Module IIModule II Introduction to Screening and Introduction to Screening and Assessment of Persons with Assessment of Persons with Co-Occurring Disorders: Co-Occurring Disorders: Screening and Assessment, Screening and Assessment, Step 1 and Step 2Step 1 and Step 2

Review of Module IReview of Module I

Reactions, questions or Reactions, questions or comments from the readiness comments from the readiness to change and motivational to change and motivational survey answers from Module Isurvey answers from Module I

Reactions, questions or Reactions, questions or comments from Module I comments from Module I

Review of AssignmentsReview of Assignments

Reactions, questions from TIP Reactions, questions from TIP 42 reading42 reading

Reactions to GAIN-SS and Reactions to GAIN-SS and Perceptions of Global Appraisal Perceptions of Global Appraisal of Individual Needs – Short of Individual Needs – Short Screener (GAIN-SS): A Pilot Screener (GAIN-SS): A Pilot StudyStudy

Module II ObjectivesModule II Objectives

The importance of screening across The importance of screening across disciplinesdisciplines

Use of the GAIN-SS for screeningUse of the GAIN-SS for screening The importance of the The importance of the

“engagement” in performing a “engagement” in performing a good assessmentgood assessment

Review Step 1: Engage the patientReview Step 1: Engage the patient Review Step 2: Identify and Review Step 2: Identify and

contact collaterals to gather contact collaterals to gather informationinformation

COD Screening & COD Screening & AssessmentAssessment

To what extent do you To what extent do you currently provide COD currently provide COD Screening and Assessment Screening and Assessment and what instruments are you and what instruments are you currently utilizing?currently utilizing?

Instrument CriteriaInstrument Criteria

The screening instrument is sensitive. The screening instrument is sensitive. The screening instrument is brief. The screening instrument is brief. The screening instrument is low or no cost. The screening instrument is low or no cost.

The screening instrument can be The screening instrument can be

administered and scored with little administered and scored with little training.training.

The screening instrument is applicable to a The screening instrument is applicable to a diverse range of people.diverse range of people.

The screening instrument includes a The screening instrument includes a question about suicide. question about suicide.

GAIN-SS GAIN-SS

Twenty-item instrument that Twenty-item instrument that screens for internalizing disorders, screens for internalizing disorders, externalizing disorders, substance externalizing disorders, substance use disorders, and behaviors related use disorders, and behaviors related to crime and violence to crime and violence

Take 3 to 5 minutes to administerTake 3 to 5 minutes to administer Meant to determine whether a Meant to determine whether a

mental, co-occurring, or chemical mental, co-occurring, or chemical dependency assessment is needed dependency assessment is needed

GAIN-SS 4 SubscalesGAIN-SS 4 Subscales Internal Disorder Screener (IDScr)Internal Disorder Screener (IDScr)

was designed to identify people was designed to identify people experiencing internalizing disorders such as experiencing internalizing disorders such as depression, anxiety, suicidal ideation, and depression, anxiety, suicidal ideation, and acute/post traumatic stress disorders acute/post traumatic stress disorders

External Disorder Screener (EDScr)External Disorder Screener (EDScr)designed to identify persons experiencing designed to identify persons experiencing externalizing disorders such as attention externalizing disorders such as attention deficit, hyperactivity, conduct disorder, deficit, hyperactivity, conduct disorder, aggression/violence and other externalizing aggression/violence and other externalizing behavioral problems behavioral problems

GAIN-SS 4 SubscalesGAIN-SS 4 Subscales

Substance Disorder Screener Substance Disorder Screener (SDScr)(SDScr)

designed to identify persons abusing or designed to identify persons abusing or dependent upon alcohol or other drugs dependent upon alcohol or other drugs

The Crime and Violence Screener The Crime and Violence Screener is comprised of five items used to is comprised of five items used to identify persons exhibiting criminal and identify persons exhibiting criminal and violent behavior.violent behavior.

GAIN-SS ScoringGAIN-SS Scoring

If a person receives a score of If a person receives a score of 2 or more on any of the GAIN-2 or more on any of the GAIN-SS subscales, then that SS subscales, then that person should be referred or person should be referred or provided either a full mental, provided either a full mental, chemical dependency, or co-chemical dependency, or co-occurring disorder occurring disorder assessment. assessment.

With your partner, take turns administering

The GAIN-SS

You have 10 minutes total!

TIP Exercise–Screening Instruments

Option 1: Role Play & Discussion

Pay attention toPay attention to

While in the role of the While in the role of the clinician what it feels like to clinician what it feels like to ask the questions.ask the questions.

While in the role of the client While in the role of the client what it feels like to answer what it feels like to answer the questionsthe questions..

Screening Protocol

• 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

• 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 CasesIntroduction 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 non-lethal 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 breaking-up 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.

Sherry appears to be a healthy 15 year-old. She is engaging and cooperative during the interview. Sherry states she has lots of friends and is doing well in school.

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 What would recommend?recommend?

An integrated treatment plan might include;An integrated treatment plan might include;

Outpatient substance abuse treatment Outpatient substance abuse treatment to address problematic use pattern and to address problematic use pattern and escalation toward dependenceescalation toward dependence

Cognitive Behavioral Therapy to provide Cognitive Behavioral Therapy to provide coping skills and reduce depressed coping skills and reduce depressed mood.mood.

Family Therapy to address parenting, Family Therapy to address parenting, relationship and communication needsrelationship and communication needs

Ongoing monitoring of mood and Ongoing monitoring of mood and suicidal ideation with possible referral suicidal ideation with possible referral trial of antidepressant medicationtrial of antidepressant medication

QuestionsQuestions

Does this plan address all Does this plan address all Sherry’s areas of need?Sherry’s areas of need?

If all of these interventions are If all of these interventions are not available within your not available within your community, what might you do to community, what might you do to modify your services to meet her modify your services to meet her needs?needs?

12 Step Assessment 12 Step Assessment ProcessProcess Please turn to page 71 in TIP 42Please turn to page 71 in TIP 42

The purpose of the assessment The purpose of the assessment process is to develop a method for process is to develop a method for gathering information in an gathering information in an organized manner that allows the organized manner that allows the clinician to develop an appropriate clinician to develop an appropriate treatment plan or recommendation.treatment plan or recommendation.

Major aims of the Major aims of the assessment process assessment process are are To obtain a more detailed To obtain a more detailed

chronological chronological historyhistory of past of past mental symptoms, diagnosis, mental symptoms, diagnosis, treatment, and impairment, treatment, and impairment, particularly before the onset of particularly before the onset of substance abuse, and during substance abuse, and during periods of extended abstinence.periods of extended abstinence.

To obtain a more detailed description To obtain a more detailed description of of currentcurrent strengths, supports, strengths, supports, limitations, skill deficits, and cultural limitations, skill deficits, and cultural barriers related to following the barriers related to following the recommended treatment regimen for recommended treatment regimen for any disorder or problem.any disorder or problem.

To determine To determine stage of change for stage of change for each problem,each problem, and identify external and identify external contingencies that might help to contingencies that might help to promote treatment adherence.promote treatment adherence.

12 Step Assessment Process

1: Engage the client

2: Identify & contact collaterals to gather additional information

3: Screen for & detect COD

4: Determine quadrant & locus of responsibility

5: Determine level of care

6: Determine diagnosis

7: Determine disability & functional impairment

8: Identify strengths & supports

9: Identify cultural & linguistic needs & supports

10: Identify problem domains

11: Determine stage of change

12: Plan treatment

Step 1: Engage the Client

• No “wrong door”

• Empathic detachment

• Person-centered assessment

• Sensitivity to culture, gender, and sexual orientation

• Trauma sensitivity

Universal access – No Universal access – No wrong doorwrong door Individuals with COD may enter a range Individuals with COD may enter a range

of community service sites and that of community service sites and that proactive efforts are necessary to proactive efforts are necessary to welcome them into treatment and welcome them into treatment and prevent them from falling through the prevent them from falling through the cracks.cracks.

The purpose of this assessment is not just The purpose of this assessment is not just to determine whether the client fits in to determine whether the client fits in mymy program, but to help the client figure out program, but to help the client figure out where he or she fits in the system of care, where he or she fits in the system of care, and to help him or her get there.and to help him or her get there.

Empathic detachmentEmpathic detachment

Requires the assessing clinician to Requires the assessing clinician to acknowledge that the clinician and acknowledge that the clinician and client are working together to client are working together to make decisions to support the make decisions to support the client’s best interest.client’s best interest.

Clinicians should be prepared to Clinicians should be prepared to respond to the requirements of respond to the requirements of clients with COD clients with COD

Person-centered Person-centered assessmentassessment Emphasizes that the focus of initial Emphasizes that the focus of initial

contact is contact is notnot on filling out a form or on filling out a form or answering several questions or on answering several questions or on establishing program fit.establishing program fit.

The focus of initial contact is on finding The focus of initial contact is on finding out what the client wants, in terms of his out what the client wants, in terms of his or her perception of the problem, what or her perception of the problem, what he or she wants to change, and how he he or she wants to change, and how he or she thinks that change will occur.or she thinks that change will occur.

Sensitivity to culture, Sensitivity to culture, gender, and sexual gender, and sexual orientationorientation Culture plays a significant role in Culture plays a significant role in

determining the client’s view of the determining the client’s view of the problem and the treatment.problem and the treatment.

Cultural sensitivity also requires Cultural sensitivity also requires recognition of one’s own cultural recognition of one’s own cultural perspective and a genuine spirit of perspective and a genuine spirit of inquiry into how cultural factors inquiry into how cultural factors influence the client’s request for influence the client’s request for help.help.

During the assessment process, it During the assessment process, it is important to ascertain the is important to ascertain the individual’s sexual orientation as individual’s sexual orientation as part of the counselor’s part of the counselor’s appreciation for the client’s appreciation for the client’s personal identity, living situation, personal identity, living situation, and relationships and relationships

Trauma sensitivityTrauma sensitivity

The high prevalence of trauma in The high prevalence of trauma in individuals with COD requires that individuals with COD requires that the clinician consider the the clinician consider the possibility of a trauma history possibility of a trauma history even before the assessment even before the assessment begins.begins.

Step 2: Identify & Contact Step 2: Identify & Contact CollateralsCollaterals Clients may be unable or unwilling Clients may be unable or unwilling

to report past or present to report past or present circumstances accurately. circumstances accurately.

It is recommended that all It is recommended that all assessments include routine assessments include routine procedures for identifying and procedures for identifying and contacting any family and other contacting any family and other collaterals who may have useful collaterals who may have useful information.information.

Client resistance to gathering this Client resistance to gathering this collateral information is a clinical issue collateral information is a clinical issue and needs to be addressed and needs to be addressed motivationally as you would any other motivationally as you would any other form of client resistance.form of client resistance.

Although gathering collateral Although gathering collateral information has been designated as information has been designated as Step 2, information from collaterals is Step 2, information from collaterals is valuable as a supplement to the client’s valuable as a supplement to the client’s own report in own report in all of the assessment all of the assessment steps steps we will discuss.we will discuss.

Steps in the Steps in the assessment process assessment process

are not always are not always sequential and may sequential and may occur in different occur in different

order.order.

AssignmentsAssignments

Review the text box on page 67— Review the text box on page 67— Advice to the Counselor: Do’s and Advice to the Counselor: Do’s and Don’ts of Assessment for COD. Don’ts of Assessment for COD.

Continue reading TIP 42 Chapter Continue reading TIP 42 Chapter 44

Teen

Peers

School

Caregivers

Neighborhood

Siblings

Social-Ecological Model

Teen Using Substances

CaregiversLow MonitoringInconsistent DisciplineHigh ConflictParental Difficulties (drug use, mental illness)

PeersDeviant PeersPoor Social SkillsLow association with + peers

SchoolPoor structureLow achievement

NeighborhoodHigh CrimeHigh Drug UseLow Opportunity

Teen on Positive Developmental Pathway

CaregiversHigh MonitoringConsistent DisciplineLow Conflict

PeersPositive PeersPeers are involved in prosocial activities

SchoolAttached to schoolAchieving-moving toward graduation

NeighborhoodMultiple adult(+) modelsRecreational ActivitiesJobs/ trainingChurches

Keys to EngagementKeys to Engagement Treatment team responsible for engagementTreatment team responsible for engagement

Therapists are strength-focusedTherapists are strength-focused

Family members full collaborators; Family members full collaborators; therapists align with parentstherapists align with parents

Services individualized and comprehensiveServices individualized and comprehensive Services provided in natural ecology (i.e., Services provided in natural ecology (i.e.,

family home)family home)

Keys to EngagementKeys to Engagement

Therapists exhibit high level of Therapists exhibit high level of commitment to family as follows:commitment to family as follows:– PersistencePersistence– CreativityCreativity– ResponsibilityResponsibility– Action-orientationAction-orientation– KnowledgeKnowledge– FlexibilityFlexibility– InvestmentInvestment

Barriers to Barriers to EngagementEngagement

Mistrust of adolescent serving systemsMistrust of adolescent serving systems Dislike, distrust, disrespect, dismissal Dislike, distrust, disrespect, dismissal

of therapistof therapist Evidence of minimal bondingEvidence of minimal bonding Alternative priorities / minimization of Alternative priorities / minimization of

problemproblem Co-occurring disorderCo-occurring disorder

Signs of Poor Signs of Poor EngagementEngagement Difficulty scheduling appointmentsDifficulty scheduling appointments Frequent changed and missed Frequent changed and missed

appointmentsappointments Treatment plans not followedTreatment plans not followed Over-arching goals contain little Over-arching goals contain little

substancesubstance Intervention progress unevenIntervention progress uneven Family members lie about salient issuesFamily members lie about salient issues

Signs of EngagementSigns of Engagement

High rates of attendance at High rates of attendance at sessionssessions

Completion of homework Completion of homework assignmentsassignments

Emotional involvement in sessionsEmotional involvement in sessions Progress being made towards Progress being made towards

meeting treatment goalsmeeting treatment goals