Assessment Review for the Addiction Counselor Exam

Welcome to the Addiction Counselor Exam review. This presentation is part of the addiction counselor certification training. Go to. Learn more about our specialty Certificates starting at $149. Hi everybody and welcome to the assessment review for the addiction counselor certification exam. We're going to be talking about. Guess what? Assessment. And a lot of this is geared to be basically just a primer, a review, a CliffsNotes version. If you are feeling weak on the assessment process, it is really important that you go back and you review assessment courses either that you've taken or you can review some of the assessment courses that are in our addiction counselor certification training track. So there are 12 steps to assessment. Engage. You know, as soon as you meet somebody, you're not going to have rapport. So you've got to develop rapport. Don't sit them down and say, you know, hey, I'm, you know, Dr. So and so, and, you know, nice to meet you. John Smith. Let's go, where do you live? And start filling out forms right away. Take time to get to know them, look them in the eye, talk to them for a minute. It doesn't have to be a huge conversation for an hour. But when people feel like numbers, they're not going to engage. So you want them to feel like you really care about them as a person. Get authorizations and gather information from collateral sources. Probation officers, family members, wherever you think you can get collateral information. Another good source is from other treatment providers that are either currently working or have worked with the client in the past. Screen for co occurring disorders. Determine the severity of mental and substance use disorders. So you may have somebody who has a moderate alcohol dependence issue, but they have got really significant clinical depression. So you know you're going to be dealing with those differently. Obviously we need to make sure that we help them get stabilized. And you want to make the appropriate placement recommendation based on the client's needs. Determine the appropriate level of care. Generally we use the ASAM to do this. Sometimes you may use the Locus, which is another patient placement guide that can help you determine where a client is best served, determine their diagnoses, and generally there's more than one. So you want to look for mental health issues, you want to look for substance issues, you want to look for polysubstance issues. You want to look for issues that may not be in the dsm. You know, you're looking for other psychosocial issues that may be contributing to the problem, like domestic violence or lack of housing. Determine disability and functional impairment. So how bad is this on a scale of, you know, One to not really bad. I could see you once a week outpatient and not a problem to 5. The patient needs to be in 24 hour medically monitored residential care in the hospital. You know you've got and the ASAM breaks it up really nice for you. You're going to determine where they need to be. How much is it impacting their ability to work, their ability to do activities of daily living, their ability to form fulfilling relationships, their ability to have a rich and meaningful life. And that's what we mean by disability and functional impairment. How much is it impairing them, keeping them from reaching their full abilities and having a rich and meaningful life? Identify their strengths and supports because we're going to build off of these. What have they done up until now to survive? What things work for them when they're feeling depressed, when they're wanting to use. Identify cultural and linguistic needs and supports. So you know, if they're talk with them about their culture and whether they want to involve any faith healers or if there are any cultural practices that they think are important to their recovery process. If you need an interpreter, obviously you're going to take care of that now. And be careful about jargon that you use. Try not to use any and colloquialisms or local phrases that you may use that they may interpret differently. So be sensitive to a person's culture and background and meet those needs as needed. Identify additional problem areas such as medical, housing and education. Determine their readiness for change for each problem. And I've said it before, I'll say it again and I'll probably say it many times after this. People may have an addiction issue, they may have a depression issue, they may have a PTSD issue and a diabetes issue. Okay, so they've got four different issues going on with their depression. They may be really ready to make that go away because they are tired of being depressed. And there is really not much of an upside to being depressed. It's painful, so they're ready to work on that. The addiction. They may not be able to envision themselves as being a non drinker, never drinking again or never using again. Or they may not be ready to give that up because smoking a joint is the only thing that helps them relax right now. So they may not be motivated to change that problem or make huge changes in that problem. So you need to determine their readiness for change for each identified problem area and then start to plan treatment. This is when you figure out, okay, where are they going to go and what kinds of services are they going to need and what do I need to link them to? So screening determines the possible presence of an issue. Assessment is a much more in depth interview and it's an ongoing process. It's not something that you do for an hour at the beginning and then you never do again. You're going to assess clients every time they come into your office. You're going to assess clients a lot the first three or four times you see them because they're not going to think to tell you everything in the intake and you're not going to think to ask about everything. You're going to learn more about them and as you learn more about them, it may change their treatment plan a little bit. Assessment determines the nature and severity of the problems, develops specific treatment recommendations and surveys clients strengths and resources for addressing life issues. So when we're talking about strengths and resources, we're talking about what do you have going for you? Let's look at social support. Do you have people who can help you out, People who you can lean on financial support? What kinds of financial resources do you have for childcare or treatment or maybe taking some time off from work? We're looking not only at strengths, the way they've coped with these problems before, but you know, things they have inside them that can help them succeed at being happy and healthy. But we're also looking at what resources they have personally as well as what resources can they tap into. You know, maybe they don't have enough money to hire a nanny to come in to help them with their three children, but maybe their church offers drop in child care or maybe there's a church that they don't even belong to that is willing to let them drop their kids off at the church's drop in child care. So we want to identify not only what resources the client personally has, but what resources are in the community that the client can access to help them address their life domains or issues in their different life domains. The a lot of law schools offer free clinics. So if the client has issues with child custody or a divorce or bankruptcy or any kind of stuff like that, they may be able to get pro bono help at a free law clinic. Some attorneys do pro bono work. So contact your local bar association and find out if there are attorneys in your area that can help your client. So this is the way you find out things. Contact local boards to find out, you know, local dental boards to find out if there are any free dental clinics. Contact the United Way Information and referral. They know about a lot of Programs that are out there that can help people get medications, eyeglasses, child care, housing assistance, paying for electric bills, you know, is limitless. So United Way 211 is a great, great resource. The substance abuse assessment focuses on historical and situational factors contributing to or triggering use. Now, remember, substance abuse doesn't necessarily just have to be drugs. We can be talking about things like gambling addiction, sex addiction. Yes. You know, they're not all in the dsm, but we do want to look at those addictive behaviors. Because addictive behaviors can cause changes in brain chemistry, can cause that dopamine rush that throws the neurochemicals out of whack, similar to what some drugs do. So it's important to recognize any behavioral, addictive, addictive behaviors as well as chemical ones. Look at their patterns of use. Do they use consistently? Are they a binge user? Do they use when they're stressed? Has their use increased over the past five years showing that they're developing a tolerance? Have they started combining substances or combining a substance with an activity in order to get that rush that they're looking for? Identify common signs and symptoms of use. You're going to be administering the cage screening or the audit. You also may be looking for, you know, your basic checklist. Have you engaged in the behavior for longer than intended? Have you spent more money on this than intended? Have you spent more time engaging in recovering from or planning to use than intended? Have you given up important psychosocial activities in order to use, you know, that whole list of things that indicates that the person has a substance use disorder. And we're going to talk about the consequences of use. You know, because you've used. How has it impacted you emotionally, physically, spiritually, socially, cognitively, occupationally and legally? You know, let's look at those seven areas at least. It examines the context in which the disorders manifest. So somebody may be. May not be using all the time or may not be depressed all the time. So what are the contexts in which this gets worse? It explores the reciprocal interactions of family and or marital life on the problem, social support and interpersonal functioning on the problem. Their physical health needs. If somebody's got fibromyalgia, for example, then when their fibro is acting up and they're in a lot of pain and their addiction or their depression may also get worse in order to as a result of the fibromyalgia. So we want to look at the physical health needs, include in there adequate sleep and proper nutrition. Spirituality. How does that impact their disorder? Does it give them hope or does it make them feel ashamed? Employment, financial issues and legal issues and any other issues which may impact treatment. How do they impact this disorder and the client's ability and willingness to participate in treatment? We also want to look at gender, cultural and linguistic issues. Some cultures are not comfortable with group treatment. Some cultures feel the family should be intimately involved in treatment. Other cultures, not so much. Sometimes gender specific programs are more helpful and appropriate than mixed programs. So you want to talk about, you know, how would you feel if you were in a group that had men and women in it? Look at their readiness for change and how that impacts their willingness to participate in treatment. Their relapse risk. Again, for every single problem issue. Not just substances, but, but their relapse risk for depression, their relapse risk for fibromyalgia or any physical issues. Recovery support. Who out there can they rely on that provides good support for them in recovery when they are not actually in treatment? Any special life circumstances that may impact their ability to participate in treatment, such as being a single parent. Single parents not only often have a hard time affording additional childcare, but childcare can flake out. Sometimes single parents can't afford to take time off from work because there's nobody else bringing in money. So they've got to work. So we want to talk about any barriers or obstacles to full participation and engagement in treatment. And also look at medical conditions. If they've got some sort of medical condition that makes it difficult them for them to sit for long periods of time or they're having insomnia, sleep apnea is one that can really zap somebody's energy and make it more difficult for them to participate in treatment. So once you've looked at all the reciprocal interactions and you've tried to figure out and identify any potential barriers and how to overcome them, you've identified all the strengths the client is bringing to the table that you've got to work with, and you've identified any resources that the client has or that are in the community that can be used to deal with these barriers and enhanced treatment engagement. Then you moved on. Move on to providing treatment or we'll talk now about providing treatment based on the client's perception of his problems. And this is going to coincide with motivation. If a client doesn't feel that their substance use is really all that bad, they may not be ready to work on it yet. So what's the client's perception of how bad this problem is? What goals does the client wish to accomplish and what strengths does the Client think he or she has. So we're going to start talking about these and I'm going to say, what is it that you want to accomplish in treatment? And a lot of times our goals can be similar. They may not be the same. You know, when I work with clients who are involuntary, they may not be wanting to give up smoking marijuana, for example, but they want to get off probation. I'd love to see them quit smoking marijuana, but I also want to see them get off probation. In order to get off probation, they have to quit smoking marijuana. So hey, I will help them reach their goal of getting off probation, which my goal is, gets accomplished in the process and all the better. But if you encourage clients to work towards goals that are meaningful to them, they will be more motivated and engaged. So the forms that we're going to use, you want to get collateral information, you want to talk with the client, you want to use standardized interviewers or standardized interviews in some cases. Standardized interviews limit the interviewer to a script. It requires limited training and it collects the same information on all clients. You know, it's kind of like when you go to the doctor's office and they start asking you about different health conditions you've had. They're just checking boxes. Structured interviews allow you to ask probing questions and require some additional training or knowledge to know what follow up questions to ask. So if you ask a client whether they've ever been exposed to traumatic event and they say yes, you have to know what the appropriate next question is that can probe, you know, tell me a little bit about the nature of that traumatic incident. The other thing that you can use and that can be really helpful are self administered tests and questionnaires. They require some motivation and reading on the client's part, but they are nice because the client can do them at home before they come in. Clients tend to be more open on self administered tests when they're checking things off, as opposed to looking you in the eye and telling you something that they may find more embarrassing or shameful, or they may think that you're going to judge them for what they did or what they think or whatever. So self administered tests can be really helpful additions to the clinical picture. Standardized instruments, when you're using them, have reliability. That means if you are using an instrument that says it measures depression, we know it actually measures depressive symptoms. And when, well that's validity, sorry, it validly measures it. And then reliability means if you give somebody that assessment today and you give somebody that assessment tomorrow, it's going to Give you some where similar in the results. It may not be exactly the same because 24 hours have passed, but it's going to be really daggone close if it's not exactly the same. That's called test retest reliability. And you want to make sure that standardized instruments you're using do have test retest reliability and what's called inter rater reliability. So if I'm going to give an assessment to John Smith, I come up with these answers and this scoring and this clinical picture. And my friend Sally, who works two offices down, administers the same instrument to John Smith. She should get a very similar clinical picture if not the same as I did. That's called inter rater reliability. So we both see the same thing when we administer this test. That would be like an example that comes up a lot is when you observe clients in natural settings. So we'll use kids for an example here. Poor inter rater reliability would be to identify how many times Johnny acts out. That's not really well defined. So how I define acting out may be very different than how Sally defines acting out. So I may end up with 17 hash marks and she may end up with 3. That's very poor inter rater reliability because we saw two different things because we were defining things differently. So test retest. If you give it the client the same test within a very short period of time, it should give you the same result and inter rater reliability. If two people are administering the test, it should give the similar result to both people. Sources of information with written consent, of course. Personal reports, reports from family, reports from other professionals, or prior treatment experiences, their employment history, criminal records and any available drug tests. Collateral information gathered should be confirmed to the extent possible to make sure it's actually valid. An accurate assessment requires the coherent integration of multiple sources of information to avoid over or underestimation of the problem. And when you're hearing it only from the client, it's hard to get a real picture on. Is it as bad as the client is saying or is it not bad? A lot of times clients, especially with substance abuse clients, will minimize their problems and minimize the issue. So it sounds like there's no problem. And then when we hear from collateral sources, we realized that they were grossly underestimating the extent of the problem. So you want to get information. When I have clients come in for an assessment for probation and parole, I always have them bring their criminal history. And if they don't bring it, then we look it up before we get started because I Want to see not only how many times they've been convicted, but drug charges, but also how many times they have been arrested for drug charges. Because that gives me a little bit more to go on when I'm looking to identify whether they're experiencing repeated problems in one or more life areas as a result of the addictive behavior. Drug testing Drug testing is part of the initial assessment in substance use disorder treatment. We want to get a baseline to figure out what, what you're using, how much is in your, in your system. It's used to identify drugs to make the most appropriate treatment recommendations. Alcohol and benzodiazepine withdrawal can be life threatening. So if I have somebody who tests positive for either one of those, I'm obviously going to make a referral to either a medical doctor who may want to do ambulatory detox or a detox unit. But I am not going to say, well, you need to dry out first and just send them on their merry way. Likewise, there may be certain drugs that people are on that they cannot be admitted to a treatment center. For the treatment center I used to work at, we didn't admit anyone who was on benzodiazepines. So if they were on them and they were not willing to detox from them or it was clinically contraindicated, then we had to refer them somewhere else. You want to use drug testing to screen to prevent adverse effects of prescribed medications. You don't want to be taking something that increases serotonin levels and then also taking an ssri and then you'll like a stimulant and an SSRI because you could precipitate a serotonin crisis. So we want to know what's in there. We don't want somebody taking prescription benzodiazepines, you know, prescribed by a physician, while they're also abusing opiates because those are both depressants and they could lead to respiratory failure. We need to know what's in the person's system. It's a component of the treatment plan. Drug testing helps keep people doing the next right thing. If they know that they could be drug tested at any time. It's a way to monitor the use of substances and compliance with medications. Now, obviously your on site drug tests are not going to tell you what the levels of Zoloft are in somebody's system or whatever. But if you send it off to the lab, then you'll get a mass spec report back and you'll be able to tell whether their psychotropic medications or Any other medications that they're on, for that matter, are staying stable or if they're wonky. And you'll also be able to see if levels of certain drugs are declining. For example, marijuana takes a long time to go out of the system. So a lot of times people are admitted to treatment when they still test positive for marijuana. And what we want to see is that THC level declining over a period of a couple of weeks. Drug testing is a method to assess the effectiveness of treatment. If they're able to stay clean and not test positive, then we're doing something to help them stay clean. I mean, something is working here. And it's a method to document abstinence for legal matters, disability issues or custody issues, you know, any of the legal stuff. Drug testing cannot replace an assessment. To diagnose a substance use disorder, though, we need to look and see what consequences the substance use is having. We need to make sure they meet the criteria for the DSM diagnosis of substance use disorder. And just having a drug in your system doesn't make you meet that criteria. Drug testing can accurately reveal drugs in the system. So if a client says, oh, I never use that, and drug test says they did, you know, mass spectrometry is not, you know, there's a very, very, very, very small margin of error. Yes, you can retest it, but I've never had a mass spec report turn up wrong or incorrect in 20 years. Time frame for detection is limited, though. So for some substances it's 24 hours. For other substances it's three days. But you need to get that in there, which is why random testing is so important. It is dependable for identifying frequent users, but less accurate for infrequent or binge users. So if Tom is an alcoholic and he binge uses, you know, one weekend every five or six weeks, the only time you're going to test he's going to test positive is after one of those weekends. And if you're seeing him for 12 weeks, that means you only have two windows of opportunity there. Another method for testing that is out there and available are sweat patches. And they stay on the arm for 14 days. They are relatively unable to be adulterated. So people can't, you know, scam the system, so to speak, and they give you a picture of the person's levels of different drugs over a longer period of time. They can sometimes get. What's the word I'm looking for? Corrupted. You know, if something gets on them, that makes it an invalid test, but you have much less ability for the client to just eliminate a particular drug so it doesn't show cocaine or something like they can try to do in some of the urine screens. Breathalyzers are usually only valid for a couple of hours once the substance is out of your system. Once your body's metabolized at breathalyzer ain't gonna work. Urine may be helpful for up to a month depending on the drug you can do on site. Which are your cups? Now a lot of on site tests have okay accuracy rates. They have about a 30% depending on the company you go with and how well people administer the tests, about a 30% failure rate, which means it can either be a false positive so it turns shows that there's something in their system when there really isn't, or a false negative which the drug test doesn't show anything being in their system when there really is. So you have to remember that they're only about 65, 70% accurate. But it's a good starting place. And the drug cups usually only run between $4.50 and eight bucks a pop. Where sending it to the lab runs anywhere from 45 to $80 or more depending on how many different panels you have run. So if you have a client and you administer on site drug tests, that gives you a general idea about how they're doing. And if there's a question about it, you can send it to the lab and then it's recommended that like every third or fourth screen you send to the lab anyway just to make sure that it's not showing a false negative. Gas chromatograph can also be used in order to identify specifically what's in the urine. Saliva will identify what the person has used within the past day. Sweat and hair can be used. Drug patterns. It shows drug patterns over time, especially hair. As the hair grows out, you know, it will show give a better idea of what was used during time. Because our hair grows really slowly. So you can get quite a bit of information from a strand of hair. It can't discriminate from recent and past drug use though. So you know, we don't have a way of saying this person used yesterday versus a month ago because the hair grows really slow and it's not able to identify use within the past three to eight days. Now that's true for hair for sweat, you know, they like to leave the patch on for a full 14 days. So you know your accuracy is a little lower if you pull it off sooner. But it does give you a 14 day snapshot. What's going on with the person and then blood can be used and withdrawn. If the substance is still in the person's system, then it can show up in blood. Another thing you need to do during assessment is a risk assessment. One of the most important functions of both screening and assessment is to identify any risks for relapse. Acute medical conditions. You know, if they look like they're getting ready to stroke out or they start slurring their words, they're detoxing from alcohol, it may mean that they need to have thiamine in order to prevent brain damage. So we want to look for anything that may indicate a medical or psychiatric crisis that requires an immediate referral to detox. Csu, which is the crisis stabilization unit or the emergency room, we want to assess for intoxication, substance toxicity. Sometimes people will overdose, you know, and we want to make sure we identify that. I've had clients use before because they wanted to get into detox and in order to get into detox they had to be under the influence and they accidentally use too much. So we want to look for substance toxicity, withdrawal, aggression or danger to others, potential for self harm or suicide, any coexisting mental health issues, especially, you know, when we're talking about risk being aware of any psychotic features, hallucinations, delusions, lack of ability to cognitively put things together like you would expect, signs of drug toxicity or intoxication. You know, we've gone over that in other reviews, especially in the diagnosis review. We're going to hit it a little bit right here. Nausea, vomiting, diarrhea, agitation, lethargy or stupor, increased or decreased heart rate, lack of coordination and slurring words. Now remember, some of these can also be signs of life threatening conditions. So you want to be aware and get medical input if people are slurring their words or have lack of coordination, especially signs of violence, if they have a history of previous violence and mental illness is not a good predictor of violent behavior. So, you know, don't just think that because they have a mental illness they're going to be. No, what we want to look at is previous violent behavior. If they've done it before, they're more, more likely to do it again. How old they were at the first incident of violence. If they started being violent when they were eight and they've been having problems ever since, then more chance, more likely that they're going to have another episode now than if their first violent episode was when they were 27 and they're 30 now. Relationship instability, employment problems, substance use problems. A lot of Substances are disinhibitors. So it takes off that filter that says this is a bad idea or they're stimulants which just get the person revved up and angry or anxious and kind of ready to go get them. A major mental illness can be a sign of violence. Now a lot of times the violence that someone with mental illness does commit is towards themselves. Suicide, self injury. So just because somebody has a mental illness, again, less than 4% of violent acts in the United States are committed by people with mental illnesses. So we want to remember that personality traits that deviate from social norms if they tend to exploit people or manipulate them. We're going to be looking for your antisocial personality disorder traits here. Early maladjustment or trauma, paranoia and failure to respond to treatment in the past can all be indicators that there's a potential for, for this client to be violent. Suicidality, alcoholism is a factor in 30% of suicides. So if you've got a client who abuses alcohol, know that they're at increased risk. 90% of people who die by suicide have a mental health disorder. 60% of people who die by suicide have depression. So again, a lot of the violence in people with mental health issues self directed, they're making the pain stop. They don't feel like they can do it anymore. They feel hopeless and helpless that life is going to get any better. Three domains for assessment for current presentation of suicidality, their history and risk management. So current presentation, are they tying up loose ends? Are they willing to talk about and make future plans? If they are, that's a good sign. It's, it doesn't mean you're in the clear, but it's a good sign. Do they have access, do they have a plan? Do they have access to the means? What might trigger them to actually commit suicide? You know, what things might happen? These are all questions that you want to ask. And there are, it's important that you take a couple of really good classes on suicide assessment because it is art, not a science. If they have a history of suicide attempts or self injurious behavior or a family history of suicide, they're at higher risk. And then as far as risk management, you know, somebody who lives alone and is clinically depressed and having suicidal thoughts is at much greater risk than someone who lives with their spouse and three kids and also has suicidal ideation. Now that doesn't, again, doesn't mean you're in the clear. I know of situations where a parent has gone upstairs and committed suicide with their spouse and the children in the house. So you can't assume that just because any one or three or five conditions are present that the person is out of the woods. You know you want to use due diligence. Signs of suicidality include suicidal or self harming thoughts, plans, behaviors or intent. A specific method identified evidence of hopelessness, impulsiveness, panic attacks or anxiety, a lack of and or unwillingness to make future plans, signs of tying up loose ends, alcohol or other substance use, especially your depressants like opiates and benzos, but any substance, thoughts, plans or intentions of violence towards others and any current psychiatric illnesses which again may make them at higher risk for suicide. Previous attempts or aborted attempts at suicide or self harm is also another risk factor, as is a family history of suicide attempts, suicide, mental illness and addiction. If there's a family history of mental illness and addiction, it indicates that the family unit may not have the skills and tools to cope. So you know, if the parents couldn't teach it to the children, then the children, because they didn't have it, then the children may not have skills and tools cope. So they may be at higher risk. Acute psychosocial crises, including financial changes or changes in status. So if somebody gets fired, demoted, passed over for a promotion or you know, something happens and they have to declare bankruptcy or whatever, this could be a risk. Chronic psychosocial stressors, including actual or perceived interpersonal losses. So fears of abandonment, for example, family discord, domestic violence, current or past sexual or physical abuse and the absence of external supports. So these are all things we're going to look for in a suicide assessment. And as we're going through each of these things, you know, when I identify if they have a specific method identified and they have the means available, you know, I'm going to talk about how can, what can you do with those means to make yourself safer. We're going to make a plan, we're going to make future plans for when they're going to call me, when they're going to contact me. We're going to talk about how they can avoid using substances. We're going to talk about what external supports they may be able to rely on in order to help get them through each hour. And we're going to talk about, you know, if they're having a financial crisis, we're going to talk about that a little bit and identify steps that they can take to start resolving this crisis. So they have some hope, they have some tools, and they have some actions that they may be able to engage in which are Going to obviously happen in the future, which may get them a little bit past this crisis point. Borderline personality disorder is something that is common in co occurring disorders. A lot of times when I'm working with clients with addictions, I refer to borderline personality characteristics because once they get clean and sober, a lot of times those characteristics kind of go away. Not always, but do be aware of a pervasive pattern of instability in personal relationships, self image and mood in addition to impulsivity. People with borderline personality disorder, they either love you or hate you and they will turn on a dime. So you're constantly walking on eggshells to keep from setting them off and to stay on their good side because there's no gray area. There's no. It really hurt my feelings that you did xyz. It's I hate you or I love you. There's no middle ground. And it's exhausting for both the person with BPD characteristics as well as their significant others. Another common issue is antisocial personality disorder. And again, the characteristics of APD are often present in people in active addiction, but they dissipate or completely disappear once the person is in recovery. So I want to see some recovery time. I personally want to see some recovery time before I assign a personality disorder diagnosis. But what you're looking for with antisocial is a pervasive disregard for and violation of the rights of others, inability to form meaningful relationships, and lack of empathy. So think about somebody who's addicted to, you know, whatever's going on. They're at the point where they're at bottom. Well, you know, they've probably been doing whatever they needed to do to get their drug in order to survive. So they've been disregarding the rights of others. They've not wanted to form meaningful relationships because they hate themselves. They feel bad about what's going on with them and they don't trust other people because they feel like they've been let down and abandoned. And they may not have empathy because they don't have any energy left to be empathetic with other people. It's just they've tried to be empathetic and they've, they've been burned too many times and they're sort of cynical at this point. So if you look at it in terms of what is causing these particular characteristics and how did this person come to feel or act this way? A lot of times you can see where the situations their life over the past five or 10 or 20 years, it really makes sense that they're acting or behaving or thinking or feeling this way, it doesn't necessarily mean that it's a personality disorder that's going to stay. Major depressive disorder is very common. When people use they have rushes of dopamine and to avoid getting into pharmacology, we're just going to stop short and say when the neurotransmitters are out of whack because that dopamine system has been in overdrive, then when they don't have something causing that dopamine to be dumped, people may feel clinically depressed and it can last for quite a while. And this can go on for over two weeks, especially with people who have been abusing stimulants. But it can go in other people. Also. When people start to sober up, they may look back over, you know, the chaos that their life has become and get clinically depressed. So do assess for clinical depression. You'll see changes in sleep, appetite, energy, concentration, excessive feelings of worthlessness and guilt, sense of apathy, you know, just nothing does it for them, they don't really care and there may be suicidal ideation. Also look for bipolar disorder. Not uncommon with people with bipolar disorder. Not wanting to take the bipolar meds because it flattens the highs, it brings up the lows. So they're not having that major depression anymore, but they're not getting the the highs from the mania. So a lot of times they may be non compliant with prescribed meds and then they self medicate with illicit drugs. So as they sober up, start paying attention and looking to see if there are signs of bipolar I or ii. Anxiety disorders are very common. Remember the teeter totter philosophy with detox. Whatever drug the person was using and the effects it had when they detox, the likely symptoms are going to be the exact opposite. So if they were using anti anxiety meds, if they were abusing benzodiazepines, when they start to sober up, they may have a lot of panic. Same thing with alcohol. Alcohol does have some depressant effects, but when people start to sober up, they often have a lot of anxiety that goes with it. So assess for panic attacks, panic disorders and obsessive compulsive disorder. Other things to look for a lot of people, more than 50% of the United States population has been exposed to trauma. Now just because you're exposed to trauma doesn't mean you develop ptsd, but it is important to assess for it because the symptoms of PTSD overlap with depression and anxiety quite a bit. So we want to make sure that we don't misdiagnose something and fail to treat PTSD when it really is there. Also, assess for eating disorders. There's a strong correlation between alcoholism and bulimia, but we want to look for anorexia, bulima, bulimia and binge eating disorder in clients and schizophrenia and psychotic disorders. Psychosis is the term for a severely incapacitated mental and emotional state involving thinking, perception and emotional control, characterized mainly by your hallucinations, you think, you see, hear, smell, taste things that aren't there, or delusions, false beliefs and a deterioration in thinking, judgment and self control. You can have some people have delusions of grandeur where they think they are head of the CIA or they think they are God. Other people will have paranoid delusions that the squirrels are after them and trying to read their minds. And so if you hear things that don't seem to make sense in your reality, start probing for psychotic features. Now, not everybody who has psychotic features is schizophrenic. You can have psychotic features with postpartum depression with depression. But it's important to recognize if you see psychotic features and probe to figure out exactly what's going on. Schizophrenia is the most common psychotic disorder, not multiple personalities. Schizophrenia is a detachment from reality. People who are schizophrenic will talk about the people on the news media, talking directly to them. They will say things that don't seem to make sense in your world. Multiple personality is completely different. That's when somebody has two different or multiple different personalities in their head. They are still in touch with reality, you know, as we understand it. But you are sort of meeting different people depending on the situation. So don't confuse the two. People do. And that's one of my pet peeves. Symptoms of schizophrenia often begin to develop before this first psychotic episode. The persons will start having hallucinations or delusions. Also, Parkinson's disease people sometimes have hallucinations and delusions. So rule out some of the physiological causes too. They may have disorganized speech where their speech doesn't make any sense at all. Disorganized or catatonic behavior and deficits in functioning, such as, you know, getting up in the morning and getting themselves ready, and typical activities of daily living. So assessment is an in depth process that involves information from the client and collateral sources to determine the nature, course and severity of all the issues, the mental health issues, the physical issues, and the substance abuse issues. Assessment is a biopsychosocial in nature. So we want to look at what are all the possible causes or contributing factors to this issue that we may need to address in treatment. You know, housing, people need safe housing. They need access to medical care, they need to be able to afford their medications, they need good nutrition and they need financial independence of some sort. So you know, they know where their next meal is coming from. They need a decent self esteem, they need social support, people, other people that provide them love and comfort and attachment and a safety net. They may need child care, legal help. There's a whole bunch of stuff that people may need and all of those things, or lack of all of those things can increase stress and precipitate a relapse or perpetuate the problem. Assessment must take into consideration cultural factors regarding having multiple illness. The participants in the treatment process and who the decision makers are for the client. So some cultures will want to have the family unit in the assessment. And obviously if that's okay with the client, then that needs to be okay with us. Some cultures are not that way. Some cultures have a specific decision maker for care for anybody in the family. Usually it's the father. Other cultures, people decide their own treatment course. It's important to evaluate for multiple co occurring disorders which may have overlapping symptoms such as PTSD and anxiety, or substance abuse and or substance use disorder and borderline personality disorder. The assessment will guide placement and the development of the treatment plan.