Co-Occurring Disorders and Military Justice
Screening for Co-Occurring Disorders for Justice-Involved Veterans
Many of the validated screening instruments for mental disorders and substance use, as well as for Post-Traumatic Stress Disorder (PTSD), require only a few minutes to complete. Screens for criminal risk and need can also be implemented, if one is not already in place, to aid service planning.
Practitioners should screen for:
- Military status
- The presence of co-occurring mental and substance use disorders
- Trauma and post-traumatic stress disorder
When to screen
There are many opportunities for implementing screening and assessment protocols along the criminal justice continuum. Screening at intake to institutional and community corrections is especially important for agencies to make informed supervision and security decisions, as well as to identify healthcare needs.
Screening opportunities also exist prior to initial appearance or arraignment hearings, by pre-trial services, as part of the pre-sentence investigation, or during transition planning. Many trauma, mental and substance use disorders screens are intended for delivery by a trained practitioner. These screens can be delivered by a practitioner as part of a medical screening process separate from an agency's general intake screening.
Screening for military status
The first step in connecting justice-involved veterans to services is the identification of a person's military status and the presence of mental and substance use disorders. The Bureau of Justice Statistics has developed a set of survey questions for identifying people who have served in the military. Instead of asking whether a person is a veteran, the first question is broadly worded to address "military service." This broad wording is important since individuals who have served in the military may not self-identify as veterans, even if they qualify for some of the benefits available to veterans. The remaining items ask for information relating to the branch of service, combat experience, length of service, and discharge status. The seven items include:
- Did you ever serve in the U.S. Armed Forces?
- In what branch(es) of the Armed Forces did you serve?
- Army (including Army National Guard or Reserve)
- Navy (including Reserve)
- Marine Corps (including Reserve)
- Air Force (including Air National Guard and Reserve)
- Coast Guard (including Reserve)
- Other - specify
- When did you first enter the Armed Forces?
- During this time did you see combat in a combat line unit?
- When were you last discharged?
- Altogether, how much time did you served in the Armed Forces?
- Number of years
- Number of months
- Number of days
- What type of discharge did you receive?
- General (honorable conditions)
- General (without honorable conditions)
- Other than honorable
- Bad conduct
- Other — specify
- Don't know
Screening for mental and substance use disorders
Effective screening begins with routine screening at the entry points to criminal justice settings. The process is aided by standardized instruments with cut-off points to determine whether a person should be referred for assessment. Trained behavioral health practitioners should administer the screening and assessment protocols, although some screens are developed for use by non-clinicians.
Co-occurring disorders screening is part of a treatment and supervision planning process that includes assessment and diagnosis.
Assessment of co-occurring disorders is not limited to developing a diagnosis. Assessment involves a clinical examination of the individual, engaging with close family members and associates, and coordination with behavioral health providers and other criminal justice agencies. The purpose is to inform treatment planning and delivery by identifying a person's strengths, weaknesses, supports, and needs.
The goals of assessment are to determine:
- History, presence, interaction, and severity of mental and substance use disorders
- Health conditions
- Level of care
- Treatment history
- State of Change
The information gathered is not solely clinical. An individual's employment status, education, and housing stability may also be incorporated into the process.
The assessment may examine symptoms of mental illness prior to and during periods of substance use and abstinence.
Engagement and consumer involvement
When screening for co-occurring disorders, criminal justice agencies can enhance the quality of the process by engaging the individual in the process. Steps to promote engagement include explaining the purpose, providing breaks to help maintain focus, providing a safe setting, and developing a rapport between the practitioner and individual.
Criminal justice settings can obtain the most accurate and reliable results by using instruments with established validity. The protocol may call for a single screen for co-occurring disorders or separate screens for mental and substance use disorders. The standardized instruments will have cut-off scores to determine who needs a more in-depth follow-up.
Screening for trauma and post-traumatic stress disorder
A trauma screen examines whether an individual has experienced trauma or is currently experiencing trauma-related symptoms. Veterans may have experienced trauma in situations other than combat, such as sexual abuse, physical abuse, or a natural or man-made disaster.
The purpose of trauma screening is to gain knowledge about an individual's experiences and/or trauma-related symptoms.
A major challenge in screening for trauma is that many people underreport their experiences. There are a variety of reasons for this, such as
- Safety concerns
- Fears of being stigmatized
- Feelings of shame
- Lack of trust between the individual and the practitioner
Screening for trauma is important for the purposes of avoiding retraumatization and providing services that match an individual's needs. However, because a sense of safety and trust are necessary for an individual to discuss traumatic experiences with a practitioner, it may be advisable to delay trauma screening or repeat the screening if it is provided at intake.
Screening and assessment instruments for trauma vary on three dimensions:
- Population of interest.
A PTSD instrument is designed to either determine the likelihood of or establish a PTSD diagnosis based on an individual's symptoms. Some PTSD instruments also have a broader focus on related disorders. Depending on the instrument, the scope may vary between single or multiple traumatic experiences. Some instruments have been designed for specific populations, such as combat veterans.
Trauma Exposure Screens
Instruments that measure trauma exposure may examine the types of trauma or the severity of a traumatic experience. In choosing an instrument, practitioners may weigh the need for specificity over the time to administer. Shorter instruments tend to focus on broader experiences and longer instruments on specific experiences. Brief trauma exposure instruments that take less than 15 minutes to administer include:
Post-traumatic Stress Disorder Screens
Practitioners that administer screening instruments for PTSD follow up with diagnostic interviews for individuals who score above the screen's cut-off point. Most PTSD screens only take a few minutes to administer. The Primary Care PTSD Screen, for example, has four questions and takes two minutes to complete. Some self-report PTSD instruments can only be used for screening. The PTSD Checklist has 17 questions but takes less than ten minutes to complete. As with other disorders, a PTSD diagnosis is best established when a practitioner administers a structured interview, such as the Clinician Administered PTSD Scale.
Resources and Links
The National Center for PTSD provides reviews the properties and research on screening and assessment tools for trauma and PTSD.
A Trauma-informed Approach to Screening and Assessment. Using Trauma Theory to Design Service Systems