Transcript COD Module II - Spokane County

Module II
Introduction to Screening and Assessment
of Persons with Co-Occurring Disorders:
Screening and Assessment, Step 1 and
Step 2
Module II Objectives
• The importance of screening across
disciplines
• Use of the GAIN-SS for screening
• The importance of the “engagement” in
performing a good assessment
• Review Step 1: Engage the patient
• Review Step 2: Identify and contact
collaterals to gather information
Review of Module I
• Reactions, questions or comments from
the readiness to change and motivational
survey answers from Module I
• Reactions, questions or comments from
Module I
Review of Assignments
• Reactions, questions from TIP 42 reading
• Reactions to GAIN-SS and Perceptions of
Global Appraisal of Individual Needs –
Short Screener (GAIN-SS): A Pilot Study
COD Screening & Assessment
To what extent do you currently provide
COD Screening and Assessment and
what instruments are you currently
utilizing?
Instrument Criteria
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The screening instrument is sensitive.
The screening instrument is brief.
The screening instrument is low or no cost.
The screening instrument can be administered
and scored with little training.
The screening instrument is applicable to a
diverse range of people.
The screening instrument includes a question
about suicide.
GAIN-SS
• Twenty-item instrument that screens for
internalizing disorders, externalizing
disorders, substance use disorders, and
behaviors related to crime and violence
• Take 3 to 5 minutes to administer
• Meant to determine whether a mental, cooccurring, or chemical dependency
assessment is needed
GAIN-SS 4 Subscales
• Internal Disorder Screener (IDScr)
was designed to identify people experiencing
internalizing disorders such as depression, anxiety,
suicidal ideation, and acute/post traumatic stress
disorders
• External Disorder Screener (EDScr)
designed to identify persons experiencing externalizing
disorders such as attention deficit, hyperactivity,
conduct disorder, aggression/violence and other
externalizing behavioral problems
GAIN-SS 4 Subscales
• Substance Disorder Screener (SDScr)
designed to identify persons abusing or
dependent upon alcohol or other drugs
• The Crime and Violence Screener
is comprised of five items used to identify
persons exhibiting criminal and violent
behavior.
GAIN-SS Scoring
• If a person receives a score of 2 or more
on any of the GAIN-SS subscales, then
that person should be referred or
provided either a full mental, chemical
dependency, or co-occurring disorder
assessment.
TIP Exercise–Screening Instruments
Option 1: Role Play & Discussion
With your partner, take turns administering
The GAIN-SS
You have 10 minutes total!
Pay attention to
• While in the role of the clinician what it
feels like to ask the questions.
• While in the role of the client what it feels
like to answer the questions.
Screening Protocol
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A professionally designed screening process or
protocol establishes precisely . . .
– how any screening tools or questions are scored
– what constitutes scoring positive for a particular
possible problem (“establishing cut-off scores”)
– what happens if a client scores in the positive range
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and provides the standard forms to document
1) results of all later assessments
2) that each staff member has carried out his or her
responsibilities in the process
Screening+Assessment Tx Plan
Screening is a process for evaluating the possible
presence of a particular problem.
Assessment is a process for defining the nature of
that problem and developing specific treatment
recommendations for addressing the problem.
A comprehensive assessment serves as the basis
for an individualized treatment plan. The
treatment plan must be matched to individual
needs.
Introduction to Cases
• Turn to page 69 in TIP 42 for
Maria’s case
Case 1: Maria M.
The client is a 38-year-old Hispanic/Latina woman
who is the mother of two teenagers. Maria M.
presents with an 11-year history of cocaine
dependence, a 2-year history of opioid
dependence, and a history of trauma related to a
longstanding abusive relationship (now over for 6
years). She is not in an intimate relationship at
present and there is no current indication that she
is at risk for either violence or self-harm. She also
has persistent major depression and panic treated
with antidepressants. She is very motivated to
receive treatment.
What would you recommend?
The TIP Consensus Panel recommended
An integrated treatment plan that might include;
• Medication-assisted treatment (e.g., methadone or
buprenorphine), continued antidepressant
medication, 12-Step program attendance, and
other recovery group support for cocaine
dependence
• Referral to a group for trauma survivors that is
designed specifically to help reduce symptoms of
trauma and resolve long-term issues.
• Individual, group, and family interventions
could be coordinated by the primary
counselor from opioid maintenance
treatment.
– The focus of these interventions might be on
relapse prevention skills, taking medication as
prescribed, and identifying and managing
trauma-related symptoms without using.
• An appropriate long-term goal would be to
establish abstinence and engage Maria in
longer-term psychotherapeutic interventions
to reduce trauma symptoms and help
resolve trauma issues.
– If a local mental health center had a psychiatrist
trained and licensed to provide Suboxone (the
combination of buprenorphine and nalaxone),
her case could be based in the mental health
center.
Questions
• Does this plan address all Maria’s areas of
need?
• If all of these interventions are not available
within your community, what might you do
to modify your services to meet her needs?
12 Step Assessment Process
• Please turn to page 71 in TIP 42
• The purpose of the assessment process is to
develop a method for gathering information
in an organized manner that allows the
clinician to develop an appropriate
treatment plan or recommendation.
12 Step Assessment Process
1: Engage the client
2: Identify & contact
collaterals to gather
additional information
7: Determine disability &
functional impairment
8: Identify strengths &
supports
3: Screen for & detect
COD
9: Identify cultural & linguistic
needs & supports
4: Determine quadrant &
locus of responsibility
10: Identify problem domains
5: Determine level of care
6: Determine diagnosis
11: Determine stage of change
12: Plan treatment
Major aims of the assessment
process are
• To obtain a more detailed chronological
history of past mental symptoms, diagnosis,
treatment, and impairment, particularly
before the onset of substance abuse, and
during periods of extended abstinence.
• To obtain a more detailed description of
current strengths, supports, limitations, skill
deficits, and cultural barriers related to
following the recommended treatment
regimen for any disorder or problem.
• To determine stage of change for each
problem, and identify external
contingencies that might help to promote
treatment adherence.
Step 1: Engage the Client
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No “wrong door”
Empathic detachment
Person-centered assessment
Sensitivity to culture, gender, and sexual
orientation
• Trauma sensitivity
Universal access – No wrong door
• Individuals with COD may enter a range of
community service sites and that proactive efforts
are necessary to welcome them into treatment and
prevent them from falling through the cracks.
• The purpose of this assessment is not just to
determine whether the client fits in my program,
but to help the client figure out where he or she
fits in the system of care, and to help him or her
get there.
Empathic detachment
• Requires the assessing clinician to
acknowledge that the clinician and client
are working together to make decisions to
support the client’s best interest.
• Clinicians should be prepared to respond to
the requirements of clients with COD
Person-centered assessment
• Emphasizes that the focus of initial contact is not
on filling out a form or answering several
questions or on establishing program fit.
• The focus of initial contact is on finding out what
the client wants, in terms of his or her perception
of the problem, what he or she wants to change,
and how he or she thinks that change will occur.
Sensitivity to culture, gender, and
sexual orientation
• Culture plays a significant role in
determining the client’s view of the problem
and the treatment.
• Cultural sensitivity also requires recognition
of one’s own cultural perspective and a
genuine spirit of inquiry into how cultural
factors influence the client’s request for
help.
• During the assessment process, it is
important to ascertain the individual’s
sexual orientation as part of the counselor’s
appreciation for the client’s personal
identity, living situation, and relationships
Trauma sensitivity
• The high prevalence of trauma in
individuals with COD requires that the
clinician consider the possibility of a trauma
history even before the assessment begins.
Step 2: Identify & Contact Collaterals
• Clients may be unable or unwilling to report
past or present circumstances accurately.
• It is recommended that all assessments
include routine procedures for identifying
and contacting any family and other
collaterals who may have useful
information.
• Client resistance to gathering this collateral
information is a clinical issue and needs to
be addressed motivationally as you would
any other form of client resistance.
• Although gathering collateral information
has been designated as Step 2, information
from collaterals is valuable as a supplement
to the client’s own report in all of the
assessment steps we will discuss.
Steps in the assessment
process are not always
sequential and may occur in
different order.
Assignments
• Review the text box on page 67— Advice to
the Counselor: Do’s and Don’ts of
Assessment for COD.
• Continue reading TIP 42 Chapter 4