Motivating People for Change with Screening and Engagement

You hey there everybody, and welcome to this video on the purpose, instrument selection and ancillary information gathering process that we go through for screening. I'm your host, Dr. Donnelly Snipes. In this video, we're going to review key skills for engagement, discuss factors impacting engagement, define screening, explore how to do a screening, and identify types of screening instruments. Screening is the process by which the counselor, or anybody actually the client and significant others review the current situation, symptoms and collateral information to determine the probability of a problem. Screening can be done by anybody. It can be done by a human resources officer. It can be done by a pastor, a nurse, a doctor. It can be done by a pharmacist, for example. Screening is not a diagnosis. It's a process to determine is there a problem that may need or might there be a problem that may need further investigation. Screening is used by all types of human service personnel to determine eligibility and appropriateness of services and needed referrals. A lot of people who are involved in the social services system undergo multiple different screenings in order to determine what types of needs they may have and what types of services they may benefit from. Screening also helps determine the immediacy of need. If I'm screening someone for substance abuse, for example, and I can tell by smelling that they are deeply intoxicated, then that's going to be what we call a clue that they probably have a more immediate need for detoxification than somebody who says, yeah, I binge drink occasionally on the weekends. If I'm screening for depression, someone who is discussing suicidal ideation is going to have a greater immediacy of need than someone who is talking about how they've been apathetic and unmotivated for six months. Screening needs to be a transparent process. You don't want to engage in screening with somebody and not have them understand what's going going on. You want to make sure that you are upfront about what you're doing. One of the things when I do my assessment with people, I actually do engage in multiple different screenings for other issues. For example, diabetes is something that I screen for with every single patient because there's such a high proportion of people who have pre diabetes or diabetes who haven't been diagnosed. So I ask them a bunch of questions that are screening questions to determine if they might be having a problem that could develop into diabetes. If they answer yes to the questions, then I refer them to their doctor. I make sure they understand I have not diagnosed them. It could be just completely benign, but better to get it checked out than not to have it checked out. We do the same thing with screening for moles for skin cancer. We look, hopefully you're looking at your moles on a regular to make sure that they're not changing. If they're changing, you have screened it and you've said, hey, doing this self screening, I determine that there is a potential need to have a doctor look at it and diagnose whether this is a problem or not. Screening requires informed consent. You don't necessarily have to have a written informed consent, but you need to have a verbal consent from the person. I am going to ask you these questions and you have the right to answer them or not answer them. Screening identifies early warning signs and helps provide early intervention services and or resources. If a child is having difficulty in school, well, okay, they're having difficulty, that's an issue. But then we need to screen the child to identify what might be causing the issue and make referrals to resources as necessary. Screening is the first opportunity to engage the person in the therapeutic relationship and the treatment process. Screening is not treatment, but it opens the door and it says, hey, there might be something going on that I can help with or that these people over here can help with. Would you like to walk through the door? Sometimes based on observation or other circumstances, people may be referred directly for assessment. And I'll be honest, if you are working in community behavioral health, a lot of times we skip over the screening. The person calls, they make an appointment for an assessment. A screening is something that is typically done in the field where or on the phone where, where a intake counselor may be asking particular questions to screen for the immediacy. Do I need to refer this person over to detox or crisis stabilization or can I refer them directly for an assessment? The client's internal motivation is the primary reason for engaging in treatment. If they are not internally motivated, they're probably not going to engage. So rapid engagement is vital. When we ask these screening questions, we don't want to increase their anxiety. We don't want want them to feel judged. We want to help them understand how the questions we're asking may help them feel better, may help them use their energy in a way to move toward their rich and meaningful life. Successful screening should be brief. And when I say brief, I mean less than five minutes. If you're asking them 40 questions, that's too long. You're going to lose a lot of people. It should be conducted in a variety of settings by a range of professionals on persons deemed to be at risk. Teachers, if they had the time would be excellent for screening. School counselors are excellent for screening. Again, pediatricians, doctors, nurses, pharmacists all have the ability to conduct screening. When your company has wellness fairs, they are offering the opportunity for a variety of screenings, from high blood pressure to blood sugar issues, depending on what they bring in. A lot of screenings can be done in a very short period of time for people to help them identify emerging issues. We know it's much easier to address an emerging issue or prevent it altogether than it is to try to treat something that is firmly entrenched. Successful screening should be a collaboration among a multidisciplinary team. As I mentioned before, I know that diabetes and irregular blood sugar can cause a variety of mood and behavioral symptoms. However, I'm not a doctor, so I am going to recognize that some of these symptoms may be caused by situational factors and cognitions and trauma and all this other stuff. But some of them also could be caused by physiological issues. When I do assessments, I. I don't require. I strongly encourage people to have a comprehensive physical that address or screens for vitamin D deficiency, anemia, blood sugar problems in order to determine if there's a physiological cause or contributing factor to their presenting issue. If a doctor screens for depression, that's great. You know, they don't have the time or the inclination probably to do therapy every week, so. So they're going to refer to a counselor. A counselor doesn't have the ability to write prescriptions or test blood sugar, so we're going to refer to a medical doctor. And that's what that collaboration is for. It's for me to say, hey, I recognize that what you do or what you address may impact what's going on with my client, but it's outside of my scope. So I'm going to screen for things that I cannot diagnose. And if the person screens positive, I'm going to refer to you. Successful screening also needs to be sensitive to racial, cultural, socioeconomic and gender related concerns. Enough said. And it should be developed from information gathered from multiple sources when possible. Most screenings are done based on client self report, and that's good, but it's not great. A lot of people with addictions are in denial about their addiction or they don't want to admit their addiction. So they're not going to tell you about stuff that may mean that they screen as possibly having an addiction. So if you have ancillary information in the screening, it helps support your ultimate conclusion. You want to screen for signs and symptoms of intoxication and Withdrawal in everybody, not just somebody presenting for substance use issues. It's super important because intoxication and withdrawal can also look like mood issues. Intoxication and substance misuse can contribute to mood symptoms. Three key elements that we have in screening, we want to verify that the person's behavior deviates from the norm for their culture, their age, their, you know, everything, and not pathologize something that is considered culturally normal. We want to rule out all non drug related causes of their behavior. If they are staggering, for example, and slurring their words. All right, well your first thought may be that's intoxication. Well, yeah, that's probably my first thought too. But blood sugar being out of whack can also cause that thiamine deficiency that gets really bad called Wernicke Korsakoff syndrome can also cause that. So we want to look and say is there anything else going on that other than being intoxicated or withdrawing that may be contributing to this? And we're Nikki Korsakoffs and I know I'm on a tangent here, but just bear with me. Is caused by a thiamine deficiency. And that thiamine deficiency initially was thought to be caused by alcoholism. And so the only time we really saw that diagnosis of we're Nikki Korsakov was in people who were hardcore alcoholic. But we're finding that people with other conditions also may develop Wernicke Coroffs, including anorexia, bulimia and people who have had gastric bypass. All of them are at risk for having severe deficiencies in the body's ability to process or access thiamine. Therefore, I do not consider Weirnicky Korsakoff a necessarily a drug related cause. Want to make sure that I evaluate what my what might be going on. And then we need to use diagnostic procedures to determine the types of drugs being used. And I probably should have used the word screening procedures to determine the types of drugs being used. Those little cups that people pee in for their on site drug tests, those are screening tools. Those are not diagnostic tools. Those do not tell you for sure that this person has been using alcohol or cocaine or opioids or barbiturates. And it says there's a such and such probability. It's giving you a. It's basically like a pregnancy test for drugs. You know, you're seeing if you see two lines or if you see one line, but they're not a hundred percent accurate. Some of them are not even 80% accurate. And it's really important that we recognize the limitations of, of on site screening tests. And we send those tests off if you're making a diagnosis or if there's some consequence to the person's results, that those results are sent off and looked at by a mass spectrometer to determine whether their test was, they were positive because they actually used that drug or something else caused a false positive. In terms of screening and assessing what's going on with clients, we want, we can screen for their mental health. We can screen for depression, anxiety, anger. We can screen for trauma history. We can screen for safety and environmental needs. We can screen for physical health needs. And we're not, I'm not a doctor, I can't tell you what, what to eat or, you know, what you need to do to fix something physically. But if I screen you and you talk about being in pain all the time, then guess what, I'm going to refer you to your physician so they can start working with you on that pain and I will start working with you on coping strategies so you don't use or abuse drugs in order to cope with that pain. We want to screen for other wraparound needs that may prevent the person from accessing treatment or may prevent the person from healing. You know, what else is going on in their life that may be contributing to their distress? Are they in a domestically violent relationship? Are they financially really struggling? Are they homeless? Are they, what else is going on that they may need? And you want to think about Maslow's hierarchy here. What physiological needs are not being fully and adequately met and what resources can we refer them to? What safety needs are not being fully and adequately met and what resources can we refer them to? Screening is not diagnosis. It's saying, hey, I see you have a need. Let me connect you with somebody who can help you fulfill that need. And we want to screen for whether somebody is a danger to self or others. If you are doing a mental health or substance abuse screening, this is something you need to screen for. And if they, if the person talks about wanting to hurt themselves or others, then you need to refer to somebody who can do a thorough assessment in terms of screening methods. You can interview the person, the client, guess what? Go figure. How awesome is that? You can also screen by talking to significant others. If the person is too intoxicated to answer the screening questions, then you can talk to significant others. If you're dealing with children, you're going to want to gather information from significant others. If the client is an adult and is able to answer the questions themselves, that's great. And if they're willing to let significant others kind of round out the picture. That's great. You can use screening instruments and there's lots of screening instruments out there. A lot of free evidence based instruments are out there. We're going to talk about those in a minute. But they're impersonal. The nice thing about them is the person doesn't have to confess, if you will, to anyone. It's something they can do on their own. So a pharmacist can hand somebody a self assessment sheet for dementia, for anxiety, for something else if they're concerned about a person's status. And that can serve as a screening. The screening instruments ideally are done with a clinician or with a person like a pastor who can process it with them. We don't want to just hand them a screening instrument and say, you know, fill this out when you get home and you know, good luck. We want to make sure that they know what to do with it once they've filled it out. But it does provide a structure and a framework for people who are not clinically trained to get the information that they need and take the appropriate steps. And then as I mentioned earlier, lab tests are great screening methods. Whether it is at a doctor's office where you're getting blood drawn or something. When they draw your blood, they're not diagnosing anything. They're looking to see if you're, you know, all your things are in their normal parameters and if they're not, then the doctor has to say, wonder why that is. Let me, let's figure out what's going on. Let's do a further diagnostic assessment. With substance abuse, most people are not going to start out with a lab test, lab urine test, unless it's a pre, pre employment or a workers computer issue. Most people who are in substance abuse treatment are going to do some sort of on site screening test and that gives information. Now as I mentioned earlier, you can have false positives, but you can also have false negatives. People can dilute their urine enough or take certain things that can make it so their urine does not trigger the two lines on the urine test. If you have suspicions, even if it comes up negative, if you have suspicions, it's important to send it off for a diagnostic evaluation from a mass spectrometer. Screening is not assessment or diagnosis. When you are engaging somebody in the screening process, you want to demonstrate or you want to use verbal and nonverbal skills that establish rapport and promote engagement. You don't want to have somebody come in and go, okay, you are number 26437. And then start rattling off these questions without even looking at them. Look at them. Welcome them. Look at them. Don't sit there at your desk and just kind of look over your shoulder. Turn so you're facing them. Acknowledge them, Call them by name. Ask them how their day is. It takes about two seconds to help somebody feel a little bit relaxed. Tell them what you're getting ready to do. Make sure they feel like they are informed, you know, and able to answer or not answer the questions and then begin asking questions. But they are a person, they're not a number and they need that eye contact. They need to feel like they are important to you at that moment. Discuss the rationale, purpose and procedures associated with screening. You don't need to go in depth into I'm going to ask you questions on this questionnaire that was validated and blah blah, blah and written by. So they don't care. They don't care. But tell them the screening process. All I'm going to do is ask you a few questions. And screening is not a diagnosis. Screening just helps us determine where to best refer you if there is a problem. Screening helps us determine if there might be something that needs further investigation. Assess immediate needs, including detoxification. Notice if their pupils are pinpoint or their pupils are blown, if they're slurring their words, if they have any signs of intoxication or withdrawal, if they're itching, if they're scratching a lot, could be eczema, could be dry skin, could be that they're having a intoxication reaction. So it is important to notice that. And when you're screening, you're not just hearing what they say, you're also seeing them. If I'm screening somebody for depression and they're telling me it's all good and I'm looking at them and they doesn't look like they bathed in about a week and I can smell them from across the room. I'm going to start wondering if their non verbal say I'm depressed, but they're telling me nope, everything's fine. The, the two don't jive so it's important to pay attention. That's another reason you gotta look at the person to assess their non verbals. 80% of our communication is non verbal. When I turn and I look at you and I make eye contact with you, that communicates something. If I don't turn, what does that communicate? That communicates you're not important, you're not willing, you're not worthy of my attention. So it is important to make sure that we actually engage with the person. Administer evidence based screening instruments to identify physical needs, medical conditions and co occurring mental health issues. I told you earlier that I regularly screen for diabetes in people that I work with. Where did I get that screening instrument? The Diabetes Association. If you screen for depression, there are depression instruments out there that can help you screen for mental health issues. It it's actually super easy. You can go to the DSM, currently DSM5TR and look at the diagnostic criteria and you just go through it with them. It's not brain surgery. What's in that book is not a secret. Your basic screening instruments are developed based on those criteria. So just ask them, do you experience this symptom, yes or no. Do you experience this symptom, yes or no. And that's it. It's not. You don't have to have some super expensive instrument in order to do a screening. Determining diagnosis is a little bit more of an art. But screening can be pretty straightforward. Obtain relevant history. You know, ask them if they're depressed or they're talking about feeling depressed. How long's it been going on? What do you triggered it? If you know, have you had other episodes like this? That's all important information to help you determine are they having a bad day or do they need to be evaluated for major depressive disorder? Interpret the results of screening and determine the appropriate course of action. Once you have the results, then you want to talk about it with the person and say, okay, this is what I'm seeing. Based on this screening, there might be an issue that could be resolved by talking with your doctor, by seeing a therapist or what have you. What is going to. What is something that you're willing to do? And we want to make sure that we provide options for the people. But we don't just automatically say okay, you screen for all these things. Here are 17 referrals. See you next. No, we want to talk with them about what the appropriate course of action is for them at this time. They may not be willing to go to treatment. They may be willing to consider support groups or something else. So we want to talk with them about what they're willing to do. Engagement puts the clinician in the best position to negotiate with the client about what to do and how to do it. Engaged clients are more likely to participate willingly, be treatment compliant and successfully complete treatment. What does engagement mean? Engagement means I've bought into it. I believe that there's a problem and I'm motivated to work with you to try to solve this problem. An engaged client is one that is with the program. In order to improve engagement. I want you to think about times that you've gone to a counselor or a doctor or something else and they've told you to do something and they haven't engaged you, they've just said, hey, you know, you're 20 pounds overweight. You need to start getting healthy. Here are the 17 things you need to do. Come back in six months. Did you follow it? Were you engaged in that? Did you feel empowered? Did you feel like it was important to do? Did you feel overwhelmed by everything? An overwhelmed person is probably not going to be engaged. So we need to engage the person and say, hey, here's what I see as a problem, here's why I think it's a problem and how it's causing your distress. Here are the options that I see and I am here to help you accomplish these goals. Establish rapport and an effective working alliance in which the person feels heard and understood. Being respectful, non judgmental and attentive. Respectful non verbals. Again, you want to communicate that non verbally. Not being closed off, not being just looking at your computer. Treat them like a human being. You want to be non judgmental. If they start talking to you about being in a domestically violent relationship and unable or unwilling to leave, questioning them on that. Being judgmental about that is going to destroy rapport. We want to hear where where they are and be respectful of their current circumstances. We can still provide resources and referrals, but we need to be respectful to not force our opinions and our beliefs and our fears onto them. And we need to be attentive. Not answering our phones, not answering emails while we're trying to talk to them. When they are with us, we are with them a hundred percent and motivate and engage the client in identified service needs. It can be really overwhelming for a person once they've gone through a screening. If you say, okay, well, here's what I want you to do. I need you to make an appointment to go see your doctor and get a blood test run. And it would be ideal if you called this place and got set up for an assessment for, for counseling or got on the waiting list for detoxification. Well, to you that may not sound like a big deal because that's what you do on the daily. You help people connect to a person who is already struggling, who already feels exhausted and overwhelmed and who may be intimidated by doctors and treatment centers and all that other stuff, or fear how much it's going to cost. There's a lot of reasons why people may not follow through, so we need to talk to them and say, okay, these are the things that I think would be helpful. What concerns do you have about it and what is it that I can do to help you take advantage of those resources that are out there for you for making appointments? Sometimes you may need to help them make those appointments or sit there with them while they make the appointment because it causes them so much anxiety to call the doctor's office and make an appointment that they may not do it. So, okay, well, before you leave, let's go ahead and have you just call your doctor and make that appointment. That way that's out of the way. Create a welcoming environment, pleasant for the person and sensitive to their age. If you are seeing children, then having an office that's designed for 30 somethings that's not going to be welcoming and the child's going to be like, okay, this feels like mom's living room or grandma's living room. And they're probably going to be less comfortable. If you are seeing adults, then obviously you don't want to have the entire office decorated for play therapy. Make sure it is sensitive to gender. And if you are seeing people, if you are seeing men, it's important to help them feel welcome in your environment. You don't want it to have it be overly flowery and fluffy and fancy because that may make them feel uncomfortable. Likewise, you don't want it to be too austere for people who prefer things that are more decorative. And that doesn't necessarily always follow along gender lines. But recognize the different temperaments and personalities that are coming into your office. You want it to be sensitive to disability. If they've got chronic low back pain, making sure that you have a chair or seating arrangements where they can that has lumbar support. And they can put their feet on a an ottoman or something to reduce the strain on their lower back. If they are in a wheelchair or on crutches or using a walker, making sure that you don't have obstructions that are going to keep them from being able to get into your office and move around. Pay attention to sensitivities. A lot of people have sensory sensitivities, whether it is sound, smell or sights. People who have epilepsy, for example, are extremely sensitive to flickering lights. People who have migraines are also sensitive to flickering lights. It can really trigger a migraine. Make sure if you've got fluorescent lights that they're not flickering Smells. A lot of people can get easily overwhelmed by smells. Making sure to keep it smell neutral. I know for me, I am extremely sensitive to VOCs, volatile organic compounds. Reading. I was reading my grandfather's bible the other day, and I opened it and I was reading it for, you know, I don't know, five or 10 minutes, and I started to get this wicked headache. Turns out the paper, as it decomposes, releases vocs. I know I'm sensitive to vocs because if I'm around paint, I'll have a migraine in 15 minutes. But I didn't think about the books. So the same sort of thing goes for our clients with sensitivities. Wear perfume that's too strong or cologne that's too strong and be sensitive to their sensory stuff and sounds. Humming from fluorescent lights can be absolutely deafening to some people. And I'm, you know, in general, I'm thinking people who are neurotypical, people who are neuro atypical may be exceptionally sensitive to some of these sights, smells, or sounds. And remember, neuroatypicality is not just autism spectrum. It's adhd, it's schizophrenia. We see a lot of people with a variety of different mental health issues who have some degree of neuroatypicality. We want to make sure that it's sensitive to sexual orientation. If you've got somebody coming and, and religion, let's just put them both together. If you've got somebody coming into your office that may be of a different sexual orientation or religion than you, it may be intimidating if you. If they walk in and what they see is rejecting. Representative of a culture or a religion that rejects who they are. Do you have to have pro. Pro sexual orientation things? It's ideal. It's ideal to make sure that people know that they are welcome. And regardless of how they're wired, how they're made, how they're, you know, their being, they are welcome and they are accepted. And socioeconomic status is also important. People who are of a lower SES, for example, walking into a Super Fufoo office on the 20th floor of some building may feel intimidated because they're around a bunch of people that they are of a different socioeconomic class. They may feel very isolated and may not feel accepted. It's important to be aware. It doesn't mean that you have to move your office, but make sure that people feel welcome when they come in. How do you do that? Well, one of the best ways to do that is to ask when people come in, hey, I just opened my New office. And I'm looking for suggestions from making this feel more welcoming and inviting. What is one thing that I could do that you think would make it more welcoming and inviting? You don't have to implement everybody's suggestions, but if you're asking the people you serve, then you're going to be able to modify your environment in a way that's meaningful to them instead of assuming and guessing. Certain factors impact engagement. Stigma is a big one. Stigma about diagnoses, whether it's depression or schizophrenia or addiction or something else, seems like a lot of stuff out there has a stigma associated with it. We need to help people recognize that mental health diagnoses are very similar to physical health diagnoses. If you've got Crohn's disease, there's no stigma against Crohn's disease. Why is there a stigma against bipolar disorder? You know, it's. It's just. It is what it is, and we need to help the person figure out how to live with it in a way that they can move toward their rich and meaningful life. Some cultures are very anti mental health services, anti mental illness, because they perceive it as bringing shame to the family or a punishment from God. And we want to understand that and work with them within their culture as they see it. It's not our place to tell us, tell somebody that their cultural beliefs are wrong. We, if they are embracing those beliefs, if those beliefs are meaningful to them, we need to say, okay, how can I help? You best navigate this issue in your culture. And there's a stigma about help seeking. Many cultures believe that you should keep your problems in the family. You shouldn't go out and tell other people about it. Or it shows weakness if you have to go see a therapist. And obviously I disagree with those, but that comes from being a therapist. That comes from the culture and the environment that I was raised in. And it's important that I validate. If somebody feels like there's a stigma about seeking help, instead of saying, you're just making a mountain out of a molehill, suck it up, buttercup. It's important that I say, I, I hear that this is causing you a lot of anxiety. What can I do to help you feel safer? When I first came to Nashville, I worked in a clinic in, in Nashville. And we had a lot of high profile clients that were coming into our treatment center. And of course, they didn't want to be photographed by the paparazzi going into the front door of an addiction treatment center. So we had different arrangements made where they could park around back so their car wouldn't be seen, or they could actually park over at the restaurant nearby and walk over if they wanted to. And then they were able to come in the back and leave out the back so they didn't have to walk through the lobby where other people were waiting. And that allowed them a certain amount of feeling safe. So ultimately, again, it's important if we're engaging them, we not only need to help them feel empowered, but we also need to hear and validate their concerns and say, okay, I hear where you're coming from. How can we work together to deal with this issue? They may have expectations about the effectiveness of treatment. If they think it's going to be super effective, then they're probably going to be on board. If they've been in treatment before or they doubt the effectiveness of treatment, they're probably not going to be engaged. They're going to be like, eh, you know, I'll dip my toe in and we'll see. So it's important to help them identify goals that they'll be able to accomplish to see the effectiveness of treatment. It's important to provide them research that helps them understand the effectiveness of that particular treatment method. They may have different expectations about their role or power in the treatment process. Some people come to treatment and they expect me to fix them. And I'm like, I don't get paid enough to do that. And they usually look at me like I have three heads. I said, I can't change you, only you can change you. I am here to provide you support, suggestions, tools, and it's up to you to figure out which ones are going to be useful to you and start using them. And I can help you become proficient at using them, but you have to do the work and I will be there to guide and support you. And they may have weird expectations or unfounded expectations about the treatment process itself. If I check into residential this, these are all the things that are going to happen. Let's be very transparent about what group therapy looks like in your organization. Be transparent about the tasks that the person's going to participate in as a member of that treatment program. That's all an informed consent. And once we clarify people's expectations, they tend to become more engaged in the process. It's not as scary anymore. So they feel knowledgeable. It's kind of like if I'm driving into Nashville and I need to go to some building in the middle of the city, I'm not going to be. I'm going to be Kind of apprehensive about doing it unless I know the route. If I've already asked Google Maps how to get there and I have the directions and I've looked at it on the map and I can see how it's going to go, I feel more confident. I'm. If you will, if you want to. I'm more engaged in driving there because I'm expecting, okay, I turn left here and this is where I'm going to go. I feel more confident and then likableness. And I know we don't like to talk about this, but it is just a human reality. People will be more engaged in the process and engaged with you if you've got good social skills. Go figure. And if they've got good social skills, you're going to be more likely to engage with them if they've got good social skills. So if they don't have good social skills, you're going to have to work doubly hard to engage them in the process. Likewise, if you're attentive to them, they're going to be more engaged. And if they're in attentive to you, they're going to be more engaged. You want to make sure that you've got the client's attention. They're not sitting there playing on their mobile device or just hung you the whole time. And as much as I hate to say it, attractiveness, when clients come in and they are unattractive, it often impacts the therapist level of engagement with them. Research has shown it. It's one of those human factors. We can work in our own minds to make sure that we buffer against this. But we do need to understand that there is a tendency for it to happen. Clients who are struggling with addiction, who may be homeless, they may come in and be disheveled, they may smell bad, they may. There's lots of things that may be going on. We need to see that as a symptom of their present condition and not representative of who they are and recognize their attractiveness as a human being. Likewise, and I know you don't want to hear this, but it's a reality, your attractiveness. If you show up to work and you've got baby vomit on one shoulder, you forgot to brush your hair, you, your, your clothes are all wrinkled and disheveled, then the client is going to look at you and go, you know, not really sure if this person cares about me, because they don't even care about themselves. Attractiveness doesn't necessarily mean whether you are a, you know, model. It means how well do you take care of yourself and how do you present yourself? And finally, projection and transference issues. If you remind a client of somebody that they despise or somebody that they're afraid of, then they're going to be less likely to engage with you and it's going to be make take more work on your part to help them feel safe and secure and recognize that you are different from that person. Likewise, if a client comes in and reminds you of somebody that you have had bad experiences with, then you are going to have to actively work to remind yourself that this is a different person and engage with the person that's in front of you, not your memory of the past person. First Impressions Impact Engagement As I mentioned earlier, your professional presentation if you're wearing jeans and a T shirt, even if they're well pressed, and you're seeing clients that are paying $300 an hour, even for screening, that's not going to probably engender a lot of confidence. Unless maybe it's casual Friday, so make it Having a professional presentation is important and one that is appropriate to that environment. If I dress in like a three piece business suit and high heels and I'm planning on working with 6 year olds, that might not go over so well either. Do I need to be bathed and you know, have my hair brushed and polished and stuff? Yes, and probably I would wear a polo shirt and some, you know, black slacks or something. I'm still dressed nicely, but it's in a way that is not going to be intimidating to the 6 year old. Be prompt. Their time is just as important as your time. And if you're late, if it communicates that their time is not important, be courteous, smile, say hi. Not everybody likes to shake hands. That's okay, but treat them with courtesy, they are another human being and handle your paperwork smoothly. If you're shuffling around and going, I know I've got that form here somewhere, just a second, they're not going to have a lot of confidence in your skills. Make sure that you are ready for that person that comes in to do their screening. Remember, you're probably the first person they're seeing at your organization, so you're setting the tone for how organized, efficient and competent your entire organization is. Make sure the environment is calm, clean and comfortable, not too formal or informal. Make sure to avoid interruptions. If you're in a if you're in a group office, make sure when you shut your door you have a sign on the outside that says in session or there's some way that people know now's not the time to just stick your head in and it provides appropriate privacy. As I mentioned earlier, not everybody's going to feel comfortable going through the waiting room or if they have had a session and they've been crying, they may not want to go back out through the waiting room. We want to make sure that they have appropriate privacy during this initial interview. This screening. Establish trust and develop rapport. Be empathetic with the person not only about their condition, but about how much courage it took to come in today. Convey warmth and respect and explore the person's strengths and skills. Instead of starting out looking for deficits and problems, let's talk about their strengths and their skills. All right, you're here today because you, you've been feeling depressed and you know it's really hard to do what you need to do when you don't have energy and, you know, you just can't get motivated for anything. Tell me about how you have survived until now. What things have you done that helped just a little bit. That helps the person start thinking about what they can do instead of what they can't. Facilitate the client's understanding of the screening purpose and procedures. Explore the person's awareness of their problems and expectations regarding treatment and recovery. So, for example, asking them, how are these symptoms keeping you from living your rich and meaningful life? How is this lack of motivation and constant exhaustion? How's it keeping you from living your rich and meaningful life? How would are your behaviors? How is drinking until you pass out every night impacting your ability to live your rich and meaningful life again? What has worked to help you address these things at least a little bit, and what hasn't? Why do we ask about the hasn't? Because we don't want to have them feel like we're going to make them repeat things that haven't worked in the past. Remember one client came in and she sat down, and before I had even started talking, doing the screening, she said, I'm not going to any of those meetings. Okay, my name's Dr. Snipes. How are you? I mean, literally she walked in, she was already on the defensive because she had been through this process before, and instead of hearing what hadn't worked for her, people kept trying to make or do the same thing over and over again and expect different results. And we know that that's insane. Ask them was it hasn't worked and if it's something that you think is important, talk with them about why it didn't work and Whether they're willing to consider making some modifications and trying something similar. And if they say no, okay. Remember, in this initial interview, we're screening, we're empowering, we're engaging. We don't want to start telling people, well, once you get into the program, then I'm going to start making you do all these things you don't want to do. Well, do you think they're going to engage and come back? No. And ask them, what do you think might work this time, what might help? Most people have an idea about what might help them this time. So let's start building off their strengths, off their hopes, off their what they anticipate, what they believe is going to work and then determine if a further assessment is needed. So after you get all this information and their expectations about treatment and stuff, determine with them whether a further assessment is needed and appropriate. When you're screening for substance use or mental health issues, it's important to get information about the circumstances of contact. Are they being sent there by a criminal attorney or the courts or a civil or involuntary referral? If so, they're probably not going to tell you the hundred percent truth. They're going to skew things to make themselves look good. It's human nature. Look at the client's demeanor and behavior. Are they oriented to person, place, time and purpose? Do they know who they are, who you are, where they are, what time it is and why they're there? And you may say, well, of course they do. No, you'd be surprised. How's their short and long term memory? You know, you introduced yourself when they came in 10, 15 minutes into the interview. Ask them what your name is, or ask them the name of the treatment center that they're at or whatever to see if they can remember something in the recent past. And then ask them about something from the distant past that you know the answer to. Not about their life, because you don't know the answer to that. But for example, who was the president before the person who's president now. Assess their coherence and judgment. Are they getting it? Do they understand the severity of the problem? Are they having any hallucinations or delusions? Seeing things or hearing things that are not there, or believing things that other people would totally just not concur with? Are they showing signs of depression, anxiety or trauma? You're screening for it, you're not diagnosing it. Are they showing signs of suicidal thoughts or behaviors? You're screening for it. These are all things that you need to screen for. Because if they are not oriented if their memory is having problems, if they're not coherent or having good judgment, they've got hallucinations or delusions. They're showing signs of suicidal thoughts and behaviors. Obviously that is a more imminent immediate assessment and referral as opposed to someone who is presenting with who is, who is oriented and their memory is fine. They've got good judgment, but they're depressed. Not to say that that person doesn't need help, but the immediacy or the urgency of the referral is going to be determine based on some of those things. Look for signs of acute intoxication or withdrawal. Know your pharmacology, know about the pupils, know about, you know, smelling it on them and do they have any sign, physical signs of drug use like needle marks or self injury, like if they are engaging in self injurious behavior, cutting themselves? Ask them about prior involvement in mental health treatment, their use of prescription medication, herbs and what we call nootropics or over the counter herbs and stuff to try to help you feel better, including cbd. Ask about recent traumas. Have there been any deaths or losses recently in your life? Ask about a family history of mental illness for genetic as well as environmental reasons. Mental illness often runs in families. And also, is there anything else that you want to tell me that you think might help me determine if there's a need to make a referral? That's information that the person will spontaneously offer. In terms of screening instruments, they can be developed by the agency or you can just use standardized instruments. The cage, very simple. Have you tried to cut down and been unable to? Do you feel annoyed when people ask you about your substance use? Do you feel guilty when you use and do you need to use when you first get up, have an eye opener in order to get through the day? The Audit is another screening tool that screens for alcohol. Use the GAIN ss. It's the Global Appraisal of Individual Needs and the Michigan Alcohol Screening Test and the SASE, which is the Substance Abuse Subtle Screening Inventory. The audit, the gain, the MAST and the SASE are all paper based screening instruments but they're available and as I mentioned earlier, you can also just go straight to the dsm. That's pretty straightforward. Currently there are no accessible screening instruments for behavioral addictions including Internet, gaming disorder, gambling, food addiction, pornography addiction, sex addiction, etc. You can ask the person you know. Again this is just screening. Are there behaviors that you continue to engage in despite knowing that they're causing you problems in your life such as Internet gaming, gambling, food, pornography that really cuts to the core of addiction issues. And if they say yes, then you can ask, have you tried to cut down and been unable to? And if they say yes, then that's what I would consider a positive screening and criteria or grounds for a referral for a further assessment for mental health screening. Remember, most people who have an addiction issue have concurrent mental health issues going on. They're depressed, they're grieving, they've got trauma, they. Lots of trauma. So we want to screen. There's the modified mini screen, there's the Mental Status Exam, the mini Mental Status Exam, the Brief Symptom Inventory, the Brief Psychiatric Rating Scale, and the symptom checklist 90R. It's important that you know the names of these screening instruments for your test. Will you actually see them in clinic? Probably not, but it is important to understand that what they are and that they exist for your test. From Screening for Mental Health, just like screening for substance use, you can go to that DSM 5tr and look at the symptoms, look at the criteria and ask them the questions. In terms of gathering ancillary information, you need to get a release of information. You can't just call up their boss or their attorney and go, hey, I screened Jim Bob today and I was wondering if you could give me some information. You need to have that sign Release of information. Ideally, they would allow you to talk to significant others, lawyers or criminal justice, if the referral came from there. When I worked with involuntary referrals from the criminal justice system, whether and the civil justice system, I insisted that they bring me a copy of their rap sheet, their convictions and their arrest sheet. And that was just part of the ancillary information. You can also ask them if you can't get release for talking to their other people. If I asked your mother or your spouse or your kids about this issue, what would they say? You will gather more ancillary information in the assessment. So if you can't get much or any at all, worry about it. Screening is only to determine if there might be a need to proceed to an assessment. Even if it does and you refer for an assessment, not all assessments will result in diagnosis, or at least not the diagnosis that you're thinking of. So you may screen somebody who's presenting with depression, for example, you refer them for an assessment, they go through the entire assessment, and instead of getting diagnosed with clinical depression, they're diagnosed with hypothyroid. All right. You know, hypothyroid and clinical depression have very similar symptoms, but very, very different treatments. Screening is the initial contact to decide if a person may need a more in depth assessment. It is a brief encounter, but requires the person to be engaged in the process in order to get an accurate result. They need to feel comfortable, they need to feel respected in that environment. How well the person is engaged in the screening process is a direct predictor of whether they will continue. Anyone can conduct a screening. The client can self screen. A significant other can do a screening. A caseworker, an attorney, nurses, doctors, clergy, even pharmacists. So screening is one of those things that we really should be doing more with the people that we work with in order to make sure that we're helping them address whatever underlying issues are causing their presenting symptoms.