DUI Process and Importance of Screening and Assessment

More than half of repeat DUI offenders have a history of mental health problems other than substance use problems. Many have never been diagnosed. Why does that matter? We know that untreated mental health problems can contribute to substance use relapse and DUI recidivism. My team and I have interviewed hundreds of DUI offenders. And most of them have every intention to stop. But when they relapse or re-offend, there’s often a triggering event we can point to – a relationship problem, an unexpected life event, a challenge at work – that, when coupled with underlying mental health issues, leads to unhealthy coping strategies including re-engagement with substances.  

So mental health issues certainly influence DUI. But why should we screen for them within DUI programs? I often hear the argument that we shouldn’t ask about mental health issues other than substance use problems among DUI offenders because we can’t do anything about them. The idea is that DUI programs know that many of these offenders suffer from mental health issues, but don’t have the resources to help with those issues, so don’t want to stir them up. This logic is flawed. The first step to addressing mental health issues is to identify them. The reasons for this are threefold. 

• First, diagnosis can itself be a part of treatment. Asking questions about mental health can help DUI offenders begin to come to terms with these issues and move toward seeking treatment.  
• Second, to gain appropriate resources, programs need to first identify the problems. A program that can document high prevalence of mental health issues in their population is better poised to gain the resources to begin to deal with those issues.  

• Third, screening for problems does not necessitate treating them in-house. A strong referral network can be built that allows programs to make referrals for the problems they identify.  

The next question is when to screen. Another argument I’ve heard is that mental health problems are clearly elevated among repeat DUI offenders, but not among first-time DUI offenders, so a better use of resources is to screen repeat offenders. This is also debatable. If psychiatric comorbidity (i.e., having multiple mental health issues) does indeed contribute to DUI recidivism, as evidence suggests it does, then first-time DUI offenders are exactly who we ought to screen, as well as repeat offenders. By screening early, we can identify DUI offenders who might be particularly at risk for recidivism and who could most benefit from treatment.  

How should we screen, and for what? Screening does not have to be complicated, and does not have to be done by a clinician. Here’s some key points:  

• What’s important is that screening be standardized – it doesn’t work if everyone asks different questions of different clients; 
• It must provide meaningful information about whether an offender is struggling with moderate to severe mental health issues. A screener doesn’t work if it identifies everyone as having problems because the criteria it uses are too widely endorsed, but it also doesn’t work if too many actual cases slip through unidentified.  

• A good screener is highly sensitive, meaning it doesn’t miss many true cases, but also has decent specificity, meaning it doesn’t over-identify cases. In a process where screening leads to additional assessment, which we recommend, it is okay for a screener to cast a fairly wide net, producing some false positives in order to ensure that there are no false negatives.  
• As far as what to screen for, we have found that trauma, anxiety, and attention and impulse problems are highly prevalent among repeat DUI offenders. A screener should be able to, in addition to screening for specific substance-related problems, screen for symptoms of PTSD, anxiety disorders (including panic attacks), ADHD, depression and mania, and anger issues (e.g., intermittent explosive disorder). Lifetime histories can be informative, but if resources are scarce, screening for past-year symptoms can identify the most pressing issues.  

Together with Responsibility.org, the Cambridge Health Alliance created a screening and assessment tool that accomplishes all of these goals. It’s available for free download at www.carstrainingcenter.org  

Ideally, screening and assessment should be a two-tiered system, with screening happening as early as possible in the DUI chain of events (e.g., pre-trial if possible) and full assessment following for those who screen positive for disorders. And screening should not be a one-time occurrence. Screening should happen throughout the DUI sentencing and treatment process. A DUI offender who does not admit to symptoms of mental health issues pre-trial might be ready to discuss those issues with a program counselor after adjudication. And a DUI offender who does not accept a referral to treatment when first presented, might accept it the third time it’s presented.  

To end, I’d like to leave you with a quote by Karl Menninger: “Treatment depends upon diagnosis, and even the matter of timing is often misunderstood. One does not complete a diagnosis and then begin treatment; the diagnostic process is also the start of treatment.  Diagnostic assessment is treatment; it also enables further and more specific treatment.”