Comprehensive Clinical Evaluation in Substance Abuse Treatment

1. Substance Abuse Treatment 2014 Clinical Service Delivery Using the Practice Dimensions Michael W. Herring

2. Screening (TAP 21 – Pg 37) • Process for determining appropriateness and eligibility for admission to program. • DSM-IV-TR criteria for Abuse and Dependency, no matter what the substance, it’s the same. Not assessing for treatment plan, just enough for determining appropriateness/eligibility. Ask questions in a different format, not just reading off list. Clinical Evaluation

3. Abuse 1 or more of the following within a 12-month period 1). Failure to fulfill major role obligations (ever quit job) 2). Recurrent use in situations that are hazardous (Drive/Wk) 3). Recurrent legal problems (DWI, Public Drunk, shoplift) 4). Continued use despite knowledge of problems Clinical Evaluation

4. Dependency 3 or more of the following occurring at the same time in the same 12 month period. 1). Tolerance 2). Withdrawal 3). Substance taken in larger amounts or over longer period of time than was intended 4). Desire or efforts to cut down or control use 5). Great deal of time getting, using or recovering from effects 6). Important activity given up or reduced due to use 7). Use despite knowledge of a problem Clinical Evaluation

5. In evaluating signs/symptoms of use/abuse/dependency be familiar with: • Psychological: Mental status, oriented x4 (person, place, time, and situation), aggressive behavior, arrested emotional development, cognitive clouding, inappropriate affective responses (crying when happy, laughing when sad). *Be careful of diagnosing Bi-Polar* -always remember Substance-Induced, Mood Disorders, Dementia, Delirium, etc. Paranoia, excessive suspiciousness, suicidal/homicidal ideation, etc. • Social: Listen for - # of friends, alienated, ostracized, withdrawn, lonely/alone. Short social hx – recreation activity, vocational hx. How do friends and family feel about use? Prostitution, promiscuity, poor judgment/problem solving skills. Legal problems, financial problems. • Physiological: Liver problems, wt loss, recurrent medical problems, stomach, pancreas, and internal organ problems. Substance-Induced medical problems. Hx of malingering. Clinical Evaluation

6. In looking for appropriateness and eligibility remember: Appropriate: Suitable; fitting Eligible: Qualified; worthy of choice • Appropriateness: determined by being suitable for environment and modality (in-patient, out-pt), residential/non-residential chemotherapy (methadone, detox), daycare (DRC, JDRC, out-pt detox, and intensive out-pt). Physical condition of client, psych functioning (level of articulation, ed level, disability), outside supports, resources, previous tx hx, motivation and philosophy of program. • Eligibilityof client determined by focus (harm reduction, re/habilitation), target population (males, females, adolescents, gays, etc), funding requirements (only county/state residents). Other eligibility requirements include age, legal status, veteran status, income level, and referral source. Clinical Evaluation

7. The procedures by which a counselor/program evaluate an individual’s strengths, problems and needs for the development of a Tx Plan. • A continuing procedure in which the counselor IDs and evaluates the client’s strengths, weaknesses, problems and needs in order to asst in the development of a tx plan. This process is used to evaluate major life areas (i.e. physical health and functioning, vocational development, social adaptation, and legal involvement). Also to assess the extent to which alc/drugs has interfered with the client’s functioning in each of these areas. • The result of this assessment should suggest the focus of tx!! Clinical Evaluation

8. Always use appropriate interview techniques – closed and open- ended questioning, “miracle” questioning, summarizing, clarification. Specific facts from hx are important. Once info is gained, counselor will use this info to assess [job loss, married 4x (relational diff), no recreational activity (avocation deficiency), few friends (no supports), meets DSM criteria (social obligations, multiple DWI’s)]. • Focus should be on how this relates to alco/drug use of client. • This leads to the development of diagnostic evaluation of results of assessment. Usually including a DSM-IV five axes Dx: I: Clinical Disorders; Other Conditions That May be a Focus of Clinical Attention II: Personality Disorders; Mental Retardation III: General Medical Conditions IV: Psychosocial and Environmental Conditions V: Global Assessment of Functioning Clinical Evaluation

9. Process in that the counselor and client ID and rank problems, establish agreed upon immediate and long-term goals, and decide upon a tx process and resources to be utilized. • This is a tx contract, based on the results of the assessment and is the product of a negotiation b/t client and counselor. The language of the problems, goals and strategy statements should always be specific, intelligible to the client and expressed in behavioral terms. The statement of the problem precisely elaborates on a client need ID’ed previously. Treatment Planning

10. The goal statements refer specifically to the ID’ed problem and may need 1 objective or a set of objectives intended to resolve or mitigate the problem. Behavioral terms are used in the goals in order for the client and counselor to determine progress in tx. • The intervention or strategy is a specific activity used to link the problem with the goal. It describes the services, who is responsible, when to be provided, and at what frequency. • Tx plans are dynamic and regularly reviewed and modified PRN. Treatment Planning

11. SMART Goals: S: Specific M: Measureable A: Attainable R: Realistic T: Time-Limited Treatment Planning

12. The results of the assessment are usually explained to the client. Dx’s should be communicated tactfully. • Problems should be ID’ed and ranked in order of priority. The client should be part of this process, all the way through. The Person-Centered approach should always be utilized. Treatment Planning

13. After problems are ID’ed and ranked, then both set out to formulate immediate (in tx) and long-term goals (post tx). Always use behavioral terms (Decrease drug use impulsively by 75%, increase refusal skills by 75%; decrease instances of cursing by 75%, increase instances of affirming by 50%, etc ). Treatment Planning

14. Always identify methods and resources used to assist the client (per their individual needs), so that they may accomplish goals. • Any resources should be id’ed– which planned interventions (group, individual), lectures, equipment, books, videos, telephone, TV, etc). Treatment Planning

15. This is identifying the needs of the client that cannot be met by the counselor/agency and assisting the client to utilize the supports and community resources available. • The counselor should be aware of the community resources, both AOD and others and be aware of the limitations of each service and if these limitations could adversely affect the client. He/she should also be able to demonstrate a working knowledge of the referral process, including confidentiality requirements and tracking outcomes of the referral. Referral

16. The counselor must be aware of the community resources, both AOD and others and be aware of the limitations of each service and if these limitations could adversely affect the client. He/she also be able to demonstrate a working knowledge of the referral process, including confidentiality requires and outcomes of the referral. Referral

17. This is closely related to case management when integrated into the tx plan. It also includes aftercare or discharge planning referrals that take into account the continuum of care. Referral

18. A licensed/certified professional serving as a clinical supervisor shall: 1. Be aware of his or her influential position with respect to students, employees and supervisees and therefore not exploit the trust and dependency of such persons. 2. Avoid dual relationships which could impair professional judgment, increase the risk of exploitation, or potentially cause harm to the supervisee. To implement this standard the supervisee shall not: Ethics: Supervisor to Supervisee

19. a). Instruct or supervise family members who are related by blood to the second degree or marriage or a member of the supervisor’s household as students or supervisees (related by marriage means related to spouse, brother-in-law, mother and father-in-law); b). Provide therapy or therapeutic counseling to students, employees or supervisees; or c). Solicit or engage in sexual activity or contact with students or supervisees during the period of supervision. Ethics: Supervisor to Supervisee

20. 3. Be trained in and knowledgeable about supervision methods and techniques. 4. Shall supervise and consult only in his or her knowledge training and competency. 5. Guide his or her supervisee to perform services responsibly competently, and ethically. The supervisor shall assign to his or her employees, supervisees and students only those tasks or duties that these individuals can be expected to perform competently, based on the supervisee’s education, experience or training, either independently or with the level of supervision being provided. Ethics: Supervisor to Supervisee

21. 6. Not disclose the confidential information provided by the supervisee except: a). As mandated by law; b). To prevent harm to a client, an organization, or other persons involved with the supervision; c). Where the supervisee is the respondent or defendant in a civil, criminal, or disciplinary action; d). In educational or training sessions where there are multiple supervisors, and then only to the other professional colleagues who share responsibility for the performance or training of the supervisee; or e). If consent is obtained in writing, and that such information shall be revealed only: i). In accordance with the terms of the consent; and ii). After being clear to the supervisee regarding the limits to confidentiality within the supervisory relationship, and pursuant to 21 NCAC 68 .0508 of the North Carolina Administrative Code. Ethics: Supervisor to Supervisee

22. 7.Establish and facilitate a process for providing evaluation of performance and feedback to supervisee. To implement this process the supervisee shall be informed of the timing of evaluations, methods, and levels of competency expected. 8.Not endorse students or supervisees for certification, licensure, employment, or completion of an academic training program if they believe the supervisees are not qualified for the endorsement to become qualified. 9. Make financial arrangements for any remuneration with supervisees and organizations only if these arrangements are clear and in writing. All fees shall be disclosed to the supervisee prior to the beginning of supervision, if practical. Ethics: Supervisor to Supervisee

23. Questions & Attempted Answers Substance Abuse Treatment 2009