a test to or investigation of members of a population to estimate the probability of their having a specific disorder. Screening is designed to identify who can be excluded from a more detailed examination for the presence of substance abuse issues, and who needs to be included for further examination or assessment. The process is conducted with DWI offenders to establish whether they have an alcohol use disorder (AUD) and/or a drug use disorder that may require some form of substance abuse treatment intervention.
• Traditionally, the screening process has involved the formal administration and scoring of a test/instrument. Increasingly, however, screening is also based on less formal methods and data collected from case files to more easily gain vital information about a defendant’s/offender’s substance use, abuse, or lack thereof. Use of actuarial-based tests almost always out-perform intuitive judgment when it comes to screening and assessment.

Assessment

• Assessment is a process for defining the nature and severity of a problem(s) and developing specific treatment recommendations and level of care for addressing the problem.
• Assessments are designed to:
  • determine the extent and severity of substance abuse problems;
  • determine the level of maturation and readiness for treatment;
  • ascertain related (co-morbid) problems, such as mental illness;
  • determine the type of intervention necessary to address the problems;
  • evaluate the resources that can be assembled to help solve the problem(s), (i.e., family support, social support, educational and vocational attainment, and personal qualities such as motivation); and,
  • engage the client in the proposed treatment process (SAMHSA 2005).
• Other factors specific to DWI offenders to consider during assessment include:
  • alcohol-related problems (including frequent and heavy consumption);
  • driving-related problems (prior moving convictions, collisions, license suspensions, reckless driving convictions);
  • criminal history;
  • high BAC at time of arrest;
  • refusal to provide a breath or blood sample;
  • prior DWI convictions (beyond a five-year window);
  • arrest during daytime hours;
  • marital status;
  • frequent job changes; and,
  • socially deviant personality traits (high levels of aggression, hostility, recklessness, thrill seeking).
• Assessments may also identify factors leading to potential gaps in services that can affect an offender’s relapse and criminal recidivism. These factors include:
  • lack of social support networks;
  • unstable employment history;
  • poor health;
  • criminality;
  • unresolved legal problems;
  • inadequate housing;
  • lack of motivation to change; and,
  • a history of physical and sexual abuse, mental illness, learning disabilities, and other socio-psychological and criminogenic factors.
  • These variables are of major significance in suggesting the intensity and nature of the intervention needed (Allen 2003).

Treatment

• The purpose of treatment for DWI offenders is to help alleviate identified problems with substance abuse that they may have or be at risk of developing. Treatment is designed to lessen and prevent negative consequences of substance abuse (e.g., DWI) and, also to support the offender during times of relapse, and to get them “back on track.”
• Depending on the offender’s screening and assessment results, substance abuse treatment may involve different techniques which may be, but are not limited to:
  • Brief interventions. These range from providing advice to individuals to cut down on or quit drinking, to agreement on goals and objectives, to brief screening and feedback, motivational interventions, and contingency contracting. One simple form of brief intervention is sharing screening results.
  • Detoxification. A period of medical treatment, usually including counseling, during which a person is helped to overcome physical and psychological dependence on alcohol. The immediate objectives of alcohol detoxification are to help the patient achieve a substance-free state, relieve the immediate symptoms of alcohol withdrawal, treat any co-morbid medical or psychiatric conditions, and help prepare the patient for entry into long-term treatment or rehabilitation.
  • Motivational interviewing or motivational enhancement therapy. Motivational treatment approaches are one-on-one patient-centered, non-confrontational counseling sessions, which are may be used in at least three different stages of an offender’s processing. First, they may be used to share screening or assessment information that is patient-centered and encourages the offender to create a plan of action which can range from reducing their drinking to seeking substance abuse treatment. Second, they may be beneficial to offenders who have been assessed as being unready to receive treatment. In such cases, the focus will be on facilitating an offender’s readiness for self-change or motivation to treatment, to encourage the offender to accept their problem(s) through engagement. This should help offenders to understand the benefits of treatment for the problem, and then to access the services necessary to overcome it. Third, it is used throughout the supervision process to provide critical feedback to reinforce progress by helping offenders learn to “analyze” their own attitudes and behavior and determine how they can advance their behavioral change.
  • Cognitive behavioral therapy (CBT). CBT encompasses a wide range of psychotherapeutic approaches that deal with cognitions and beliefs to reduce problematic behaviors. Some of the approaches include cognitive therapy, rational emotive behavior therapy, reality therapy and multimodal therapy. All share the objective of identifying thoughts, assumptions, beliefs and behaviors that are related to negative emotions and underlying dysfunctional problems (e.g., drinking problems), and replacing these with more realistic and functional attitudes and behaviors.
  • Group counseling. This is abstinence-oriented counseling (intensive out-patient and traditional out-patient).
  • Multi-program agencies vs. DWI-only agencies. DWI offenders are not a homogeneous group and can present a range of potential problems with varying degrees of severity. Multi-program agencies are more likely than DUI/DWI-only agencies to offer comprehensive substance abuse assessment, comprehensive mental health assessment, individual therapy, and family counseling. Multi-program agencies were also more likely than DWI-only agencies to offer various service coordination and post-treatment services such as: case management; aftercare counseling; relapse prevention groups; discharge planning; and assistance obtaining social services.
  • Pharmacological intervention. It is generally agreed that greater use of pharmacological interventions could enhance treatment progress since it stabilizes the patient and creates a facilitating environment. This approach helps patients reduce drinking, avoid relapse to heavy drinking, achieve and maintain abstinence, or gain a combination of these effects.
• Treatment can be delivered under different models (i.e., harm reduction, behavioral model, gender or culturally specific). Treatment can take place within three main types of care: out-patient, non-hospital residential, and hospital in-patient.
• Treatment can be court-ordered, or a person may enter treatment voluntarily. However, many “voluntary” clients enter treatment under coercion from external pressures (e.g., from family, peers, courts and employers). Generally, coerced treatment has not proven to be detrimental to successful treatment.

Research has consistently demonstrated that a significant percentage of DWI offenders is known to be alcohol dependent or to have issues related to alcohol abuse (Baker et al. 2002; Maruschak 1999; Yao, Voas, & Lacey 2018). So, an efficient and effective method is needed to determine the nature and extent of such problems, with referral to effective treatment available for those who need it. Without adequate information to guide decision-making in impaired driving cases, authorities rely solely upon traditional and popular short-term solutions, such as incarceration and the enforcement of probation supervision to address impaired driving. Treatment is a key component in the array of countermeasures needed to deal effectively with convicted impaired drivers. It is estimated that some 44% of the jail population have mental health disorders (Bronson & Berzofsky 2017). Furthermore, 60% of people on probation have alcohol or drug problems (Brooker et al. 2012). Significantly, impaired driving offenders account for almost 14% of the probation population (NSAC 2018). These statistics underscore the fact that approaches to impaired driving that do not address alcohol and other related problems will be limited in their effectiveness.

• The level of resources allocated towards screening, assessment and treatment in a jurisdiction can limit the number of DWI offenders who can be properly diagnosed and treated. Challenges in this area include: the cost of screening and/or assessment, the quality of available screening instruments, the availability of staff to screen or professionals to assess offenders, the availability of treatment interventions, and the lack of aftercare following treatment.
• The quality and quantity of research (e.g. methodological weaknesses, unvalidated screening and assessment instruments, lack of treatment matching) relating to the screening, assessment and treatment of DWI offenders is insufficient and/or inaccessible to allow practitioners to:
  • identify and select reliable and accurate instruments that can identify and diagnose offenders with substance abuse issues;
  • ascertain which interventions or strategies are most appropriate to apply to this group; and,
  • select appropriate measures of effectiveness by which to evaluate success.
• There are also common myths, misconceptions or concerns related to screening, assessment and treatment which discourage justice practitioners from routinely applying these strategies as part of effective sentencing practices. Examples of such myths include:
  • Screening is too time-consuming and human-resource intensive.
  • Screening, assessment or treatment is too expensive.
  • Coercive treatment is ineffective.
  • Self-help programs qualify as treatment.
  • Treatment is “soft on crime.”
  • Offenders participate in treatment to avoid tougher sanctions.
  • The use of medications to treat substance abuse is not appropriate.
  • The “one-size-fits-all” approach to treatment is okay.
  • There is lack of support for treatment options in rural communities.
• Legislation pertaining to health and privacy may impede the effective delivery of treatment.
• Implementation and delivery of screening, assessment, and treatment protocols is inconsistent within and across jurisdictions.

• Good research is critical to guide decision-making. There is a substantial need for more definitive and dependable research relating to the screening, assessment and treatment of DWI offenders. Such research would provide the basis for developing sound processing and sentencing strategies and guide the early identification of offenders in need of these forms of interventions.
• Education and cross-professional training opportunities are needed to assist practitioners to understand evidence-based, promising practices as they relate to screening, assessment and treatment of DWI offenders.
• Resource allocation should be considered a function of community decision-making among local justice professionals, who have the empirical knowledge of effective interventions and the best understanding of how their system works. These practitioners are well-suited to identify the impact impaired driving is having on their local communities and budgets beyond the justice system.
• DWI systems need to focus on providing comprehensive services. Research has consistently shown that combinations of interventions have better outcomes then single interventions.
• Simple strategies are important to consistently identify offenders in need of screening, assessment and treatment for alcohol abuse and related issues. Agencies should be encouraged, at a minimum, to use informal methods at every phase of the system and formal methods where appropriate and practicable.
• Decision makers should ensure the use of streamlined and effective strategies to apply screening, assessment and treatment. This provides more and comprehensive information to improve decision-making throughout the processing of offenders, reducing recidivism and changing offending behavior. Such practices should also require limited time and be easily applied to facilitate an increase in screening, assessment and treatment.
• Facilitate information-sharing across agencies (e.g., courts, probation, treatment, service providers) to increase accountability among offenders and ensure that interventions are effectively and appropriately applied. Increased information-sharing can reduce opportunities for offenders to fail to appear or “opt-out” of programs, while increasing the level of monitoring, which has been shown to improve treatment outcomes.

System-wide strategies

• High-visibility enforcement or targeted enforcement efforts.
• Traffic safety resource prosecutors (TSRPs). TSRPs are usually grant-funded and provide guidance, support and training statewide to prosecutors in relation to impaired driving cases.
• Increase all system staff training, support, and resources. To improve the way strategies, programs and interventions are implemented and delivered, practitioners need up-to-date and research-supported information regarding guiding principles and the necessary skills. Training and educational opportunities should be delivered through a variety of sources, materials, and delivery strategies. Training and education in relation to the following topics can improve implementation of DWI responses:
  • DWI detection tactics;
  • uniform DWI training and certification;
  • pre-sentence report writing;
  • impaired driving prevention and intervention technologies; and,
  • strategic sanctions and interventions.
• DWI courts. Specialized courts provide accountability, supervision and treatment for impaired driving offenders. System practitioners should receive education on DWI court policies and practices. Understanding the Ten Guiding Principles of DWI Courts created by the National Center of DWI Courts can assist in the implementation of an effective court.
• Multi-agency task forces. Information-sharing and communication regarding experiences between practitioners can occur within a task force and help refine effective practices, allocate resources, and streamline strategies and programs. Training initiatives reaching across various professions and including diverse practitioners can better inform them about the implications their decisions can have on other segments of the system. The benefit of cross-professional training opportunities is viewed as a strategy to encourage collaborative approaches and improve communication so practitioners who process DWI offenders are not working at cross-purposes. See the Guide for Statewide Impaired-Driving Task Forces created by NHTSA.
• Screening, assessment and treatment. Staff need training on understanding and, if appropriate, administration of screening and assessment instruments. The increased availability and use of treatment interventions is a priority.

Treatment approaches

• Gender and culturally sensitive strategies. These specialized strategies account for the way people react to certain types of treatment based upon their gender, native language and cultural/ethnic background. Practitioner education should include information regarding gender, culturally, and demographically sensitive programs and strategies. An understanding of which techniques will likely have a positive impact on different types of people is beneficial to match offender characteristics with suitable interventions.
• Quality assessments. Assessments help determine the nature of the intervention needed and determine whether the treatment intervention is having a positive impact on the involved population.
• Medications. If deemed necessary, the use of medications can help treat individuals who suffer from addiction or other mental health problems which have contributed to their offending.
• Cognitive behavioral approaches. These approaches identify thoughts, beliefs, and behaviors contributing to negative consequences and then work to correct and replace them with more acceptable ones.
• Motivational interviewing (MI). MI empowers the individual to recognize problematic behavior and devise a plan to alter it. This requires staff being trained in and regularly assessed on their motivational interviewing skills.
• Impaired driving technologies. Technologies such as transdermal alcohol monitoring and alcohol ignition interlocks can be partnered with an appropriate treatment intervention to improve outcomes and ensure individuals cannot drive while impaired.

• Allow research-supported screening and assessment to guide decision-making related to treatment intervention.
• Provide education and cross-professional training to assist practitioners in understanding promising, evidence-based practices and promising practices as they relate to screening, assessment, and treatment of DWI offenders.
• Allocate resources to interventions and strategies that are proven or likely to work in the jurisdiction.
• Recognize that a variety of treatment services should be offered to address a range of offenders and their unique circumstances and issues. Varying approaches and combined interventions have the most desirable outcomes.
• To consistently identify those in need of treatment, fund the use of informal screening with validated tools at every phase of the system and ensure more formal assessments as appropriate.
• Streamline policies and practices to respond in a timely manner to offender needs and improve decision-making to reduce recidivism and change offender behavior.
• Create protocols enabling sharing of screening, assessment, and treatment information to help move offenders toward readiness for change and assist them in recognizing the consequences of their substance abuse and/or mental health issues. Also, share information across agencies to increase offender accountability and ensure interventions are effectively and appropriately applied.
• Throughout the course of any intervention, monitor offender behavior to hold them accountable for their problem behavior and recognize and reinforce successes to improve outcomes. Aftercare is necessary to provide offenders with ongoing support which will assist them in maintaining positive behavior changes and reduce opportunities for them to relapse or engage in other negative behavior.

The purpose of treating DWI offenders is to help alleviate identified problems with substance abuse that they may have or be at risk of developing. Treatment is designed to lessen and prevent negative consequences of substance abuse (e.g., DWI) and, also to support the offender during times of relapse. Additionally, many DWI offenders are also diagnosed with a mental illness.  No one treatment approach works for everyone. There are a variety of forms of treatment that can be effective with DWI offenders, including:

• motivational interviewing or motivational enhancement therapy;
• cognitive behavioral therapy;
• brief interventions;
• counseling/therapy (patient-centered or group);
• pharmacological intervention;
• detoxification; and,
• multi-program agencies.