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October 31, 2023 Fall 2023

One Size Does Not Fit All – The Importance of Screening and Assessing to Determine Appropriate Interventions for Impaired Drivers

Julie Seitz, Project Director, AllRise Impaired Driving Solutions

Impaired driving represents a complex problem, one that cannot solely be punished or incarcerated away. The characteristics of individuals involved in this habitual behavior show that fatal crashes involving impaired drivers often include higher blood alcohol concentration (BAC), are more likely to have prior impaired driving convictions and involve more than one impairing substance. These behaviors often point to an underlying symptom: addiction, resulting in high-risk/high-need individuals who pose a significant risk to public safety. Additionally, this population experiences a higher incidence of co-occurring mental health disorders. The complex problem of impaired driving requires a diverse solution, including accountability and individualized treatment. Historically, the justice system has focused on accountability while downplaying or outright ignoring the treatment piece.

Substance use disorder (i.e., addiction) is a complex and multifaceted condition that uniquely affects individuals. Therefore, it remains essential to provide individualized treatment that addresses the specific needs of that individual. Screening and assessment are critical to determining the individual's risk level and treatment needs. To effect long-term change for this population, every individual who enters the system for impaired driving should be screened and/or assessed for co-occurring disorders to ensure that all behavioral health needs are identified and addressed.

Screening and assessment represent two essential processes with key differences, while serving a similar purpose. The primary purpose of screening focuses on identifying individuals who may be at risk or potentially have a substance use disorder. Screening instruments are brief, and the preliminary process seeks to determine if further assessment is needed; it does not provide a definitive diagnosis.  Various professionals can conduct screenings in many settings, including the courts.

One example of innovative integration of screening with impaired drivers is a program in Duluth, MN. The Sixth Judicial District Court conducted a Screening, Brief Intervention, and Referral to Treatment (SBIRT) pilot project on all first-time DWI arrests. Partnering with the local Department of Human Services and a treatment center, all first-time DWI arrestees were referred at arraignment to meet with an SBIRT screening navigator for a validated screening. Results of the pilot determined that much like the national data for repeat impaired drivers, about 2/3 of those screened demonstrated low-risk for having a substance use disorder, and thus were offered a brief intervention and no further recommendations. The screening of approximately 1/3 found risk substance use and were referred for further clinical assessment. A recently completed five-year evaluation, the publication of which remains in production, the results show promise, including a reduction in recidivism, demonstrating the importance of early screening and intervention. If the screening uncovers potential problems, an assessment must be done to understand those problems fully.

The assessment gathers comprehensive information about substance use patterns, related behaviors, and problems. Completed by professionals with specialized training and qualifications, a comprehensive clinical assessment provides a diagnosis, which informs treatment planning. The evaluation involves utilizing validated tools to examine substance use history, co-occurring mental health disorders, biomedical conditions, continued use potential, recovery environment, and motivation to change. 

In addition to comprehensive screening and assessment, addressing substance use and mental health disorders requires clinical placement that meets the individual's complex needs. Moving away from "one size fits all" models of care to an individualized approach, recognizes the need to match treatment settings, service, and intensity based on the individual's clinical needs. Substance use disorder occurs on a spectrum; treatment intervention necessitates a continuum of care. Effective treatment recognizes the Transtheoretical Stages of Change model (TTM). The TTM framework, developed by James Prochaska and Carlo DiClemente, describes the process individuals experience when making behavior changes. The six-stage model recognizes that change is not a linear process but a series of individual stages. For treatment to be effective, it is essential to tailor the interventions to meet the individuals where they are in their change process. 

The high-risk, high-need impaired driving population has demonstrated a high degree of compliance-driven change. In other words, with the discontinuation of supervision and accountability of probation or programming, individuals return to use/problem behaviors.  Adherence, on the other hand, lies in finding what intrinsically motivates the client to change, meeting them where they are at in their stage of change, and creating a meaningful and lasting change plan for the client, something they will continue to employ after the programming ends. Moving from program and time-driven treatment planning to individual outcome-driving treatment planning effectively aids in the process of change.

Time-driven treatment frequently represents an arbitrary practice, and the requirements refer to criteria or guidelines lacking in evidence-based practices. The requirements of time-driven treatment often promote subjectivity and lack validity resulting in treatment agencies and courts employing program-driven care (a certain number of hours, modules, etc.). This approach fails to consider the complexity of substance use disorder and the need for comprehensive assessments to determine clinical needs and placement. 

The research supports that, while treatment works, not all interventions work for everyone. One of the best predictors of positive outcomes in treatment remains a solid therapeutic alliance, the collaborative relationship between a therapist or treatment provider and the client. Alliance factors promote client engagement, collaboration, empowerment, and treatment adherence. When clients feel heard, understood, and agree on goals, they are more likely to adhere to their treatment plans. To understand if a therapeutic alliance exists, using validated tools is vital, as relying on the therapist’s interpretation alone often demonstrates bias.  Several methods can be employed when measuring therapeutic alliance, varying from client self-report to therapist-rated measures. While no single tool captures the complexity of substance use disorders and therapeutic alliance, effective treatment must integrate these practices when working with all individuals in clinical practice.  

Historically, treatment for substance use disorders stemmed from the acute care model. In other words, periods of brief intervention followed by cessation of services. The traditional model may work well in an emergency room although impractical for substance use and mental health disorders. Substance use disorders represent chronic illnesses like diabetes or hypertension. Effective treatment requires long-term involvement, continued care, regular check-ups, and linkage to community resources.

The success of the justice system focusing on the accountability piece for impaired drivers fails to recognize the need adapt the system to those who present with treatment needs, a necessity if the systemic goal adjusts to a genuine desire to make an impact on all segments of the impaired driving population. Treatment reform aims to decrease barriers to persons seeking substance use disorder treatment, ensuring that people have timely access to the continuum of needed services. Good outcomes depend on individualized treatment plans and adequate treatment length.  Said differently, outcomes improve when an individual participates in the right treatment for the right amount of time.

Julie Seitz

Project Director, AllRise Impaired Driving Solutions

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