Getting Real About Assessing Substance Abuse

Joseph Nevotti, Ph.D.1

The Problem
The impetus for this paper comes from working with over one hundred psychologists,
mainly those working with inmates in jails and prisons. What I’ve seen leads me to
believe that most psychologists lack sound knowledge of this area. They routinely “get
conned” by the inmates, resulting in serious underestimates of substance abuse and
dependence.

In the California prison system alone only a small percent of the inmates are formally
diagnosed with either substance abuse or substance dependence. However, virtually
all of the approximately 1800 inmates I worked with in the California Department of
Corrections and Rehabilitation (CDCR) had a problem with substance abuse. Well over
half should have been diagnosed as dependent on one or more substances. The
typical clinical psychologist simply does not know how to adequately assess people for
substance abuse or substance dependence. They seriously underestimate the
presence or seriousness of this disorder, and the pervasive impact substance abuse
has on the individual and his/her chances for success (on parole or anything else).

Such underestimates are problematic because substance abuse is a significant reason

why 85% of the inmates released from California prisons return to prison (i.e. recidivate)
in nine months or less.

Addiction as Mental Illness

Someone who meets criteria for substance abuse or substance dependence is mentally
ill just as someone who is psychotic is mentally ill. They are both Axis I disorders. The
psychologist must regard substance abuse/dependence in the same manner s/he would
regard paranoid schizophrenia: it does not “come and go” and the odds of successful
self-treatment are about the same. The symptoms may come and go, but the
underlying disease is permanent.

Drug addiction/alcoholism is a life style as well as a mental illness. Technically it’s a

“syndrome” which entails physical, psychosocial and emotional factors. It becomes the
totality of the addict/alcoholic’s life, and his/her number one priority; everything and
everyone else in that person’s life (e.g. children, spouse, job, health, material
possessions, freedom, self-respect) are second best, at best. As DSM-IV informs us:
a) Important social, occupational or recreational activities are given up or reduced
because of substance abuse and/or substance dependence;
b) the substance abuse and/or substance dependence continues despite persistent
or recurrent problems that are the direct result of substance abuse and/or
substance dependence, i.e. a cardinal characteristic of the addict/alcoholic is the
inability to change his/her behavior based on past mistakes.

1 Dr. Nevotti is a licensed psychologist who performs forensic evaluations. From 2/02 until 5/07, he worked as a
Contract Psychologist in several California prisons, working with inmates at all Levels of Care (i.e. GAF 25 to 80)
and all Levels of Custody. He has been a member of Alcoholics Anonymous continuously since July 17, 1984.
One of several slogans in Alcoholics Anonymous (AA) is, “It’s the first drink that gets
you drunk.” One drink or “hit” will impact the substance abuser and/or substance
dependent individual in the same way that eating Haagen Das will impact a diabetic, i.e.
it sets off a physiological reaction the person cannot control. Someone afflicted with
substance abuse and/or substance dependence cannot have just one or two drinks, and
cannot “take it or leave it” as the person who is not addicted can (e.g. most
psychologists). Few people who are not substance abusers and/or substance
dependent can comprehend this point. This is one of the reasons why substance abuse
counselors are almost always in recovery themselves; those who are not get
conned . . . especially those who “just want to help.”

Someone who meets criteria for substance abuse or dependence either is or is not
abstinent. There is no middle ground. The natural state of affairs for the addict/alcoholic
is to be “high”, “loaded” or intoxicated. When they are not loaded they are ill at ease,
“restless, irritable and discontent” and usually thinking about (if not obsessed with) their
next drink/fix unless they are in recovery (see “Requiem for a Dream”).

Assessment & Diagnosis

I begin my evaluation with a review of records to determine what the individual has
abused and what problems it has caused. Police and Parole Officer reports are very
useful. Because of the amount of distortion present in interviews, my primarily source of
information is the documentation (medical and criminal); I regard the interview as a way
to confirm and clarify. It’s important to remember that when performing a forensic
evaluation with an inmate the person I’m assessing is not my client, and I’m not there to
form a “therapeutic alliance.” If the “clinician” cannot get past these two self-imposed
filters they will not be able to accurately see what they are doing.

I start with the assumption the interviewee is Polysubstance Dependent, and then
conduct the rule out process in reverse. In terms of substance abuse and/or substance
dependence, those in prisons and jails have a high base rate of alcoholism and/or
addiction. I use the DSM-IV Diagnosis 304.8, Polysubstance Dependence, more
frequently than any of the single substance diagnoses because

for someone who is truly substance dependent, drugs and/or alcohol “take over;”
drinking and/or drugging become the raison d’etre of the addict or alcoholic’s life. As
the DSM informs us: “A great deal of time is spent in activities necessary to obtain the
substance, use of the substance, or recovering from its effects.” Today, almost no
alcoholic/addict is addicted to one substance; the overwhelming majority are addicted to
two or more substances. Probe: do not settle for “I tried it a couple of times” or “I
smoked ‘sherm’ (i.e. PCP) once but didn’t like it.” Most addicts/alcoholics will tell you
they would drink, inhale, snort or shoot up peanut butter if they thought it would get
them high. This is the one area where most psychologists fail because (a) they believe
what the addict/alcoholic tells them; (b) their good intentions and desire to help cause
them to give the addict/alcoholic the benefit of the doubt; and (c) they don’t understand
how drugs/alcohol take over the totality of the addict/alcoholic’s life.

In addition to determining whether or not the individual meets criteria for diagnosis,
another goal of the assessment is to predict a negative, i.e. the person’s ability to not
take the first drink or drug. The best indicator of that (like any behavior) is past history,
i.e. the number of times he has not picked up and/or used, measured in months or years
since his/her last drink/drug. “Trying” and good intentions definitely should be
encouraged in the person who is in recovery, but it doesn’t count in terms of making
predictions about future behavior. The reliability of your prediction about the
interviewee’s future behavior (e.g. violence risk, ability to stay out of jail, etc.) is directly
related to the amount of uninterrupted abstinence together with active participation in
the recovery process.

This is a black-or-white issue and not a good place for “clinical judgment.” 2 When
establishing length of sobriety/recovery, the starting point for making a prediction
regarding the odds a person will remain drug/alcohol free is to accept nothing less than
the date the person took their last drink or fix, i.e. their “sobriety date.” Any
equivocation on this issue is symptomatic as are “good intentions.” Part of the problem
with substance abuse and/or substance dependence is poor reality testing or what
therapists refer to as “denial”.

Someone who is really in recovery will know his sobriety date and be willing (usually,
proud) to state it just as they know their own birth date. Dig, and make sure the
interviewee confirms that his/her sobriety date is the last time s/he used or drank
anything, It’s also important to remember that someone who claims 17 years of
sobriety but had one beer (or toke or snort or sip of wine) three days ago, has three
days of sobriety. The previous time does not count insofar as making predictions about
future behavior. If someone “broke” sobriety for any reason, they will very likely break it
again “for any reason.”

Once under the influence it is highly likely that the individual will return to his previously
destructive, dysfunctional lifestyle. If you’re dealing with inmates the evidence is
overwhelming that they will violate the terms and conditions of parole. Moreover,
“recreational” use of alcohol/drugs by someone with this diagnosis is a fantasy or
rationalization (and they will try their best to get you to believe it). The psychologist
must do their best not to get sucked into this in the guise of “good intentions” or the
Harm Reduction model.

The DSM modifier of “In Remission” is for the naive. The only thing that comes close to
being accurate is “In A Controlled Environment” and even that is suspect. Just because
someone with the DSM-IV diagnosis of 304.8, Polysubstance Dependence, is locked up
(even in the SHU at Pelican Bay where I’ve worked) does not mean he cannot get any
drug he wants. Even using this latter label I will only stipulate “In A Controlled
Environment” if I have solid evidence they are working a program and have been
abstinent for several years.

Every evaluation requires a careful examination of the individual’s substance abuse

history. Substance abuse/dependence is chronic, and operates much like diabetes,
hypertension, and heart disease, i.e. once developed it continues to function during the
course of the individual’s life, chronically influencing thinking and behavior. The
condition may go into remission but it never goes away. Therefore, when I do an
2 There is over 50 years of research demonstrating that “clinical judgment” results in poor predictions of human
behavior. The reader is directed to the works of Meehl (1954), Monahan (1981) and Hanson and Morton-Bourgon
(2007) for an introduction.
evaluation I take the position of attempting to prove the negative, i.e. that the Individual
has control over what is not happening, i.e. abuse of drugs/alcohol. To this end I need
to see (a) no evidence of recent SA (e.g. arrests or other negative consequences with a
drug/alcohol component in past five years), and (b) the Individual must convince me
they have internalized the changes necessary to remain sober once they have ready
access to drugs/alcohol, i.e. can explain to me how they got sober and how the changes
they’ve made have positively influenced their thinking and behavior. For example, if
someone tells me they are in recovery I ask them to name any one of the 12 Steps of
AA. If they can do this (most cannot) I then ask them to describe: (a) their experience
with Step 5 and Step 9, and (b) to tell me how working the steps has changed their life.

Below is an excerpt from an assessment I conducted on an individual with long-

standing, well documented polysubstance dependence. Although he did not participate
in AA or a 12 Step program, Mr. James’ (pseudonym) response was indicative of the
internal change necessary to produce behavior change:

First, Mr. James was able to provide a detailed description of the sequence of events that lead to
his becoming abstinent. This began with a highly emotional intervention conducted by his mother
and sisters in 1982, the result of which was he made a conscious decision to change. This was
followed by Mr. James’ moral inventory: “I started writing down what I was doing wrong, who I
was being, and how I was hurting my family.” Although he continued to engage in antisocial
behavior while in prison as evidenced by his Rules Violations Reports (RVRs) in CDCR, this
ended in 1992 when he made the decision to abstain from drugs and alcohol. Mr. James reports
he has remained abstinent for the past 17 years.

Next, his behavioral record during his last 5 years in CDCR as well as throughout his 7 years at
Atascadero and Coalinga State Hospitals has been free of documented serious negative
behaviors. As stated in numerous Interdisciplinary Treatment Notes (IDNs), “he is a low risk for
escape, and he displays no behavioral problems.” Although passive compliance has limitations
noted above, clearly Mr. James has become more cooperative.

For the record, I have heard stories similar to Mr. James’ less than ten times while
working with over 1,800 inmates.

Treatment
There are two ways to recover from substance abuse/dependence: alone or through
some kind of dedicated/structured, group program (e.g. AA, NA). Any form of recovery
that does not involve a structured support group is (a) based on the self-discipline of the
addict/alcoholic, the failure of which is documented in his criminal records; and (b) is
virtually certain to fail. Incidentally, “why” the addict/alcoholic is an addict/alcoholic is
absolutely irrelevant to his/her diagnosis or recovery from drugs/alcohol. The etiology of
this disease is unknown, and attempts to understand it, especially through
psychodynamic interventions, only prolongs (and possibly perpetuates) the problems.

Effective treatment involves (a) regular attendance in a structured recovery program; (b)
a psychiatric evaluation in the first 90 days to treat possible co-occurring Axis I
disorders (e.g. Major Depressive Disorder, Bi-Polar Disorder); and (c) on-going, active
support (e.g. daily attendance at AA meetings). “Understanding” has very little to do
with recovery, and psychotherapy is best delayed until after the person has stabilized (>
2 years). Otherwise, therapy runs the risk of emotionally overwhelming the person with
“issues” the understanding of which has little to do with the early stages of recovery.
Recovery is measured by days/months/years of continuous (i.e. unbroken)
abstinence/sobriety. The clock starts ticking when the addict/alcoholic takes his/her last
drink/fix. If a person has been sober for “most” or even 99% of the past three years, but
his/her last drink or fix was three months ago, then that person has three months of
sobriety.

Paradoxically, the solution to addiction/alcoholism has nothing to do with the problem.

The only thing that has any track record of success is AA which is based on having a
spiritual awakening. What does a spiritual awakening have to do with a psycho-
physiological problem? Nothing, but it works. Incidentally, the concept of a “spiritual
awakening” as the solution came from Carl Jung when one of his patients carried this
message to Bill Wilson, the founder of AA, in 1934.

AA is the best game in town . . . . and it has a terrible track record. Unfortunately, no
individual or group does better, and AA’s success rate is optimistically estimated to be
five percent, i.e. 5% make it to their fifth anniversary, i.e. >95% return to alcohol, a
dysfunctional lifestyle, and premature death. Drug addicts are worse. Betty Ford and
Hazelton, arguably two of the best 28 day rehab programs, will tell you 40% to 60%
make it. What they don’t tell you is that is just for the first year. Just being a “walk on”
to AA (which costs $1/day vs. $20,000 for 28 days at BFC) the alcoholic’s odds using
AA alone are about 50% for the first year. In short, the 28 day rehab programs have not
empirically demonstrated their superiority in the area of recovery (but they are “cool”
and you can rub elbows with the stars).

Recovery is not intellectual nor is it a spectator sport. It requires active and continuous
participation; internalization of the change process; and personal transformation. If it
was an intellectual process one could go to a bookstore and buy “Recovery for
Dummies” and be done with it, but it doesn’t work that way.

The first step in recovery, literally, is open acknowledgment of the problem. Therefore,
one critical indicator of whether or not the person is abstinent and going to stay that way
is he will tell you what he liked to use, how much he liked to use it, how it made him feel,
and the trouble it got him in. (“why” he used it is irrelevant and a diversion from the
recovery process). If he is not willing to tell you these things or he underestimates (“I
had a few beers” or “occasionally I smoked weed”), he is malingering. Malingering and
underestimates are the norm among addicts and alcoholics. Another slogan from
recovery is, “The way to tell if an addict/alcoholic is lying is to see if his lips are moving.”

Dealing with those who are substance abusers/dependent is no place for sissies, and
people with “good intentions” need to be especially careful. Support, encouragement
and structure (e.g. 12 Steps + meetings) work, especially when coupled with swift and
sure negative consequences when the addict/alcoholic has a dirty UA (e.g. Steve
Buschemi’s role in “28 Days”). Anything less (e.g. giving them a second chance without
negative consequences) is enabling. The hard reality of this disease is that the chances
are overwhelmingly against anyone staying sober for any length of time. Incidentally,
those with a substance abuse and/or substance dependence diagnosis are masters at
finding and conning those who will enable her/him.

How many “chances” should you give an alcoholic/addict? In my opinion, as many as

they want. If they present for treatment (i.e. show up at an AA/NA meeting), my job (as
an alcoholic in recovery, not a psychologist) is to welcome them, encourage them and
provide whatever help they ask for regardless of how many times they’ve been thru the
“revolving door.” Very few make it the first time, and a surprising number are able to
survive numerous attempts.

Alcoholics Anonymous
One of the many slogans in AA is, “Meeting Makers Make It.” The key to getting and
staying abstinent (i.e. sober or clean) is recovery, and that means continual, active
participation in a structured program (e.g. AA) for as long as the person is alive and
chooses to remain sober. It’s a life-long program as is the management of diabetes
or hypertension. Conversely, those who don’t go to meetings on a regular and continual
basis have a higher probability of failure. Unfortunately, there are no studies or survival
analyses on this although much of the above is apparent to anyone who goes to an
Alano Club (in all major cities and open to the public) that has a “Birthday Board” and
plots number of people in recovery on the “y-axis”, and years of recovery on the “x-
axis.”

AA meetings (i.e. recovery) are everywhere. In large cities there are over 1000
meetings per week, and all of them publish meeting schedules (day/time/place). Even
small towns have meetings and these may be found by calling the number provided in
the local telephone directory or by calling the local police department. Also, in every
meeting I’ve been to there is usually one person there who walked, took a bus or rode a
bicycle to the meeting because they lost their driver’s license and/or had no car. There
is NO excuse for not going to a meeting, and there is very little chance of recovery
without AA.

I recommend newcomers attend AA rather than Narcotics Anonymous (NA). NA

meetings are much more “raw” and there are few people at any given NA meeting with
more than one or two years of abstinence. In any given AA meeting about half the
people there will have one year or less, but there will also be some “old timers” there
who have double digit sobriety (i.e. >10 years). In addition, there is often more
romanticizing of the problem (i.e. drug use) at NA meetings as well as someone out in
the parking lot selling drugs out of the trunk of their car.

Substance Abuse/Dependence Interview Guide

What follows are the questions I ask and things I look for during the interview. Note: I
always conduct a file review before the interview, and I make sure the interviewee
knows this when we begin. Any time I hear a discrepancy during the interview I bring it
up and make sure it is answered to my satisfaction. Moreover, if there is doubt I
believe the documented evidence, especially if from a parole officer or multiple sources,
rather than the inmate. I also inform them at the start of the interview that I have 25
years in recovery and have some understanding of this area.
1) How old were you when you first used drugs or alcohol? What did you use? What
happened?

2) What have you tried (circle ALL that apply)? Inhalant / Alcohol / MJ / Meth / Cocaine /
Crack / Heroin / PCP / Hal / Rx Meds (list) / “Street” Pills (list). (PROBE. It is extremely
 rare that someone abuses one substance or abuses it one time, especially if they were < 15
when they began)

3) When was the last time you drank and/or used; last date you had even so much as one beer or
one hit? (Accept nothing less than the last date they drank/used)

4) What is the longest you have gone on the outside (i.e. not incarcerated) without so much as
one beer or one hit, nothing? (Note: typical answer will be in days or months; rarely more
than one year)

5) Have you had any contact with the police while you were drinking and/or using?
(List any documented contacts and discuss with interviewee)

6) Were you under influence at time of instant offense? (Note what is documented in police
report and have individual explain what he was thinking and doing before and during the
offense, and how drugs and alcohol affected his thoughts and feelings at the time)

7) Tell me about the problems substance abuse has caused you. (If they deny, confront them
with information from file review and ask for explanation)

8) Does substance abuse remain a problem for you today or will it be a problem for you when
you get out? (PROBE. If they deny ask them how they will avoid repeating previous SA-
related problems)

9) What are your plans for dealing with your substance abuse problem when you get out? (Note
whether or not they understand it is a life long process. Evaluate how solid their plans are i.e.
do they understand the need for an on-going structured recovery program such as AA?)

10) What are you currently doing to recover from substance abuse? (Record number of times per
week they go to meetings specifically designed for recovery)

11) Have you worked the 12 Steps? Recite all the steps you can remember: (Record verbatim)

12) How has “working the Steps” changed your life? (Probe for facts and details. Someone truly
in recovery will tell you specific stories about how working a step has changed their life.)