Module II Introduction to Screening and Assessment of Persons with Co-Occurring Disorders: Screening and Assessment, Step 1 and Step 2
Review of Module I • 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 • 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 • 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 information
COD Screening & Assessment To what extent do you currently provide COD Screening and Assessment and what instruments are you currently utilizing?
Instrument Criteria • 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 • 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 • Internal Disorder Screener (IDScr) was designed to identify people experiencing internalizing disorders such as depression, anxiety, suicidal ideation, and acute/post traumatic stress disorders • 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 • Substance Disorder Screener (SDScr) designed to identify persons abusing or dependent upon alcohol or other drugs • The Crime and Violence Screener is comprised of five items used to identify persons exhibiting criminal and violent behavior.
GAIN-SS Scoring • 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.
Pay attention to • 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.
An integrated treatment plan might include; • 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 • 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 • 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 • 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.
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.
Universal access – No wrong door • 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 • 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 • 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 • 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.
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 • 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 • 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.
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 • 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 • Treatment team responsible for engagement • Therapists are strength-focused • Family members full collaborators; therapists align with parents • Services individualized and comprehensive • Services provided in natural ecology (i.e., family home)
Keys to Engagement • Therapists exhibit high level of commitment to family as follows: • Persistence • Creativity • Responsibility • Action-orientation • Knowledge • Flexibility • Investment
Barriers to Engagement • 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 • 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 • High rates of attendance at sessions • Completion of homework assignments • Emotional involvement in sessions • Progress being made towards meeting treatment goals