SAMHSA TIP 42 Treatment of Co-Occurring Disorders Part 4 | Addiction Counselor Exam Review

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs register@allceus.com counselortoolbox hey everybody and welcome back to treatment of persons with co occurring disorders based on SAMHSA tip 42 and this is part 4. During this class we're going to define the purpose of screening. We're going to define assessment and learn the 12 steps in the assessment process. Now, this may be old hat for some of you, and you know, I get that, but you know, bear with me a little bit. So screening. Screening is an initial procedure. It can be completed by paraprofessionals. So screening can be completed by judges, by law enforcement officers, by social workers, by caseworkers. You know, pretty much anybody that comes in contact with somebody else, by pastors, can be trained to do screenings. It's a process where a counselor or a paraprofessional client and the significant others review current information and symptoms. So we're just talking about kind of what's going on here. It identifies whether the person may be showing signs of a substance abuse or mental health issue and can also assess for related service needs, like do they need legal assistance or occupational assistance or, you know, food stamps or anything like that. Screening is not a diagnostic procedure. Screening is just something that we do if, you know, outside of a clinical setting where you're doing an assessment in order to identify if someone may need a referral for counseling. Screening should be conducted on persons who may be at risk in a variety of settings by a range of professionals and paraprofessionals. Agencies should all collaborate on screening procedures. So if somebody at the jail screens a client and refers them to your facility when they get out, you know, we want to know what screening was done. Ideally, all of the agencies in the recovery oriented system of care have agreed on a standardized method and set of instruments to use for screening. That way, when John gets referred and shows up, we know what's already been asked. All screening procedures should be culturally responsive and trauma informed. So we do want to be sensitive to any cultural issues that may come up and not ask questions which might re traumatize a person or make them feel vulnerable. Initial screenings are brief and when possible contain information from multiple sources, including significant others, criminal history, their physician, any other therapist, and definitely from the referral source, whoever referred the person for screening. Why did they refer them? If the person self referred, you know, why did they refer themselves? Common screening instruments. The cage is, you know, a really Quick and dirty one that I've seen used actually in court as well as other places. Have you tried to cut down on your use? If yes, then that's a positive. Have you ever felt annoyed when people talk to you about your use? Have you ever felt guilty for your use? Or have you ever had to have an eye opener to get the day started after, you know, using? So if the person answers yes to a certain number of those, then they will be considered positive and be referred for an assessment. The GAIN SI is another instrument that can be used to provide an initial screening. And, you know, let me see. Here we go. You know, it's not a super long instrument, and it helps you look at multiple different dimensions, including criminal history, dangerousness of self to self and others, and substance abuse issues. So it does. It's a really good, quick screening tool to identify whether someone may have some presenting issues. The Michigan Alcohol Screening Test, or the MAST is another one that's commonly used. Maybe I'll get that to come up. Here we go. And this one is really easy to administer. Do you enjoy drinking? Now and then, do you feel you're a normal drinker? You know, there's a lot of questions here. Obviously, this is alcohol, so it's only about drinking. Have you gotten into physical fights when drinking? And then it tells you how to score it at the bottom, and it gives you an idea about what the cutoff threshold is to identify a problem drinker. So that's one that some agencies use. Other agencies may use something called the SASI or the Substance Abuse Subtle Screening Inventory. We used this at my agency. We also used to use the CAGE and the gain. We kind of were all over the place. But the SASI does measure, you know, what it purports to measure. However, it tends to be long. They say it takes 15 minutes. I never had it take 15 minutes. But most of my clients, it took about 30 minutes to administer, which is a long instrument, especially for a screening. Some agencies like it, some require it. If you have to do it, you have to do it. A screening should be relatively short. The assessment is going to be long. So people don't want to have to sit through a long screening and then rehash the same stuff in an assessment. So look at that when you're considering, when you read through some of the questions on the screening instruments. Obviously if somebody has a substance abuse issue and they're not wanting to admit it, they can lie on these questions. Have you ever gotten into a fight while drinking? No. You know, disagreements, maybe but never a fight or, you know, have you ever felt annoyed when people talk to you about your drinking? No. I mean, a lot of people who are in pre contemplation who don't think their addiction is an issue may answer the way they think you want them to answer on a lot of these screening instruments. So you don't want to base a screening just on an instrument alone. An effective screening protocol specifies how any screening tools are used and scored what established cutoff scores are. So do you have to score 5 or more? 3 or more? You know, what's our cutoff? What happens when a client scores in the positive range? So if the cutoff is 5 and the person scores 6, what happens? Where do they get referred? What's the next step? How do you document the results of the screening and make the referral? And how do you document seamless referral and service coordination? So if I do a screening, how do I document it? And then am I still responsible for tracking this person or am I handing this person off? Or how does that happen? Once I've screened and made the referral, who's in charge and who's going to take the next step and take the reins? At this point, there are a number of circumstances that can affect validity and test responses that may not be obvious. So the manner in which the instructions are given to the client, if you give them and you tell them to answer 100% honestly or, you know, do your best, that can affect answering. If the setting where the screening or assessment takes place doesn't have a lot of privacy, that can affect answers. If there's no trust and rapport between the client and counselor when you're doing the screening, then they're probably going to put their best foot forward, even if that means lying. So, okay, we have to understand that people want to save face, they're going to protect themselves and other mitigating circumstances which may not be immediately present, including legal issues, child welfare, custody, or employment. You know, I've had people come in before who worked for air traffic control or who worked trucking, and if they get found to have a substance abuse issue, it's really a problem with their employment. Same thing with nurses and doctors and everybody else. So people may have alternate reasons for not wanting to be 100% truthful about the extent of their use or their problem. Now, screening identifies the possibility of the presence of a problem, and it can be done by a doctor, a cop, judge, probation officer, dcf, caseworker, you name it. Pastor assessment, on the other hand, defines the nature of the problem and develops specific treatment recommendations for addressing the problem. So you do the assessment and then you recommend a placement. So maybe I'm going to refer this person to residential or outpatient, or I'm going to refer them over here to mental health. You know, that's what an assessment does. A comprehensive assessment oftentimes is the same thing as an assessment because you're doing it at an agency, but sometimes it's a little bit different and it serves the basis for an individualized treatment plan. And in the client's treatment setting of choice, the primary therapist usually does the comprehensive assessment to determine all the little nitty gritty and then prioritize goals. So do's and don'ts for assessment. Keep in mind that assessment is about getting to know a person with complex individual needs. So above all it's about getting to know a person not completing paperwork. Don't rely on tools alone for a comprehensive assessment. You want to be able to make eye contact, talk to people, hopefully be able to ask some follow up questions. Always make every effort to contact all involved parties like the referral source and significant others and the doctor if you have appropriate releases of information. Don't allow preconceptions about addiction interfere with learning about what the client really needs. Don't assume that, well, once the client gets clean and sobers up a little bit, a lot of the rest of this stuff will fall away. That's a bad assumption to make. It could happen, but it might not if they've got co occurring issues. Do become familiar with diagnostic criteria for common mental disorders, including personality disorders, and with the names and indications of common psychiatric medications. Because when you're doing your assessment, the person may say, you know, they're on Zoloft and Bus bar and Seroquel and you know you're writing these things down and if they don't mean anything to you, you're not going to know what follow up questions to ask. We want to know for every medication, what was it prescribed for and how's it working for you? Most important, do remember that empathy and hope are the most valuable components of your work. So this is what we want to provide. We want people to feel cared about and we want them to believe that they can get better, which means we have to believe that they can get better. And don't assume there's one correct treatment approach or program. Two different people with the same exact seemingly presenting issues may need two different, totally different courses of treatment. So a basic assessment covers the key information required for treatment, matching and treatment planning. Specifically, it offers a structure with which to obtain basic demographic and historical information. It identifies established or probable diagnoses and any functional impairments. It helps identify and kind of ferret out some general strengths as well as problem areas. It identifies the stage of change or stage of treatment for both or all problems that are presented. Remember, people may not be in the same stage of readiness for change for everything. You know, they may be ready to get their depression over with or deal with their ptsd, but that alcohol abuse, they're not quite ready to give up drinking yet. So they're in different stages of readiness for change. That's okay, we can work with that. And in a basic assessment we make a preliminary determination of the severity of the co occurring disorders to serve as a guide to the final level of care. Determination and we're going to talk about the ASAM and the locus in a few minutes for, for determining patient placement status. Assessment of the client with co occurring disorders is an ongoing process that should be repeated over time to capture the changing nature of the client's status. Now some things are not going to change. You know, their family of origin, that's probably not going to change. When they were born, that's not going to change. But their relationship with their family may change, their trauma history may change. You know, there's a lot of things that can change. So we want to make sure to periodically touch in touch base with clients. When we, where I used to work, we had to update treatment plans every week. We had to do a treatment plan reassessment every month and every 90 days we had to do a brief client reassessment. Now it wasn't a full assessment, but it was a reassessment of what's changed, where are you at, do we need to adjust treatment goals, etc. Assessment consists of background information such as their family and trauma history, marital status, yada yada, substance use, including their age of first use. Why? Because we know that people who start using in their adolescence tend to have more significant and longer lasting brain changes than people who didn't start using until later. But it also gives us an idea about, you know, some other presenting issues that may be there as well as the severity of the problem. We want to know the primary drugs used, including patterns of use and treatment episodes. So do they binge use, do they use consistently? Have they had tolerance? Maybe they used, you know, a little bit at first and now they're using 10 times what they used to or you know, they use and they develop a Tolerance and then they detox and they're clean for six months or a year, and then they relapse. Okay, let's know about all those things. If they were in treatment before, you know what helped them stay clean for however long they stay clean and how can we build on that? And we also learn about mental health problems, including family history of mental health problems and the client's history of mental health problems, including their diagnosis, hospitalization, other treatment, what worked, what didn't, and current symptoms and medications, and whether they're adhering to their medications. So those are all important parts to feed in. Because substance use and addictive behaviors impact neurotransmitters. Medication for depression and anxiety, and those sorts of things impact neurotransmitters. Mood is impacted by neurotransmitters. We need to make sure that we are understanding everything that might be contributing to the person's mood, cognitive or impulse control issues. So the assessment process has 12 steps. We want to engage the client, identify collateral information, screen and detect for co occurring disorders, determine the quadrant and locus of responsibility, determine the level of care, the diagnosis, the disability and functional impairment, identify strengths and supports, identify cultural and linguistic needs and supports, identify problem domains, determine the stage of change and plan treatment. So if you're studying for your substance abuse counselor exam, this is probably something that you're going to need to figure out how to remember all 12 steps. I can't say that for sure, but this is one thing that I see that repeatedly comes up in the literature. Okay, so through those steps, and we're going to talk about them in detail, the counselor seeks to accomplish the following. You want to obtain more detailed chronological history of past mental health symptoms, diagnosis, treatment, impairment, particularly before the onset of substance use and during the periods of extended abstinence. That'll give us an idea of whether their mental health issues are a result of substance intoxication or withdrawal, and including post acute withdrawal or whether it is something else, we want to obtain a more detailed description of the client's current strengths and supports. Strengths are what's worked for you in the past, what's helped you stay clean, even if it's for four hours. What helps you when you're feeling really depressed, even if it just takes the edge off so you're not feeling suicidal. Who are your social supports? What things do you have that are going well for you in your life right now? I mean, are you employed? Do you have a job that you don't hate? Do you have a safe place to live? You know, we Want to identify all these and help the person start seeing what strengths and resources they have at their disposal. Then we want to look at their limitations, skill deficit and skill deficits, so we can identify things this client needs to learn or referrals that the client may need in order to improve his or her quality of life. Then we look at cultural barriers related to the recommended treatment regimen and determine the stage of change for each problem. Remember I said they're not necessarily in the same stage of readiness for change for all their problems and identify external contingencies that might help promote treatment adherence. So, for example, if they're involuntary, an external contingency may be that they have to stay clean for 30 days in order to get off probation. That's a motivating factor for some people. So we need to look at what motivators are out there that we can use to help the person shore up their resolve to keep moving forward. So step one, engage the client. Remember, there's no wrong door. Whoever they see that does the screening is the right person to do the screening. And we want to make sure that they can easily and seamlessly access and get into the system. We need to have empathic detachment and recognize that the clinician and the client are working together. If the client doesn't want to do it, you know, you're kind of fighting against yourself, if you will. It doesn't mean it can't happen. When you are working with a client who's in pre contemplation, a lot of times you've got to find mutually agreeable goals. When I worked with clients that were on probation and parole, they had to go through treatment. They weren't interested in treatment. And okay, you know, I am not going to sit here and try to talk you into it because you're not interested in it right now. But in order for them to get off probation, they had to stay clean for 30 days. That was just how it was. So instead of arguing about whether they needed to be abstinent and go through counseling, we talked about the fact that they wanted off probation. And the only way to do that was to stay clean. So let me help them stay clean for 30 days. Mutually agreeable goal. I didn't tell them they couldn't go back to using after they got off probation. That was, you know, they were adults. That was going to be their choice anyway. But we work towards mutually agreeable goals, recognize that we, the clinicians, cannot transform the client, but we can only support change that he or she is already making or willing to make. So we're not going to be talking and all of a sudden the client says, you're right, I've been doing my whole life wrong. I need to start all over again. No, no, no, no, no. We can help the client move toward the goals that are important to him or her to create the life that they define as rich and meaningful. And we need to maintain empathic connection, even if the client doesn't seem to fit into our expectations. So if you're one of those people who really likes voluntary clients and you get a client who's involuntary and they're just, you know, fighting you tooth and nail the whole way, try to maintain empathic connection. Try to back up instead of approaching it like they want treatment. Back up and go, okay, how do I need to approach this problem a little bit differently? How can I be creative? How can we form mutually agreeable goals? Person centered assessment finds out what the client's perception of the problem is, what he or she wants to change, and how he or she thinks that change will occur. So instead of me going, this is the problem, this is how bad it is. This is what you need to change, and this is how change is going to occur. Because, you know, I'm the expert, I'm going to back up and go, what do you think? How bad do you think your problem is? Okay, what do you think needs to change? What could help you move toward your goal? You know, whatever this mutually agreeable goal is that we have. Engagement involves cultural sensitivity. If you're working with a client that is from an interdependent culture where family believes they should be involved in the treatment process. We need to encourage family to be involved if they believe that there are certain approaches that work better than others. We need to be sensitive to that. Many cultures assign different meanings to mental health and substance use disorders. So we do need to be sensitive to that as well as provide all of these services from a trauma informed approach, Recognizing the assumption that the majority of clients have experienced trauma at some point in their life, and we don't want to re traumatize them, we want to empower them in this process. Assessment considerations. What does the client want? What is the treatment contract? What are the immediate needs of the client, and what are the client's DSM diagnoses? You know, these are questions that we have to ask in order to determine where the client needs to go. You know, maybe intervention, maybe residential. We have to figure out what's going on. We need to identify which assessment dimensions are most severe to determine Treatment priorities. So if the client presents and is suicidal, obviously mental health is going to be the overriding treatment priority. We need to choose a specific priority for each medium or severe dimension. So there could be, you know, severe substance abuse, severe mental health issues, as well as severe physical health issues. I've had clients come into detox who were in really bad shape physically. In addition to mental health, what specific services are needed to address these priorities? Where can these services be provided in the least intensive but safe level of care or site? How will outcomes be measured? And then following up the ongoing assessment is just repeatedly asking when the client comes in, what is the progress of the treatment plan and how is this placement decision working? You know, is it doing what it's supposed to, or can the client step down or does the client need to step up? So, you know, again, you're going to have a laundry list of symptoms or problem issues that may need to be addressed, but you're going to have to prioritize. So you look at the ones that are most severe and from those you identify, you know, two or three treatment goals. Step two is to collect collateral information, including their treatment history. They've been in treatment before, where did they go, what worked, how long did they stay clean, what caused their relapse, what is their criminal history, their legal issues, including child welfare. This will give us an idea about how their mental health or substance use issues may also be impacting their functioning in society. If somebody, for example, has bipolar disorder, when they are in a manic episode, they may, you know, do some risky things and end up acquiring charges. When somebody is using, they may make poor decisions and end up acquiring charges. So we need to be aware. What are the significant other's impressions? If you can get a release to talk with a significant other, what's the person's medical history? We want to look for anything that might be underlying their mood disorders or their compulsive behaviors, which can include hormone disruptions and a variety of other things. So a good physical is really helpful. We need to look at their employment history to see can they get a job that pays enough to keep a roof over their head? If they've been in and out of work, is that because they weren't showing up? Is that because they didn't play nice with others? Is it because they were drunk on the job? Or what was it that caused that sporadic employment history? And what can we do to help them find high wage, high demand employment so they can be financially self sufficient? And what is their recovery environment like? If they are not going to be in residential. We need to know what their life is like the other 6 days and 23 hours that they're not in treatment. Step 3 Screen for CO occurring disorders. All individuals presenting for substance abuse treatment should be screened for co occurring mental health disorders and traumas. All individuals presenting for mental health treatment should be screened routinely for substance use disorders and trauma. So if your clinic is primarily substance abuse, you still need to screen for mental health. All clients should be screened for safety, including suicidal ideation, homicidal ideation, intoxication and withdrawal and their recovery environment. You know, is it safe? Are they living on the streets? Are they in a relationship that's domestically violent? You know, there are some things that we can screen for that might inhibit progress in treatment. The Mini International Neuropsychiatric Interview or the Mini, a simple 15 to 30 minute device that covers 20 mental disorders including substance use disorders. So yes, it's a screening, yes, it does take about 30 minutes, so it's long. But unlike the SASE, which you know, only screens for substance use, this screens for up to 20 mental disorders including substance use. So you're covering a lot more ground. This is a good one to be used in homeless shelters as well as by probation and parole and those sorts of places. All right, step four, Determine the quadrant. When we talk about quadrants, there are four quadrants of treatment. Quadrant one is low substance abuse, low mental health issues. So these people are probably going to function really well in once a week outpatient with the mental health or substance abuse provider of their choice, probably mental health. Quadrant 2 is high mental health issues, low substance abuse. So they may have, you know, significant anxiety or depression or schizophrenia and they're misusing substances. It's not to the point where it's causing the substance abuse is causing significant problems in their life, but it's creeping up there in the problematic use range. Quadrant 3, their mental health issues are pretty low. I mean they've got some use related intoxication or withdrawal, related anxiety or depression or something, or they've got bipolar or schizophrenia. But it is managed pretty well right now and is relatively stable. But their substance abuse is off the charts. So these people are going to go into a primarily a substance abuse treatment program. And then quadrant 4 is high mental health, high substance abuse. These people really need to be in a treatment facility that is co occurring enhanced. It needs to be able to handle both of these at the same time. So you know, they need to be able to have a crisis stabilization unit as well as substance Abuse counselors and mental health counselors on staff. So once you determine what the diagnosis is, once you determine kind of what type of setting the person is going to go to, you know, whether they're going to go to mental health or substance abuse, then you go to determining level of care, and that's whether it's outpatient, intensive, outpatient, residential, or hospitalization. One of the most common ways to do this is through the ASAM PPC2R. That's the American Society of Addiction Medicine Patient Placement criteria, second edition, revised. But with the asam, it's really an awesome tool to use because it's quick and in clinic settings. You really like something that is effective and efficient because, you know, time is of the essence. So you look at six different dimensions. Acute intoxication or withdrawal potential. So you want to look at, not only are they currently intoxicated or at risk of withdrawal, but we want to look at post acute withdrawal potential, especially again, for people who are withdrawing from marijuana or benzodiazepines, but definitely all other drugs too. Protracted withdrawal can last for quite a while. So we do want to pay attention to that. When I had clients that were in detox who were detoxing from benzos, for example, they may come over to residential before they are completely through that post acute withdrawal phase, which could last for up to 30 days because they needed to step down. But their dimension number one, because they were still experiencing protracted withdrawal, identified them as being a good candidate for residential and needing closer supervision than, for example, IOP could provide. Dimension two, we look at biomedical conditions and complications. This includes everything from pain, you know, from a car accident or whatever, to cirrhosis of the liver, to hiv, anything that's medical that might compound what's going on. Diabetes is another one. Dimension number three, and this one's kind of a big one. Emotional, behavioral or cognitive conditions and complications. So that's like, you know, everything else under the sun besides substance abuse. What is their suicide potential and level of lethality as well as their homicide potential and level of lethality. Will their mental health or cognitive issues interfere with addiction recovery efforts? A lot of times clients have difficulty with cognition and or mood issues during that post acute withdrawal period. As their neurotransmitters are stabilizing. Once they sober up, they realize that their life is kind of a mess and they get overwhelmed. So there could be a lot of mental health stuff that may interfere with their addiction recovery efforts. We just need to be aware because we want to put them in the safest place possible. What is their social functioning? Do they have good, sober social supports? What is their ability for self care? You know, can they behaviorally get up, shower, you know, do the basic activities of daily living? Or for example, are they so depressed that they can't get through the basics of the day? And what is the course of their illness? Are their mental health and cognitive conditions stabilized? Are they expected to improve as they get further away from the initial detox period? Or are they expected to worsen, as in the case of Alzheimer's and certain dementias? We need to be aware. Dimension four is the client's readiness to change. If the client is really ready to change, then they're going to be motivated to be treatment compliant and they may do better in intensive outpatient than in residential. Dimension five, we want to look at relapse, continued use, and continued problem potential. Well, if they're not ready to change, then their relapse potential is pretty high, as well as continued use. But we want to look at anything that might contribute to that, such as maybe they've got impending legal charges or they're going through a divorce right now or something else that may be a huge relapse trigger for them. And Dimension 6 is their recovery and living environment. Are they in a safe environment? If they are homeless, if they are living in a house where people are actively shooting up in front of them, if they are in a situation, if they're living by themselves, for example, any of those can be a dangerous living environment for somebody in early recovery. So we do want to find out, is your recovery environment a safe one that promotes your recovery, or does it leave you vulnerable? When we do the asam, we look at all of these things and there's a scoring chart. I mean, you don't just have to wing it and go, well, sounds like the person should be here. You use the scoring chart. And the ASAM chart will recommend whether the person should be in residential, iop, PHP or outpatient. So it makes it easy. That doesn't mean the person's going to choose that. It is important to recognize that clients do have choice. And I've had a lot of clients who've scored out for residential who've said, you know what, that's just not going to fit right now. Either your program doesn't fit my needs, culturally, whatever, or, you know, maybe they had children and animals at home and nobody to take care of them and they wanted to try outpatient. Okay, you know, I, 99% of the time, well, I can't force Anybody to do anything. Sometimes the courts can, but I want to support them in their process. So we may try enrolling them into intensive outpatient. And if they do well, great. You know, no harm, no foul. If they don't do well, then we revisit that and consider stepping them up to residential at a later date. Like the asam, the locus uses multiple dimensions of assessment. ASAM and locus do the same thing. Locus is a much longer instrument, but it gives you a lot more information. So. So whatever your agency chooses to use, locus looks at risk of harm. The client's functional abilities, any comorbidity, including medical, addictive, and psychiatric their recovery support environment and their current stress levels, their motivation or treatment attitude and engagement, and their treatment history. So you get a lot of really good information from the locus as well. And the locus also will recommend what level of intensity of treatment. Step six is to determine diagnosis. Now, I generally do this before I determine intensity, but whatever you know, as far as the assessment goes, step six is determine diagnosis. Diagnosis is established more by history than by current symptom presentation. So how they are in your office today, how they are, and they're probably putting their best foot forward. So we want to look at their history and what's going on. How have they been over the past month or the past three months? It's important to document prior diagnoses and gather information related to the current diagnoses. Even though substance abuse treatment counselors may not be licensed to make mental disorder diagnoses. So if you are a substance abuse counselor and you're doing this assessment, remember, you're screening for mental health issues, and you need to be aware of these things and how they all interact. You cannot make that diagnosis. In some agencies, you may be able to give a provisional, and then a licensed person will review it, interview the client, and then sign off on it. You know, it just kind of depends on your agency. But even if you can't legally make that diagnosis, you do need to be able to screen for it and be aware of it. For diagnostic purposes, it is almost always necessary to tie mental symptoms to specific periods of time in the client's history, in particular, those times when active substance use disorder were not present. So you want to look back and say, was there any period where you were clean for three months or more that you experienced this depression or anxiety? Because we're trying to get an idea about whether there's something else organically or otherwise going on with the client besides the substance use, or whether the substance, the mood issues are A result of substance use intoxication and post acute withdrawal symptoms. It doesn't mean that we don't treat the anxiety or the depression or whatever. Even if it's a post acute withdrawal syndrome symptom, we have to treat it. But how we go about treating it may be different if it's something that's been long standing, especially if it existed before the substance use started. Step seven is determine functional impairment. Is the client capable of living independently? Can they maintain abstinence while living independently? If not, what types of support are needed? Now you can have a case manager. There's what we have called fact teams that go out and provide intensive case management. Instead of having a person in residential, you can have somebody who comes to php, which meets eight hours a day, five to seven days a week. So kind of like a job. Most of their day is spent in treatment, so they have less time to try to maintain sobriety on their own. Can they go to support groups? You know, what can they do? Is the client capable of supporting himself financially? If so, how? Reasonable question. And if not, what resources are needed? Is the person getting ssdi? Does the person have a family member paying their rent? How are they keeping a roof over their head and getting food in their bellies? Can the client engage in reasonable social relationships and do they have good social supports? If not, what interferes with this ability and what supports would the client need? So here again we want to look at interpersonal skills as well as mood disorders and trauma history. What's the client's level of intelligence? Are there developmental or learning disabilities that are causing problems somehow? Are there cognitive or memory impairments that impede learning? Part of counseling and recovery is a learning process, but part of life is a learning process too. And it can be really frustrating for people who are having difficulty with cognitive abilities in the outside world. And they can be taken advantage of, they can have high anxiety, they can feel helpless and hopeless. There's a lot of ways that having some sort of a disability can impact a person or not. And we want to help empower them to be have the highest quality of life that they choose to, as they define it. Do they have difficulties focusing, concentrating and completing tasks? Now, it's important to remember that in post acute withdrawal as well as an acute withdrawal, people are periodically going to have difficulties focusing, concentrating and completing tasks. So we need to adjust treatment to be sensitive to that. But if it goes beyond post acute withdrawal symptoms, then we may need to refer them out, for example, for a neurological assessment. Make sure there's no dementia, Wernicke, Korsakoff syndrome, early onset Alzheimer's, Parkinson's, anything like that. Step 8 Identify strengths and supports. So start out with their talents and interests instead of always going for the negative. Let's find out what are they good at? Because if they're good at something, then we may be able to use that to our advantage. Salespeople, for example. They are the best people in the world at trying to explain away, minimize and justify their addiction. However, if we can get them to use those talents for their benefit in order to succeed at work, for example, then you know, it's a strength. So we need to take their talents and help them use them to move forward. We need to look at areas of educational interest and literacy, vocational skills, social skills, and capacity for creative self expression. We want to look at areas connected with high levels of motivation for change for either disorder. So for example, if they're abusing substances and they also happen to work in a bar, maybe they want to find a different type of employment. So, okay, so this is a strength. If you want to find a different type of employment, let me help you figure out how to do that. Identify existing supportive relationships. Talk about previous mental health services and explore what worked and build on that. If cognitive behavioral worked, build on that. If experiential worked, build on that. Identify current successes. What has the client done right recently in their life, in their relationships to help themselves feel better? One of the things they've done right is show up for their assessment and counseling and build treatment plans and interventions based on utilizing and reinforcing strengths and extending or supporting what has worked previously instead of starting at the beginning. So maybe a client comes in and they went to rational recovery and that worked for them. But you know, your program is primarily 12 step. You know, we really want to build on what's worked for them and figure out how to incorporate if they still want to use that, figure out how to incorporate that into their treatment. Identify cultural and linguistic needs. Specific considerations include asking the client, how are your substance use and mental health problems defined by your parents, your peers, and maybe even other clients? This will help them understand or help us understand their cultural perspective on this issue. What do you think you should be doing to remedy these problems? Again, they're the expert and they have a preference for what the next step is. I mean, they may say, I have no idea and that's totally cool. But they also may say I think I need to and then fill in the blank. How do you decide which suggestions to follow in what Kinds of treatment settings do you feel most comfortable? Not everybody is comfortable in group settings based on culture. Not everybody feels like they're most comfortable and individual based on culture. So we need to talk with them about what settings they might feel most comfortable. I've worked with clients before who didn't feel comfortable in the large 12 step group meetings, but they did great in big book studies and home groups. But the big groups of people, of 30 or 40 people in a room were just completely overwhelming. So we needed to ferret that out and say, okay, so how can you go about using the 12 step program in a way that's meaningful to you? And what do you think that I, the counselor, should be doing to help you improve your situation? So, again, I'm putting the onus on them. I am empowering them to guide their own treatment. They are the navigator. And, you know, I'm just there to provide a little bit of instruction and maybe help them see some shortcuts along the way. Step 10. Identify problem domains, including substance abuse, eating disorders, behavioral addictions, medical issues, mental health issues, interpersonal functioning, legal issues, employment and education issues, and housing and recovery environment. Any of these things can interact to prevent or inhibit recovery in any of the other areas. So it's important to understand how all of these things fold in on one another, which is way past the scope of this particular talk. So you can sort of ferret it out, but you don't miss anything in the assessment. Then determine their stage of change. And there are two different ways you can go about it. The typical one we use is the one posited by Prochaska and Diclemente. Pre contemplation. The person says they have no problem or they have no interest in change. Contemplation. They agree there might be a problem and they might consider change at some point, but probably not right now. Level three is preparation. They're definitely getting ready to change. They're looking at the different treatment options that are out there and trying to get all their ducks in a row so they can start on this journey. Stage four is action, where they're actively working on changing, even if slowly. And stage five is maintenance. They've gone through the action phase and they're at a plateau right now, and they just need to hold their own. The other one you can use is called the Substance Abuse Treatment Scale. And you can use this with mental health issues, too. Both of these pre engagement. You know, the person's not even engaged in treatment engagement. Generally that's during the screening. Early persuasion, maybe Screening, maybe assessment period, late persuasion, getting the person motivated. They're thinking about enrolling in treatment. Early active treatment is when they arrive for that first appointment and they're starting to do the next right thing in terms of their recovery. Late active treatment, they've been involved in treatment for a while and they're starting to get their rhythm and get some momentum and see some changes. At some point during late active treatment, they're going to be discharged and you need to look at developing a relapse prevention plan and helping them stay in remission, which is akin to maintenance. And finally, step 12. You've identified their problem issues, you've identified their diagnosis, you've figured out what level of treatment works for them. You've identified cultural and linguistic needs, you've identified their motivation for each problem and figured out which ones you're going to focus on. Now it's time to plan the treatment program. Placements and treatment interventions should be matched individually to the needs of each client. Each disorder or problem has a specific intervention that's matched to a problem or diagnosis as well as the stage of change and external contingencies. So for each, you don't want to say the client will go to self esteem groups. Why you need to tie these interventions if you're going to have them go to self esteem group, you need to tie that back to a problem issue or a goal statement so we know why they're going. What do you hope the client is going to get out of the self esteem group that is going to move them towards their goals. So you need to tie things together, determine areas of prior success around which to organize future treatment interventions. So if they're doing really well in managing their substance use, for example, we want to organize future treatment interventions around that and keep their motivation going in that area. And then we want to look and say, okay, what's worked over here? Maybe cognitive behavioral is working really well over here for substances, maybe we could use it a little bit differently but for the mental health issues. But we do need to figure out kind of what works for this client and see if we can use that to help them address other issues as well and determine areas of skills building needed for disease management of either disorder. So if they need help with emotional dysregulation, if they need help with distress tolerance or coping skills or problem solving, you know, those are cross cutting issues. So we can identify what kind of skills they might need and make sure that they have access to those either through individual or group treatment or self help activities. So screening identifies a potential problem. Assessment determines the nature and severity of problems. There are 12 essential steps in the assessment process that you need to be aware of. Both screening and assessment services need to be culturally responsive. Check out SAMHSA Tip 59 remember, you go to store.samhsa.gov and look for Tip 59 and your services need to be trauma informed. And to learn more about that, go to SAMHSA Tip 57 for more information on the stuff that we talked about a little bit more in depth. You can go to our Assessment Playlist, our Multicultural Playlist, or or our Trauma Informed care playlist on allce.com YouTube that's our YouTube channel. You can also go to Addiction Counselor Exam Review podcast, especially episodes 3, 4 and 5 which cover screening and assessment. To earn CEUs for this presentation, go to allce.com podcastceus where you can find a direct link to the class associated with this presentation. Thanks and have a great day. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. If you want to attend and participate in our live webinars with Dr. Snipes, you can subscribe at. 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