Module IV Introduction to Screening and Assessment of Persons with Co- Occurring Disorders: Screening and Assessment, Step 8 though Step 12 and Case Study review.

Module IV Objectives Introduction to “Considerations in Treatment Matching” Grid Introduction to “Considerations in Treatment Matching” Grid Review Step 8: Identify Strengths and Supports Review Step 8: Identify Strengths and Supports  Review Step 9: Identify Cultural and Linguistic Needs and Supports  Review Step 10: Identify Problem Domains  Review Step 11: Determine Stage of Change  Review Step 12: Plan Treatment Case Studies Case Studies

Review of Module III Reactions, questions or comments from the readiness to change and motivational survey answers from Module III Reactions, questions or comments from the readiness to change and motivational survey answers from Module III Reactions, questions or comments from Module I Reactions, questions or comments from Module I

Considerations in Treatment Matching grid p. 97 It answers three (3) questions It answers three (3) questions “What do I need to consider?” “What do I need to consider?” “What will that information help me decide?” “What will that information help me decide?” “What specific data do I need?” “What specific data do I need?”

Acute Safety Needs and Steps 1 through Step 3 What do I need to consider? What do I need to consider? What will the information help me decide? What will the information help me decide? –Determines if there is a need for immediate acute stabilization to establish safety prior to routine assessment.

What specific data in this area do I need? What specific data in this area do I need? –Key data needed includes: Immediate risk of harm to self and others Immediate risk of harm to self and others Immediate risk of physical harm or abuse from others Immediate risk of physical harm or abuse from others Inability to provide for basic self-care Inability to provide for basic self-care Medically dangerous intoxication or withdrawal Medically dangerous intoxication or withdrawal Potentially lethal medical condition Potentially lethal medical condition Acute severe mental symptoms Acute severe mental symptoms

Think back to our previous assessment steps. How would we get that data? Engage the client, gather information from collateral sources, screen the client. In other words, Steps 1-3. Engage the client, gather information from collateral sources, screen the client. In other words, Steps 1-3.

Quadrant Assignment What will the information help me decide? What will the information help me decide? –The most appropriate setting for treatment. What specific data in this area do I need? What specific data in this area do I need? –Key data would include whether the client’s mental illness is severe and persistent, moderate or mild. Also is the substance use disorder high severity or lower severity or in remission? Information related to quadrant assignment was discussed in Step 4.

Level of Care What will level of care help me decide? What will level of care help me decide? –The client’s program assignment. What specific data do I need? What specific data do I need? –Dimensions of assessment of each disorder using criteria such as the ASAM PP-2R or the LOCUS. This process was discussed in Step 5 and in Chapter 2.

Diagnosis This information will allow us to select treatment interventions best suited to the individual client. Much of the specific information needed here was discussed last session for Step 6. This information will allow us to select treatment interventions best suited to the individual client. Much of the specific information needed here was discussed last session for Step 6.

Disability This helps us decide if the client has cognitive, functional or skill deficits that may require an “enhanced” level of case management. This helps us decide if the client has cognitive, functional or skill deficits that may require an “enhanced” level of case management. Are there deficits that would impede standard treatment or require modifications? Are there deficits that would impede standard treatment or require modifications?

Strengths and Skills, Availability and Continuity of Recovery Support This will help us organize future treatment around the client’s prior successes and interests. This will help us organize future treatment around the client’s prior successes and interests. Will help us determine what personal and treatment related relationships are already available. Will help us determine what personal and treatment related relationships are already available. Will also help determine whether new relationships need to be established and what those relationships may be. Will also help determine whether new relationships need to be established and what those relationships may be.

Cultural Context Cultural Context Problem Domains Problem Domains Phase of Recovery/Stage of Change (for each problem) Phase of Recovery/Stage of Change (for each problem)

Step 8: Identify Strengths and Supports Attention to the strengths and supports often provides a more positive approach to treatment engagement than does focusing exclusively on deficits that need to be corrected. Attention to the strengths and supports often provides a more positive approach to treatment engagement than does focusing exclusively on deficits that need to be corrected. How do we identify a client’s strengths and supports? (p. 91) How do we identify a client’s strengths and supports? (p. 91)

Application to Case Examples

How do you typically assess for client strengths and supports? How do you typically assess for client strengths and supports? Do you think you put these to maximum use in the treatment process? Do you think you put these to maximum use in the treatment process? Can you give an example? Can you give an example?

Step 9: Identify Cultural and Linguistic Needs and Supports Three important issues for those with COD: Three important issues for those with COD: –Not fitting into the treatment culture (do not fit into either substance abuse or mental health treatment culture) and conflict in treatment –Cultural and linguistic service barriers –Problems with literacy

What attitudes might clients in the mental health system have towards substance abusers? What attitudes might clients in the mental health system have towards substance abusers? How about attitudes in the substance abuse treatment systems towards mental illness? How about attitudes in the substance abuse treatment systems towards mental illness? What conflicts in treatment can result from two different systems? What conflicts in treatment can result from two different systems? What effect would that have on a COD client? What effect would that have on a COD client?

Traditional culture carriers (parents, grandparents) may have different views of the problems and the most appropriate of the problems and the most appropriate treatment for individuals with COD.

Imagine a mental illness diagnosis and a substance abuse diagnosis for yourself Imagine a mental illness diagnosis and a substance abuse diagnosis for yourself How might some of your family or co- workers view your problems? How might some of your family or co- workers view your problems? What would they think of treatment? What would they think of treatment? Would the specific diagnosis affect whether or not you could count on their support? Would the specific diagnosis affect whether or not you could count on their support? How might their views or reactions affect you and your treatment? How might their views or reactions affect you and your treatment?

Some specific considerations to explore –How are your substance abuse and mental health problems defined by your parents? Peers? Other clients? –What do they think you should be doing to remedy these problems? –How do you decide which suggestions to follow? –In what kinds of treatment settings do you feel most comfortable? –What do you think I (the counselor) should be doing to help you improve your situation?

What of the routine tasks and activities within your program? How accessible is such treatment for someone that cannot read or write or can do so only at a very low level? How accessible is such treatment for someone that cannot read or write or can do so only at a very low level? Someone whose way of communicating and understanding does not include the written word? Someone whose way of communicating and understanding does not include the written word?

Application to Case Examples

Step 10: Identify Problem Domains Individuals with COD may have difficulties in multiple life domains (e.g., medical, legal, vocational, family, social). Individuals with COD may have difficulties in multiple life domains (e.g., medical, legal, vocational, family, social). Research has shown the value of providing assistance in each problem area in promoting better outcomes. Research has shown the value of providing assistance in each problem area in promoting better outcomes.

Application to Case Examples

Step 11: Determine Stage of Change Stages of Change developed by Prochaska and DiClemente. Stages of Change developed by Prochaska and DiClemente. Five (5) stages are: Five (5) stages are: –Precontemplation –Contemplation –Preparation (or determination) –Action –Maintenance –Relapse.

Questionnaire Examples URICA (information is available in Appendix G) URICA (information is available in Appendix G) Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES)

Why would readiness to change matter? Why would readiness to change matter? How would your interventions differ for a client who has recognized he has a problem and wants help vs. for a client who truly believes he does not have a problem and has no interest in changing? How would your interventions differ for a client who has recognized he has a problem and wants help vs. for a client who truly believes he does not have a problem and has no interest in changing?

Stages of Change Pre-contemplationContemplationDetermination Preparation Preparation Action Action Maintenance Maintenance

Current Behavior Behavior Change Cons Pros Cons Pros DECISIONAL BALANCE NO CHANGEAMBIVALENCE CHANGE AMBIVALENCE

How worried are you about________? Not at all Losing Sleep

How confident are you that you can do something to change_____________? Not at all 100% Sure I can do something

How does___________impact the family? Not at all Tearing us Apart

How much do you think___________is a problem? Not at all Life Threatening

Step 12 – Plan Treatment A major goal of the screening and assessment process is to ensure the client is matched with appropriate treatment. A major goal of the screening and assessment process is to ensure the client is matched with appropriate treatment. Since clients with COD are not all the same, program placements and treatment interventions should be matched individually to the needs of each client. Since clients with COD are not all the same, program placements and treatment interventions should be matched individually to the needs of each client.

Treatment planning for individuals with COD and associated problems should be designed so that each disorder or problem has a specific intervention that is matched to problem or diagnosis, as well as to stage of change and external contingencies Treatment planning for individuals with COD and associated problems should be designed so that each disorder or problem has a specific intervention that is matched to problem or diagnosis, as well as to stage of change and external contingencies