The Importance of Co-occurring Screening & Assessment in All Settings

1. The Importance of Co-occurring Screening & Assessment in All Settings Presented By Jill Perry, MS, NCC, LPC, CAADC, SAP January 25, 2019 JP CounselingHealing for Adults, Youth and Families

2. What does COD Look Like? JP CounselingHealing for Adults, Youth and Families

3. What does COD Look Like? JP Counseling & Associates, LLCHealing for Adults, Youth and Families

4. What does COD Look Like? JP Counseling & Associates, LLCHealing for Adults, Youth and Families

5. What does COD Look Like? JP Counseling & Associates, LLCHealing for Adults, Youth and Families

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8. Stigma JP Counseling & Associates, LLCHealing for Adults, Youth and Families

9. Stigma • Where does it come from? • Labels that follow people through their life • Labels that can limit a person’s identity • HOW DO WE CONTRIBUTE? JP Counseling & Associates, LLCHealing for Adults, Youth and Families

10. 5 Rules to Eliminate Stigma • 1) Don’t label people who have a mental illness or addiction • 2) Don’t be afraid of people with mental illness or addiction • 3) Don’t use disrespectful terms for people with mental illness or addiction • 4) Don’t be insensitive or blame people with mental illness or addiction • 5) Be a role model JP Counseling & Associates, LLCHealing for Adults, Youth and Families

11. SAMHSA

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13. Statistics of Co-occurring Disorder • Over the last 6 years, the percentage of people in drug rehab who were treated for substance issue, but were also diagnosed with co-occurring mental health disorder increased significantly JP Counseling & Associates, LLCHealing for Adults, Youth and Families

14. Statistics of Co-occurring Disorder • When it comes to genders, employed men were twice as likely as employed women to have struggled with substance abuse in the past year (13.2% for men, and only 6.9% for women). • However, employed women were twice as likely to have dealt with serious mental issues in the past year as employed men (14.2% for women, and 7.3% for men). JP Counseling & Associates, LLCHealing for Adults, Youth and Families

15. Statistics of Co-occurring Disorder • More than 50% of people diagnosed with co-occurring disorder did not receive any medical treatment • Out of the 3 million adults who are employed and diagnosed with co-occurring disorder, only 40% received a treatment for either of their disorders • Less than 5% received treatment for both disorders. JP Counseling & Associates, LLCHealing for Adults, Youth and Families

16. Multiple Co-occurring Problems Are the Norm and Increase with Level of Care Source: CSAT & Cannabis Youth Treatment (CYT), Adolescent Treatment Model(ATM), and Persistent Effects of Treatment Study of Adolescents (PETS-A) Studies JP CounselingHealing for Adults, Youth and Families

17. In the past, the attitude was that the client with COD was the exception. Today, clinicians should be prepared to demonstrate responsiveness to the requirements clients with COD present. JP CounselingHealing for Adults, Youth and Families

20. Most Common Drugs of Abuse • Alcohol • Marijuana • Opioids (prescription pain pills, heroin, Fentanyl) • Benzodiazepines (Xanax, Valium) • Cocaine Other Drugs of Abuse Include: • Amphetamines • Methamphetamine • Inhalants • Club Drugs (X) JP CounselingHealing for Adults, Youth and Families

22. Other Psychiatric Disorders • Personality Disorders (Borderline, Narcissistic) • Post-Traumatic Stress Disorder • Psychotic Disorders • Eating Disorders JP CounselingHealing for Adults, Youth and Families

23. Screening & Assessment for ALL Disorders is Necessary Because... • Having one disorder increases the risk of developing another disorder; • The presence of a second disorder makes treatment of the first more complicated; • Treating one disorder does NOT lead to effective management of the other(s); • Treatment outcomes are poorer when co-occurring disorders are present. JP CounselingHealing for Adults, Youth and Families

24. Know Your Limitations…. • Counselors should understand the limitations of their licensure or certification authority to diagnose or assess mental disorders. Generally, however, collecting screening & assessment information is a legitimate and legal activity even for unlicensed providers, provided that they do not use diagnostic labels as conclusions or opinions about the client JP CounselingHealing for Adults, Youth and Families

25. Know Your Limitations…. There are a number of circumstances that can affect validity and test responses that may not be obvious to the beginning counselor: • The manner in which instructions are given to the client • The setting where the screening or assessment takes place • Privacy (or the lack thereof) • Trust and rapport between the client and counselor JP CounselingHealing for Adults, Youth and Families

26. Basic or Comprehensive Screening & Assessment Must Address: • Medical issues (including physical disability and sexually transmitted diseases) • Cultural issues • Gender-specific issues • Sexual orientation issues • Legal issues JP CounselingHealing for Adults, Youth and Families

27. Screening • Screening is a formal process of testing to determine whether a client does or does not warrant further attention at the current time in regard to a particular disorder and, in this context, the possibility of a co-occurring substance use or mental disorder. The screening process for COD seeks to answer a “yes” or “no” question: Does the substance abuse (or mental health) client being screened show signs of a possible mental health (or substance abuse) problem? Note that the screening process does not necessarily identify what kind of problem the person might have or how serious it might be, but determines whether or not further assessment is warranted. JP CounselingHealing for Adults, Youth and Families

28. Screening Protocol Screening processes always should define a protocol for: • Determining which clients screen positive • Screening Tool • Cut-off Scores • Ensuring that those clients receive a thorough assessment • Who Performs the Assessment • Documentation JP CounselingHealing for Adults, Youth and Families

32. Parasuicide or Self-harm • Expressed in a less extreme form • Self cutting • Self burning • Self mutilation JP CounselingHealing for Adults, Youth and Families

33. Key  Issues  and  Concerns • All    clients  should receive  at  least  a  basic  screening  for  suicidality.  All  treatment  professionals  should  know how  to  conduct  at  least  basic screening  and  triage. Questions could include: “In the past, have you ever been suicidal or made a suicide attempt? Do you have any of those feelings now?” • The  counselor  should  know  his  or  her  own skills  and  limitations  in  engaging,  screening, assessing,  and  intervening  with  suicidal clients.  Work  out  these  issues  before an  emergency. • Providers  are  advised  to  develop  clear answers  to  the  following  questions:  • Do  you  or your  agency  have  the  knowledge,  tools,  skills, and  personnel  for  crisis  stabilization  and/or ongoing  work  with  suicidal  clients?  • How  suicidal  can  clients  be  and  still  be  retained  in your  practice  or  agency?  • What  about  suicidality  that  emerges  later  in  treatment  or  in conjunction  with  a  relapse? JP CounselingHealing for Adults, Youth and Families

34. Key Issues and Concerns • The  counselor  should  know  what  immediate onsite  and  offsite  resources  are  available  to help  with  someone  identified  as  suicidal. • Establish  standardized  protocols  and  staff training  around  suicide  screening,  assessment,  intervention,  and/or  triage:    • Who asks?  • What  is  asked?  • When  is  this done? • When does this take place? • How is this documented? • What is done with the results? JP CounselingHealing for Adults, Youth and Families

35. Key Issues and Concerns • Suicide “contracts” are written statements in which the person who is suicidal states that he will not kill himself, but rather call for help, go to an emergency room if he becomes suicidal. These contracts are not effective as the sole intervention for a client who is suicidal. While such contracts often help to make the client and therapist less anxious about a suicidal condition, studies have never shown these contracts to be effective at preventing suicide. What good contracts really do is help to focus on the key elements that are most likely to keep clients safe, such as agreeing to remove the means a client is most likely to use to commit suicide. JP CounselingHealing for Adults, Youth and Families

38. Addiction Severity Index (ASI) • General intake screening tool • Effectively assesses a client’s status in several areas • Composite score measures how a client’s need for treatment changes over time • Designed for adults of both sexes who are not intoxicated when interviewed  • Structured interview takes between 50 minutes to 1 hour • Scoring time takes about 5 minutes for severity rating  • Computer scoring is available • A self ­training packet is available as well as onsite training by experienced trainers • No cost; minimal charges for photocopying and mailing may apply • Available in Spanish • Available from: A. Thomas McLellan, Ph.D.  Building 7 PVAMC  University Avenue  Philadelphia, PA 19104  Phone: (800) 238­2433 JP CounselingHealing for Adults, Youth and Families

39. Alcohol Use Disorders Identification Test (AUDIT) • Identifies persons whose alcohol consumption has become hazardous or harmful to their health. • Linked to a decision process that includes brief intervention with heavy drinkers or referral to specialized treatment for patients who show evidence of more serious alcohol involvement. • Adults, particularly primary care, emergency room, surgery, and psychiatric patients; DWI offenders; criminals in court, jail, and prison; enlisted men in the armed forces; and workers in employee assistance programs and industrial settings. • 10 ­item screening questionnaire • Administration time: 2 minutes • Scoring time: 1 minute • No computer scoring • Training is required for administration. A detailed user’s manual and a videotape training module explain proper administration, procedures, scoring, interpretation, and clinical management. • No fee for use • Available at www.Drugabuse.gov JP CounselingHealing for Adults, Youth and Families

40. CAGE Questionnaire • Detects alcoholism • Popular in nursing, primary health agencies • Adults and adolescents (over 16 years) • Very brief, relatively non-confrontational questionnaire  • Takes less than 1 minute    • Instantaneous Scoring time • No computer scoring • No training required for administration • Easy to learn, easy to remember, and easy to replicate  • No fee for use JP CounselingHealing for Adults, Youth and Families

42. Drug Abuse Screening Test (DAST) • Provides a brief, simple, practical, but valid method for identifying individuals who are abusing psychoactive drugs • Yields a quantitative index score of the degree of problems related to drug use and misuse • Individuals with at least a sixth­ grade reading level • 20 ­item instrument that may be given in either a self ­report or a structured interview format • Takes 5 minutes  • Reading and adherence to the instructions required • Nominal cost • Available from: Centre for Addiction and  Mental Health Marketing and Sales Services 33 Russell Street Toronto, Ontario, Canada M5S 2Sl  Phone: (800) 661­1111 (Continental North America) International and Toronto area: (416) 595­6059 JP CounselingHealing for Adults, Youth and Families

43. Michigan Alcoholism Screening Test (MAST) • Screens for alcoholism with a variety of populations • 25­ item questionnaire designed to provide a rapid and effective screen for lifetime alcohol ­related problems and alcoholism • Adults   • 10 minutes to administer • 5 minutes to score • No computer scoring • No training required. • Fee f • Available from: Melvin L. Selzer, M.D. 6967 Paseo Laredo La Jolla, CA 92037­6425 JP CounselingHealing for Adults, Youth and Families

44. Mental Health Screening Form­ III (MHSF­III) • Screening device for those seeking to enter Substance Use Treatment • Questions reflect the respondent’s entire life history • Schizophrenia; Depressive D/Os; PTSD; Phobias; Intermittent Explosive D/O; Delusional D/O; Sexual & Gender Identity D/Os; Eating D/Os; Manic Episode; Panic D/O; Obsessive Compulsive D/O; Pathological Gambling; Learning D/O & Mental Retardation • Preferred method of administration is verbally by staff • No fees • Available at www.samhsa.gov JP CounselingHealing for Adults, Youth and Families

45. Simple Screening Instrument for Substance Abuse (SSI-SA) • Previously called Simple Screening Instrument for Outreach for Alcohol & Other Drug Abuse (SSI) or Simple Screening Instrument for AOD (SSI-AOD); • No fee • 16 questions • Administered by interview of self-report • Available at www.samhsa.gov JP CounselingHealing for Adults, Youth and Families

46. Assessment JP CounselingHealing for Adults, Youth and Families

48. Assessment is a process for defining the nature of the problem(s) and developing specific treatment recommendations for addressing the problem(s). JP CounselingHealing for Adults, Youth and Families

49. Purposes of Basic Assessment • Provides key information for treatment matching & treatment planning • Offers a structure to obtain the following: • Basic Demographic & historical information • Identification of established or probable diagnosis and associated impairments • General strengths & problem areas • Stage of change for both SU & MH • Preliminary determination of the severity of COD as a guide to final level of care determination JP CounselingHealing for Adults, Youth and Families

50. Purposes of Basic Assessment • Background—family, trauma history, history of domestic violence (either as a batterer or as a battered person), marital status, legal involvement and financial situation, health, education, housing status, strengths and resources, and employment • Substance use—age of first use, primary drugs used (including alcohol, patterns of drug use, and treatment episodes), and family history of substance use problems • Mental health problems—family history of mental health problems, client history of mental health problems including diagnosis, hospitalization and other treatment, current symptoms and mental status, medications, and medication adherence JP CounselingHealing for Adults, Youth and Families