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Treatment of Persons with Co-Occurring Disorders
Based on SAMHSA TIP 42 Part 4
Host: Dr. Dawn-Elise Snipes
Executive Director: AllCEUs Counselor Education
Podcast Host: Counselor Toolbox and Addiction Counselor Exam Review


~ Define the purpose of screening
~ Define assessment
~ Learn the 12 steps in the assessment process
~ Screening is
~ An initial procedure
~ Can be completed by paraprofessionals
~ A process where counselor, client and SO’s review current information and symptoms
~ Identifies whether the person may be showing signs of a substance abuse or mental health issue
~ Can also assess for related service needs
~ Screening is NOT
~ A diagnostic procedure

~ Screening should be conducted on persons who may be at risk in a variety of settings by a range or professionals and paraprofessionals
~ Agencies should collaborate on screening procedures
~ All screening procedures should be culturally responsive and trauma informed
~ Initial screenings are brief and when possible contain information from multiple sources (SOs, criminal history, physician, other therapist, referral source)

Common Screening Instruments
~ Cut down
~ Annoyed
~ Guilty
~ Eye opener
~ Michigan Alcohol Screening Test MAST
~ Substance Abuse Subtle Screening Inventory SASSI
~ An effective screening protocol specifies
~ How any screening tools are used and scored
~ What established cutoff scores are
~ What happens when a client scores in the positive range
~ How to document results of the screening and referral
~ How to document seamless referral and service coordination

~ There are a number of circumstances that can affect validity and test responses that may not be obvious
~ 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
~ Mitigating circumstances (legal, child welfare, custody, employment)
~ Screening identifies the possibility of the presence of a problem (Doctor, LEO, Judge, PO, DCF case worker)
~ Assessment defines the nature of the problem and develops specific treatment recommendations for addressing the problem (placement) (Intake Counselor or Agency Clinician)
~ A comprehensive assessment serves as the basis for an individualized treatment plan in the client’s treatment setting of choice.(Primary therapist)
Dos and Don’ts for Assessment
~ Do keep in mind that assessment is about getting to know a person with complex and individual needs.
~ Do not rely on tools alone for a comprehensive assessment.
~ Do always make every effort to contact all involved parties
~ Don't allow preconceptions about addiction to interfere with learning about what the client really needs
~ Do become familiar with the diagnostic criteria for common mental disorders, including personality disorders, and with the names and indications of common psychiatric medications
~ Most important, do remember that empathy and hope are the most valuable components of your wor
~ Don't assume that there is one correct treatment approach or program
Basic Assessment
~ A basic assessment covers the key information required for treatment matching and treatment planning. Specifically, the basic assessment offers a structure with which to obtain
~ Basic demographic and historical information, and identification of established or probable diagnoses and associated impairments
~ General strengths and problem areas
~ Stage of change or stage of treatment for both substance abuse and mental health problems
~ Preliminary determination of the severity of the COD as a guide to final level of care determination

~ Assessment of the client with COD is an ongoing process that should be repeated over time to capture the changing nature of the client's status.
~ Consists of
~ 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

Assessment Process
~ Assessment Step 1: Engage the Client
~ Assessment Step 2: Identify and Contact Collateral Information
~ Assessment Step 3: Screen for and Detect Co-Occurring Disorders
~ Assessment Step 4: Determine Quadrant and Locus of Responsibility
~ Assessment Step 5: Determine Level of Care
~ Assessment Step 6: Determine Diagnosis
~ Assessment Step 7: Determine Disability and Functional Impairment
~ Assessment Step 8: Identify Strengths and Supports
~ Assessment Step 9: Identify Cultural and Linguistic Needs and Supports
~ Assessment Step 10: Identify Problem Domains
~ Assessment Step 11: Determine Stage of Change
~ Assessment Step 12: Plan Treatment

Assessment Process
~ Through these steps, the counselor seeks to accomplish the following aims:
~ 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
~ No Wrong Door
~ Empathic detachment
~ Acknowledge that the clinician and client are working together
~ Recognize that the clinician cannot transform the client, but can only support change that he or she is already making
~ Maintain empathic connection even if the client does not seem to fit into the clinician's expectations
~ Person centered assessment finds out what the client’s perception of the problem, what he or she wants to change, and how he or she thinks that change will occur.
~ Cultural sensitivity
~ Trauma informed practices
Assessment Considerations
~ What does the client want?
~ What is the treatment contract?
~ What are the immediate needs?
~ What are the DSM-V diagnoses?
~ Identify which assessment dimensions are most severe to determine treatment priorities.
~ Choose a specific priority for each medium/severe dimension.
~ 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 of care?
~ How will outcomes be measured?
~ Ongoing Assessment: What is the progress of the treatment plan and placement decision?
Step 2: Collect Collateral Information
~ Tx History
~ Criminal History/Legal Issues (including child welfare)
~ SO Impressions
~ Medical History
~ Employment History
~ Recovery Environment

Step 3: Screen for Co-Occurring Issues
~ All individuals presenting for substance abuse treatment should be screened routinely for co-occurring mental disorders and trauma.
~ All individuals presenting for treatment for a mental disorder should be screened routinely for any substance use disorder and trauma.
~ All clients should be screened for safety
~ Intoxication/withdrawal
~ Recovery Environment
~ the Mini-International Neuropsychiatric Interview (M.I.N.I.) is a simple 15- to 30-minute device that covers 20 mental disorders, including substance use disorders

Step 4: Determine the Quadrant
~ Quadrant 1: Low/Low
~ Quadrant 2: High MH/Low SAB
~ Quadrant 3: Low MH/High SAB
~ Quadrant 4: Hi MH/High SAB
Step 5: Determine Level of Care
~ Dimension 1: Acute Intoxication and/or Withdrawal Potential
~ Dimension 2: Biomedical Conditions and Complications
~ Dimension 3: Emotional, Behavioral, or Cognitive Conditions and Complications
~ Suicide potential and level of lethality
~ Interference with addiction recovery efforts by MH Issues
~ Social functioning
~ Ability for self-care
~ Course of illness
~ Dimension 4: Readiness to Change
~ Dimension 5: Relapse, Continued Use, or Continued Problem Potential
~ Dimension 6: Recovery/Living Environment

Step 5 cont…
~ Like the ASAM, LOCUS uses multiple dimensions of assessment:
~ Risk of Harm
~ Functionality
~ Comorbidity (Medical, Addictive, Psychiatric)
~ Recovery Support and Stress
~ Treatment Attitude and Engagement
~ Treatment History

Step 6: Determine Diagnosis
~ Diagnosis is established more by history than by current symptom presentation
~ It is important to document prior diagnoses and gather information related to current diagnoses, even though substance abuse treatment counselors may not be licensed to make a mental disorder diagnosis.
~ 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 was not present
Step 7: Determine Functional Impairment
~ Is the client capable of living independently (in terms of independent living skills, not in terms of maintaining abstinence)? If not, what types of support are needed?
~ Is the client capable of supporting himself financially? If so, how? If not, what resources are needed?
~ Can the client engage in reasonable social relationships? Are there good social supports? If not, what interferes with this ability, and what supports would the client need?
~ What is the client's level of intelligence? Is there a developmental or learning disabilities? Are there cognitive or memory impairments that impede learning? Are there difficulties with focusing, concentrating, and completing tasks?

Step 8: Identify Strengths and Supports
~ Talents and interests
~ Areas of educational interest and literacy; vocational skill, interest, and ability, such as vocational skills, social skills, or capacity for creative self-expression
~ Areas connected with high levels of motivation to change, for either disorder or both
~ Existing supportive relationships, treatment, peer, or family, particularly ongoing mental disorder treatment relationships
~ Previous mental health services and addiction treatment successes, and exploration of what worked
~ Identification of current successes: What has the client done right recently, for either disorder?
~ Building treatment plans and interventions based on utilizing and reinforcing strengths, and extending or supporting what has worked previously

Step 9: Identify Cultural/Linguistic Needs

~ Specific considerations to explore with the client include:
~ 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?

Step 10: Identify Problem Domains
~ Substance abuse
~ Eating Disorders
~ Behavioral Addictions
~ Medical Issues
~ Mental Health
~ Interpersonal Functioning
~ Legal Issues
~ Employment/Education Issues
~ Housing and Recovery Environment
Step 11: Determine Stage of Change
~ Prochaska
~ No problem and/or no interest in change (Precontemplation)
~ Might be a problem; might consider change (Contemplation)
~ Definitely getting ready to change (Preparation)
~ Actively working on changing, even if slowly (Action)
~ Has achieved stability, and is trying to maintain (Maintenance)

~ Substance Abuse Treatment Scale (SATS)
~ Pre-Engagement
~ Engagement
~ Early Persuasion
~ Late Persuasion
~ Early Active Treatment
~ Late Active Treatment
~ Relapse Prevention
~ Remission

Step 12: Plan 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 is matched to problem or diagnosis, as well as to stage of change and external contingencies
~ Determine areas of prior success around which to organize future treatment interventions
~ Determine areas of skills building needed for disease management of either disorder
~ Screening identifies a potential problem
~ Assessment determines the nature and severity of the problem
~ There are 12 essential steps in the assessment process
~ Both screening and assessment services need to be culturally responsive (SAMHSA TIP 59) and Trauma Informed (SAMHSA TIP 57)
More Information
~ Assessment Playlist
~ Multicultural Playlist
~ Trauma Informed Care Playlist

~ Addiction Counselor Exam Review Podcast, especially episodes 3, 4 and 5

~ To earn CEUs for this presentation, go to where you can find a direct link to the class associated with this presentation