Transcript Document

Module II
Introduction to Screening and
Assessment of Persons with CoOccurring Disorders: Screening and
Assessment, Step 1 and Step 2
Review of Module I
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Reactions, questions or comments
from the readiness to change and
motivational survey answers from
Module I
Reactions, questions or comments
from Module I
Review of Assignments
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Reactions, questions from TIP 42
reading
Reactions to GAIN-SS and
Perceptions of Global Appraisal of
Individual Needs – Short Screener
(GAIN-SS): A Pilot Study
Module II Objectives
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The importance of screening
across disciplines
Use of the GAIN-SS for screening
The importance of the
“engagement” in performing a
good assessment
Review Step 1: Engage the
patient
Review Step 2: Identify and
contact collaterals to gather
COD Screening & Assessment
To what extent do you currently
provide COD Screening and
Assessment and what
instruments are you currently
utilizing?
Instrument Criteria
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The screening instrument is sensitive.
The screening instrument is brief.
The screening instrument is low or no
cost.
The screening instrument can be
administered and scored with little
training.
The screening instrument is applicable to a
diverse range of people.
The screening instrument includes a
question about suicide.
GAIN-SS
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Twenty-item instrument that screens for
internalizing disorders, externalizing
disorders, substance use disorders, and
behaviors related to crime and violence
Take 3 to 5 minutes to administer
Meant to determine whether a mental,
co-occurring, or chemical dependency
assessment is needed
GAIN-SS 4 Subscales
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Internal Disorder Screener (IDScr)
was designed to identify people experiencing
internalizing disorders such as depression, anxiety,
suicidal ideation, and acute/post traumatic stress
disorders
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External Disorder Screener (EDScr)
designed to identify persons experiencing
externalizing disorders such as attention deficit,
hyperactivity, conduct disorder,
aggression/violence and other externalizing
behavioral problems
GAIN-SS 4 Subscales
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Substance Disorder Screener
(SDScr)
designed to identify persons abusing or
dependent upon alcohol or other drugs
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The Crime and Violence Screener
is comprised of five items used to identify
persons exhibiting criminal and violent
behavior.
GAIN-SS Scoring
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If a person receives a score of 2
or more on any of the GAIN-SS
subscales, then that person
should be referred or provided
either a full mental, chemical
dependency, or co-occurring
disorder assessment.
TIP Exercise–Screening Instruments
Option 1: Role Play & Discussion
With your partner, take turns administering
The GAIN-SS
You have 10 minutes total!
Pay attention to
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While in the role of the clinician
what it feels like to ask the
questions.
While in the role of the client
what it feels like to answer the
questions.
Screening Protocol
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A professionally designed screening process or
protocol establishes precisely . . .
– how any screening tools or questions are scored
– what constitutes scoring positive for a particular
possible problem (“establishing cut-off scores”)
– what happens if a client scores in the positive range
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and provides the standard forms to document
1) results of all later assessments
2) that each staff member has carried out his or her
responsibilities in the process
Screening+Assessment Tx Plan
Screening is a process for evaluating the possible
presence of a particular problem.
Assessment is a process for defining the nature of
that problem and developing specific treatment
recommendations for addressing the problem.
A comprehensive assessment serves as the basis
for an individualized treatment plan. The
treatment plan must be matched to individual
needs.
Introduction to Cases
Sherry is a 15 year-old girl in the 9th grade. She was referred
for a chemical dependency evaluation after being taken to the ER for
a suicide attempt. Sherry agreed to the evaluation only if she could
be seen without her parents. Sherry took an overdose of pills
including aspirin, Zoloft and, over-the-counter sleeping pills. The nonlethal OD did not result in hospitalization. The urine toxicology screen
done at the ER was positive for THC and Sherry's blood alcohol
content at the ER was .09.
Sherry acknowledged use of alcohol and marijuana in her
evaluation. She reported drinking every weekend, 3-6 drinks at a time
and smoking marijuana three to four times weekly. She denies any
problems with her substance use other than being placed on
restriction when she comes home late. She doesn't think her parents
know she drinks or smokes marijuana.
Sherry does not think alcohol played a role in her overdose.
She took the pills, she says, because she was upset over breakingup with her boyfriend. She denies intending to die, but "just did it."
She denies any previous attempts.
Sherry was prescribed Zoloft by her family doctor for
"Adjustment Disorder" following her parent's divorce. Sherry doesn't
think she needs the Zoloft and doesn't think it is doing anything. The
doctor also recommended counseling but Sherry hasn't gone.
According to her parents, Sherry exhibited no emotional and
behavioral problems prior to age 13 when they began having difficulty
"controlling" her. Sherry became increasingly defiant and alternately
sad and withdrawn during this time. This pattern has persisted for two
years. Sherry's parents suspected that she had been drinking and
frequently placed her on restriction to keep her home on the
weekends. Sherry has run away from home three times, staying away
for two weeks the last time.
School records corroborate that Sherry was an excellent
student until the 8th grade when her grades declined from A's and B's
to C's and D's. Sherry never posed a discipline problem at school
until this year when she was suspended for smoking.
Sherry's family physician indicates that Sherry was a normally
developing child. She prescribed Zoloft after Sherry's sadness and
irritability persisted for two years after her parents divorce. She was
also concerned about decreased appetite and sleep. Sherry is
sexually active and using birth control pills prescribed by her
physician.
What would recommend?
An integrated treatment plan might include;
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Outpatient substance abuse treatment to
address problematic use pattern and
escalation toward dependence
Cognitive Behavioral Therapy to provide
coping skills and reduce depressed mood.
Family Therapy to address parenting,
relationship and communication needs
Ongoing monitoring of mood and suicidal
ideation with possible referral trial of
antidepressant medication
Questions
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Does this plan address all Sherry’s
areas of need?
If all of these interventions are not
available within your community, what
might you do to modify your services
to meet her needs?
12 Step Assessment Process
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Please turn to page 71 in TIP 42
The purpose of the assessment
process is to develop a method for
gathering information in an organized
manner that allows the clinician to
develop an appropriate treatment plan
or recommendation.
Major aims of the
assessment process are
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To obtain a more detailed
chronological history of past mental
symptoms, diagnosis, treatment, and
impairment, particularly before the
onset of substance abuse, and during
periods of extended abstinence.
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To obtain a more detailed description of
current strengths, supports, limitations,
skill deficits, and cultural barriers
related to following the recommended
treatment regimen for any disorder or
problem.
To determine stage of change for each
problem, and identify external
contingencies that might help to
promote treatment adherence.
12 Step Assessment Process
1: Engage the client
2: Identify & contact
collaterals to gather
additional information
7: Determine disability &
functional impairment
8: Identify strengths &
supports
3: Screen for & detect
COD
9: Identify cultural & linguistic
needs & supports
4: Determine quadrant &
locus of responsibility
10: Identify problem domains
5: Determine level of care
6: Determine diagnosis
11: Determine stage of change
12: Plan treatment
Step 1: Engage the Client
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No “wrong door”
Empathic detachment
Person-centered assessment
Sensitivity to culture, gender, and sexual
orientation
• Trauma sensitivity
Universal access – No wrong
door
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Individuals with COD may enter a range of
community service sites and that proactive
efforts are necessary to welcome them into
treatment and prevent them from falling
through the cracks.
The purpose of this assessment is not just
to determine whether the client fits in my
program, but to help the client figure out
where he or she fits in the system of care,
and to help him or her get there.
Empathic detachment
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Requires the assessing clinician to
acknowledge that the clinician and
client are working together to make
decisions to support the client’s best
interest.
Clinicians should be prepared to
respond to the requirements of clients
with COD
Person-centered assessment
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Emphasizes that the focus of initial contact
is not on filling out a form or answering
several questions or on establishing
program fit.
The focus of initial contact is on finding out
what the client wants, in terms of his or her
perception of the problem, what he or she
wants to change, and how he or she thinks
that change will occur.
Sensitivity to culture, gender,
and sexual orientation
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Culture plays a significant role in
determining the client’s view of the
problem and the treatment.
Cultural sensitivity also requires
recognition of one’s own cultural
perspective and a genuine spirit of
inquiry into how cultural factors
influence the client’s request for help.
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During the assessment process, it is
important to ascertain the individual’s
sexual orientation as part of the
counselor’s appreciation for the client’s
personal identity, living situation, and
relationships
Trauma sensitivity
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The high prevalence of trauma in
individuals with COD requires that the
clinician consider the possibility of a
trauma history even before the
assessment begins.
Step 2: Identify & Contact Collaterals
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Clients may be unable or unwilling to
report past or present circumstances
accurately.
It is recommended that all assessments
include routine procedures for
identifying and contacting any family
and other collaterals who may have
useful information.
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Client resistance to gathering this
collateral information is a clinical issue
and needs to be addressed
motivationally as you would any other
form of client resistance.
Although gathering collateral
information has been designated as
Step 2, information from collaterals is
valuable as a supplement to the client’s
own report in all of the assessment
steps we will discuss.
Steps in the assessment
process are not always
sequential and may
occur in different order.
Assignments
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Review the text box on page 67—
Advice to the Counselor: Do’s and
Don’ts of Assessment for COD.
Continue reading TIP 42 Chapter 4
Social-Ecological Model
Neighborhood
School
Peers
Caregivers
Teen
Siblings
School
Poor structure
Low achievement
Peers
Deviant Peers
Poor Social Skills
Low association with + peers
Caregivers
Low Monitoring
Inconsistent Discipline
High Conflict
Parental Difficulties (drug use,
mental illness)
Teen Using
Substances
Neighborhood
High Crime
High Drug Use
Low Opportunity
School
Attached to school
Achieving-moving toward graduation
Peers
Positive Peers
Peers are involved in prosocial activities
Caregivers
High Monitoring
Consistent Discipline
Low Conflict
Teen on Positive
Developmental
Pathway
Neighborhood
Multiple adult(+) models
Recreational Activities
Jobs/ training
Churches
Keys to Engagement
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Treatment team responsible for engagement
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Therapists are strength-focused
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Family members full collaborators; therapists
align with parents
Services individualized and comprehensive
Services provided in natural ecology (i.e., family
home)
Keys to Engagement
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Therapists exhibit high level of commitment
to family as follows:
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Persistence
Creativity
Responsibility
Action-orientation
Knowledge
Flexibility
Investment
Barriers to Engagement
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Mistrust of adolescent serving systems
Dislike, distrust, disrespect, dismissal of
therapist
Evidence of minimal bonding
Alternative priorities / minimization of
problem
Co-occurring disorder
Signs of Poor
Engagement
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Difficulty scheduling appointments
Frequent changed and missed appointments
Treatment plans not followed
Over-arching goals contain little substance
Intervention progress uneven
Family members lie about salient issues
Signs of Engagement
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High rates of attendance at sessions
Completion of homework assignments
Emotional involvement in sessions
Progress being made towards meeting
treatment goals