Substance abuse and addiction

Substance abuse and addiction

All Assignments will be submitted through safe assign for plagiarism

Assignment 1: At least 250 words APA format, cite scholarly sources

What would you do as a counselor if you notice symptoms of addiction in a client who has NOT acknowledged using/abusing substances?

 

Assignment 2: At least 250 words APA format, cite scholarly sources

Which should be treated first: mental disorder or the substance abuse?  You may not discuss how this is a standing issue; instead, you must choose one.

 

Assignment 3: At least 250 words APA format, cite scholarly sources What are some of the more common drugs used to treat people with addictions?  Argue the pros and cons of harm reduction.

Assignment 4:

Discuss two (2) instruments discussed in chapter 7 that you think would or could be useful to you. Explain why.  Prepare your response in a one-page, double spaced document using formal English, APA format, and be sure to credit your source(s) of information properly.

Please see chapter 7 below

Textbook: van Wormer, K., & Davis, D. R. (2018). Addiction treatment: A strengths perspective (4th ed.). Belmont, MA: Brooks/Cole, Cengage Publishing.

 

7-1Introduction

The process of screening and assessment is changing as the addiction field moves steadily in the direction of client-centered, strength-based practices and into more diverse health care settings because of the  2013 Affordable Care Act . In the traditional framework, screening and assessment has been the centerpiece of the initial point of client contact within the agency or treatment program, where clients may spend a great deal of time filling out various assessment instruments or being interviewed by designated intake workers. This arrangement serves three purposes: it “qualifies” the client with an appropriate problem so that it is clear the client is in the right place, it allows the agency or treatment program to get reimbursed based on the client having an appropriate diagnosis, and it quickly furnishes information to the counselor who will eventually be assigned to work with the person. There are, however, unintended consequences to such an arrangement (Miller, Forcehimes, Zweben, & McClellan, 2011).

Asking a lot of questions initially can set up an expectation that the agency (counselor) is the expert on the client’s condition, and given enough information, can come up with the right answer to fix the problem. Spending a lot of time on filling out assessments can delay the important business of building a trusting relationship between the client and the counselor. The delay can be especially critical if the client is not 100% motivated to be “helped.” A more strength-based approach is to find ways to integrate screening and assessment into the ongoing process of treatment and keep it centered on how exactly this information will be useful to identifying and achieving goals that reflect what the client wants. Some clients who have serious trauma history or are currently struggling to maintain survival status cannot tolerate formal questioning. The Harm Reduction Therapy Center in San Francisco, which typically works with homeless and seriously marginalized clients, conducts their formal assessments over long periods of time (Little & Franskoviak, 2010). They call this “assessment as treatment,” where the therapist continually observes and inquires about the client’s experience as the relationship builds, offering recommendations only when the clients have given their permission to do so.

Using assessment tools with persons who are part of ethnic minority groups or who do not use English as a first language requires additional cautions. Measurement error can occur because not many instruments have been normed on clients of color (Blume & Lovato, 2010). When the only instruments available are those developed from the majority culture (often white college students), then care must be taken in interpreting the results. In addition, the clients may have a different cultural worldview than the Western definitions of the particular addiction. Among some Native Americans, for example, peyote use may be considered a ritualized experience, not a destructive practice associated with loss of control. Questions on assessment forms concerning hallucinations need to take into account cultural practices of some persons where participants go to great lengths to induce hallucinations for spiritual purposes. When clients and therapists speak different first languages, translation problems and misunderstandings are rampant, whether through written forms or with personal translators. As an example, the English word craving is neither easily translated into Spanish, nor is the concept easily understood (Blume, Morera, & de la Cruz, 2005). In Norway, in van Wormer’s experience, the term powerless (as in “powerless over alcohol”) was most commonly translated with the word hjelpeløs or “helpless” in English.

With these cautions in mind, there are many screening and assessment tools in the addiction field that can be helpful and effective, ranging from one question screens that can be incorporated into any intake process to more complex instruments that require training and scoring. With the advent of the Affordable Care Act and the expansion of both mental health and substance use disorder benefits, screening and assessment for these problems has expanded into many health care arenas. The  SBIRT model  (Screening, Brief Intervention, and Referral for Treatment) is being advocated by SAMHSA as a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with addiction disorders and/or mental health problems. SBIRT includes the universal screening for addiction and mental health problems, further assessment and brief intervention for those at a risky or harmful level of problem, and referral to treatment for those who may have a disorder (SAMHSA, 2015).

The function of screening and assessment will vary, depending on the context and environment of the first meeting with the client. Does it take place in the emergency room after a person has come in with injuries from a motor vehicle accident? Is it a meeting with a client who comes to his family doctor for an annual check-up? Does the assessment take place in prison, or a homeless shelter, or an outpatient treatment program for problem gamblers or alcohol or drug users? This chapter will describe several common brief screens and assessment tools for alcohol, drug, gambling, and mental health problems and their use in various settings. We will also suggest a toolbox of screening and assessment types of questions that can be helpful in building a relationship with the client, increasing motivation for change, assessing client strengths, and finding supports available to help clients through the change process.

7-2Screening Instruments and Strategies

Screening instruments are the first step of the SBIRT process. They are tools (one question or a short series of questions) that can quickly help detect the possibility of a problem with substance use, gambling, or whatever problem is of interest. Screens cast a wide, more imprecise net than assessment tools, so sometimes people show up “positive” on a screen, when in fact they have no problem at all, or they are “negative” on a screen when they actually do have a problem. Screening questions can be asked in a variety of settings, such as the emergency room, the doctor’s office, the mental health center, and addiction treatment programs (for other disorders). Because of the Affordable Care Act, screening and brief intervention services are increasingly covered by insurance plans. However, only one of six U.S. adults, including binge drinkers, reported ever discussing their alcohol use with a health professional (McKnight-Eily, Liu, Brewer, Kanny, Lu, Denny, Balluz, & Collins, 2014).

It is becoming increasingly clear that it is critical to screen for a gambling problem at a substance abuse treatment program. One recent study on 300 individuals recruited from intensive outpatient substance use treatment or methadone maintenance found that 4 out of 10 people had a DSM-5 diagnosis of Gambling Disorder (Himelhoch, Miles-McLean, Medoff, Kreyenbuhl, Rugle, Bailey-Kloch, Potts, Welsh, & Brownley, 2015). Initial studies on the implementation of SBIRT in primary care settings show positive results for reducing the frequency and intensity of alcohol use in heavy drinkers and preventing the development of many physical and mental health conditions associated with excessive alcohol use. Additional research is needed to measure the impact of SBIRT on clients who are using drugs (Sacks, Gotham, Johnson, Padwa, Murphy, & Krom, 2015).

The examples that follow are screens that are short, simple, and easy to work into the intake process in any setting and context, and have a reasonable chance of screening accurately. Because of the stigma that surrounds addiction, or even the possibility of having these kinds of problems, it is a good idea to let people know that the screening questions are routine and asked of all clients. It is also helpful to first ask, “Do you sometimes drink?” or “Do you sometimes gamble?” or “Do you sometimes use drugs of any kind?” as a prescreening question to rule out people who never engage in any of these behaviors.

The Lie/Bet questionnaire (Johnson, Hamer, Nora, Tan, Eistenstein, & Englehart, 1988) is valid and reliable for ruling out gambling disorders, that is, these two questions differentiate between disordered and nonproblem gambling and tell the clinician if further assessment is warranted. If the client answers “yes” to one or both questions, further assessment is needed. The Lie/Bet questions are:

1. Have you ever felt the need to bet more and more money?

2. Have you ever had to lie to people important to you about how much you gambled?

A “yes” answer to either of these questions also calls for a follow-up open-ended question like “Tell me more about that …” to further understand the client’s experience.

The Brief Biosocial Gambling Screener (BBGS) is the only screen that assesses for gambling disorder in a 12-month time frame, which is the frame that has been established by the DSM-5 to diagnose gambling disorder (Gebauer, LaBrie, & Shaffer, 2010). The BBGS is a three-item screen that evaluates withdrawal, lying, and borrowing money (see Box 7.1). In an evaluation of the accuracy of brief screens for gambling disorder in the substance use treatment setting, the BBGS was slightly more accurate than the Lie/Bet although both screens had excellent accuracy (Himelhoch et al., 2015).

Box 7.1

Brief Biosocial Gambling Screen (BBGS)

1. During the past 12 months, have you become restless, irritable, or anxious when trying to stop/cut down on gambling?

2. During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled?

3. During the past 12 months, did you have such financial trouble that you had to get help from family or friends?

BBGS Scoring: Answering “yes” to one or more questions indicates likely disordered gambling.

Source: Gebauer, L., LaBrie, R. A., & Shaffer, H. J. (2010). Optimizing DSM-IV classification accuracy: A brief bio-social screen for gambling disorders among the general household population. Canadian Journal of Psychiatry, 55(2), 82–90.

A simple one-question screen for men or women to rule out alcohol and drug problems is recommended to clinicians by SAMHSA and is used to implement the SBIRT model (OHSU, 2015). A study by Williams and Vinson (2001) found that this one question identified 86% of individuals who had an alcohol use disorder. In this screen, one or more heavy drinking days indicates the client is an at-risk drinker, and further assessment is warranted, such as the AUDIT explained below. One standard drink is equivalent to 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits.

(For men): “How many times in the past year have you had five or more drinks in a day?”

(For women): “How many times in the past year have you had four or more drinks in a day?”

With a slight change, the same question can be used with good results for ruling out illicit drug or prescription drug problems (Smith, Schmidt, Allensworth-Davis, & Suitz, 2010). The question becomes:

“How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”

Clients who answer “one or more” should receive a full drug screen (such as the DAST explained below).

To quickly screen possible mood disorders, these two questions can be used:

1. “During the past two weeks, have you been bothered by little interest or pleasure in doing things?”

2. “During the past two weeks, have you been bothered by feeling down, depressed, or hopeless?”

Clients who answer “yes” to either question should receive a full screen for depression (such as the PHQ-9) (OHSU, 2015). The Patient Health Questionnaire (PHQ-9) is a nine-question screen that is the most common tool used to identify depression. It is readily available for free download (www.integration.samhsa.gov/clinical-practice/screening-tools), is available in Spanish as well as a modified version for adolescents.

These simple screening questions are especially helpful in primary care settings or other helping contexts (family agencies, vocational rehabilitation, child welfare, etc.) where the presenting problem is something other than problematic substance use or problem gambling. Davis recently conducted a local training with child welfare workers on problem gamblers and found that there is no gambling screen in the state-wide intake protocol. However, as the participants in the workshop pointed out, there are cases coming to their attention where problem gambling is the primary cause behind child neglect. Utilizing a simple screen could help pinpoint the problem in a timely manner.

Slightly more complicated and longer screens have also proven helpful and are still simple enough to carry around in the clinician’s head in acronym form. The CAGE, developed by Ewing (1984) for screening alcohol problems, is probably the most familiar and has been validated extensively (Abbott, 2011). A later version, the CAGE-AID, changed the wording to include drug problems (Brown, Leonard, Saunders, & Papasouliotis, 1998). If the client answers “yes” to two or more questions, then further assessment is warranted:

CHave you ever felt you ought to cut down on your drinking or drug use?
AHave people annoyed you by criticizing your drinking or drug use?
GHave you ever felt bad or guilty about your drinking or drug use?
EHave you ever had a drink or used drugs early in the morning to steady your nerves or get rid of a hangover?

According to Bradley and colleagues (1998), the CAGE and TWEAK were the optimal screening tests for identification of alcohol problems in women. However, effectiveness varied by ethnicity. For Black obstetric patients and for White women, questionnaires that asked about tolerance for alcohol (e.g., TWEAK) were more sensitive. For use with mixed populations, therefore, the researchers recommend TWEAK. Again, an answer of “yes” to two or more of these indicates a problem:

TTolerance: How many drinks can you hold? (six or more drinks indicates tolerance) or How many drinks does it take before you begin to feel the first effect of the alcohol? (three or more drinks indicates tolerance)
WWorried: Have close friends or relatives worried or complained about your drinking in the past year?
EEye openers: Do you sometimes take a drink in the morning when you first get up?
AAmnesia: Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?
KKut down: Do you sometimes feel the need to cut down on your drinking?

The Alcohol Use Disorders Identification Test (AUDIT), developed by the World Health Organization (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001), is the only screening test designed and validated for international use in a wide variety of populations, cultures, and languages. It is brief, rapid, and flexible, and it can be used in many contexts: primary care health clinics, emergency rooms, outpatient clinics, jails and prisons, and other human service agencies. The AUDIT is comprised of 10 items that cover amount and frequency of drinking, alcohol dependence symptoms, personal problems, and social problems (e.g., “Have you or someone else been injured because of your drinking?”). The scoring is designed to discriminate between different levels of risk—hazardous, harmful, and possible dependence—so it can be used as a prevention tool to help clients assess their current status and the road ahead if things do not change. The AUDIT can be given to the client as a questionnaire to fill out, or it can be used as interview questions. It takes approximately two minutes to complete the AUDIT. Both versions can be downloaded for free on the Website http://apps.who.int/iris/bitstream/10665/67205/1/WHO_MSD_MSB_01.6a.pdf. This helpful Website also provides complete scoring and interpretation instructions (which are not complicated), as well as a wealth of suggestions on how to introduce the screen and use the results in a client-centered, strength-based manner.

SAMHSA has developed a free SBIRT app for physicians and mental health professionals, which provides evidence-based screening questions for alcohol, drugs, and tobacco use. This includes the CRAFFT to assess substance use in adolescents, the AUDIT for alcohol use in adults, and the DAST for drug use in adults. The app can be found, along with many other SBIRT resources, on www.integration.samhsa.gov/clinical-practice/sbirt. There are also a number of Internet-based screening tools available through a simple Google search of “Alcohol Screens,” or whatever behavior you are focusing on. One good example, “About my drinking,” has been developed by Hazelden using the AUDIT as the basis for the screen (http://www.aboutmydrinking.org). Depending on how one answers the questions, the interpretation will rate your risk of alcohol-related harm and discuss possible physical consequences, prevention strategies, and reasons for seeking further assistance if indicated. As a counselor, taking this test for yourself is an easy way to be introduced to the usefulness of the AUDIT.

7-3Assessment Tools

Screening and assessment are not the same process. While a screen can point you in the right direction, the assessment defines the nature of the problem and assists in developing specific treatment recommendations for addressing the problem. There are all kinds of ways to do that, ranging from simply telling the client you are “interested in what brought them in to see you and what they want to get out of your time together,” to using formal assessment tools to get a deeper picture of the client’s readiness to change, problem areas, their severity, and the client’s strengths and “recovery capital.” As Miller and his colleagues (2011) remind us, “neither screening nor diagnosis, however, provides much information about what is actually happening in a particular person’s life and substance use, why problems are emerging, and what treatment options would be most appropriate to try” (p. 71). That kind of information develops through the careful effort of building a trusting relationship with the client. As a working relationship is built, there are assessment tools that can be helpful in pinpointing the uniqueness of the person’s experience.

Many times clients figure out for themselves they have a problem with substance use or gambling. Perhaps they attended a Gamblers Anonymous (GA) meeting, and chimed in with the rest of the group to answer GA 20 Questions, which are usually read aloud at every meeting. In GA, as in other 12-Step groups, it does not matter how many signs you have of the problem, or whether an expert has diagnosed you with the problem. The real issue is to figure out for yourself if you want to quit gambling. The GA 20 Questions help people figure that out (see Box 7.2) by raising their awareness of the consequences of continuing to gamble. According to GA, most compulsive gamblers will answer “yes” to at least seven of the questions. Self-described compulsive gamblers, not treatment providers or researchers, developed these questions in the 1950s. However, two researchers (Ursua & Uribelarrea, 1998) tested the Spanish version of the GA 20 Questions and found it to have high reliability and validity in discriminating between problem gamblers and social gamblers. They recommend it “as good as the best clinical and diagnostic instruments proposed at present” (p. 11). A more recent psychometric study by Toneatto (2008), using the English version, confirmed high reliability and a high correlation with the DSM-IV-R as well as the South Oaks Gambling Screen.

Box 7.2

Gamblers Anonymous 20 Questions

1. Did you ever lose time from work or school due to gambling?

2. Has gambling ever made your home life unhappy?

3. Did gambling affect your reputation?

4. Have you ever felt remorse after gambling?

5. Did you ever gamble to get money with which to pay debts or otherwise solve financial difficulties?

6. Did gambling cause a decrease in your ambition or efficiency?

7. After losing, did you feel you must return as soon as possible and win back your losses?

8. After a win did you have a strong urge to return and win more?

9. Did you often gamble until your last dollar was gone?

10. Did you ever borrow to finance your gambling?

11. Have you ever sold anything to finance gambling?

12. Were you reluctant to use “gambling money” for normal expenditures?

13. Did gambling make you careless of the welfare of yourself or your family?

14. Did you ever gamble longer than was planned?

15. Have you ever gambled to escape worry or trouble?

16. Have you ever committed, or considered committing, an illegal act to finance gambling?

17. Did gambling cause you to have difficulty in sleeping?

18. Do arguments, disappointments, or frustrations create within you an urge to gamble?

19. Did you ever have an urge to celebrate any good fortune by a few hours of gambling?

20. Have you ever considered self-destruction or suicide as a result of your gambling?

Source: Reprinted from the official Gamblers Anonymous Website, www.gamblersanonymous.org, with permission.

Since the advent of the DSM-5 (APA, 2013), the criteria for disordered gambling has changed. One item was eliminated (“has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling”), and the threshold for diagnosis was lowered from five criteria to four criteria. In addition, instead of being classified as an impulse-control disorder it is now called a Gambling Disorder and classified as a Substance-Related and Addictive Disorder. The following is an assessment re-written from the DSM-5 criteria and phrased as “yes” or “no” questions (Himelhoch et al., 2015, p. 465):

Assessment of DSM-5 Gambling Disorder

Instructions: Now, I have a few questions about your gambling over the last 12 months. Please respond “yes” or “no.”

1. Over the last year, do you need to gamble with increasing amounts of money in order to achieve the desired excitement?

2. Over the last year, are you restless or irritable when attempting to cut down or stop gambling?

3. Over the last year, have you made repeated unsuccessful efforts to control, cut back, or stop gambling?

4. Over the last year, are you often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble)?

5. Over the last year, do you often gamble when feeling distressed (e.g., helpless, guilty, anxious, depressed)?

6. Over the last year, after losing money gambling, do you often return another day to get even (i.e., “chasing” losses)?

7. Over the last year, do you lie to conceal the extent of involvement with gambling?

8. Over the last year, have you jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling?

9. Over the last year, do you rely on others to provide money to relieve desperate financial situations caused by gambling?

Based on DSM-5 criteria, persons who scored a “yes” in four or above were considered to have Gambling Disorder. It’s interesting to compare these DSM-5 related assessment questions developed by experts to the Gambler’s Anonymous 20 Questions developed by recovering gamblers from their own experience and see the similarities and differences.

A good start to finding out the nature and severity of substance use problems is to ask the client some open-ended questions about what he or she has been using, how he or she is using the substance, how often, and what have been the costs and benefits of the use. If you want to cover all the possibilities, there are many instruments available. The Alcohol and Drug Abuse Institute Library at the University of Washington maintains an extensive Website that will help you access screening and assessment instruments and  documentation  from various sources. The instruments whose validity and reliability have been well-documented are marked. The Website is http://lib.adai.washington.edu/instruments. Another source is the SAMHSA Website, which also includes suicide risk, bipolar, anxiety, and trauma screening tools. To help narrow down your many choices, Miller and colleagues (2011) recommend the following structured assessments: the Addiction Severity Index (ASI), the Alcohol Dependence Scale, the Drinker Inventory of Consequences (Drinc), the Inventory of Drug Use Consequences (InDUC), and the Severity of Alcohol Dependence Questionnaire (SADQ).

An example of one of the recommended instruments that is in the public domain is The Drinker Inventory of Consequences (Drinc) (Forcehimes, Tonigan, Miller, Kenna, & Baer, 2007). Originally designed for Project MATCH, it is a 50-item questionnaire that covers physical, social, intrapersonal, impulse control, and interpersonal problem areas.  Psychometric testing  suggests it is reliable, valid, and can be clinically useful. Sample questions include some potential positives from drinking (“How often has drinking helped me to relax?”), and mostly negative possibilities (“How often has my ability to be a good parent been harmed by my drinking”). The Drinc can be downloaded free at http://casaa.unm.edu/instruments. The Inventory of Drug Use Consequences (InDUC) (Tonigan & Miller, 2002) has the same purpose and format only changed to assess drug consequences. It is also in the public domain and can be downloaded free at http://casaa.unm.edu/instruments.

The Substance Abuse Subtle Screening Inventory (SASSI) (Miller & Lazowski, 1999) is a somewhat different approach to assessment instruments. Known by some as the “stealth assessment,” most of the true/false items on one side of the form do not inquire directly about alcohol or drug use. Items such as “I am often resentful,” and “I like to obey the law” can indicate whether the respondent fits the profile of a chemically dependent person in areas such as defensiveness, willingness to acknowledge problematic behavior, depressed affect, likelihood of legal problems, and so on. The reverse side of the form inquires directly about alcohol and drug use. The use of less obvious measures at the beginning of the form is designed to minimize client defensiveness. However, in a review of the effectiveness of the SASSI, no empirical evidence was found for the SASSI’s claimed unique advantage in detecting substance use disorders through its indirect (subtle) scales to circumvent client denial or dishonesty (Feldstein & Miller, 2007).

7-4Assessing Levels of Care

There are several systems for assessing the appropriate level of care for a person with substance use problems. The ASAM Criteria—Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions (Mee-Lee, Shulman, Fishman, Gastfriend, & Miller, Eds., 2013), formerly known as the ASAM Patient Placement Criteria is one of the most widely recognized systems for guiding addiction treatment. Over 30 states and the Department of Defense addiction programs around the world use the ASAM criteria as guidelines for assessment, service planning, placement, continued stay and transfer/discharge of individuals with addiction and co-occurring disorders (Mee-Lee, 2014). The ASAM system outlines treatment as a continuum within which there are five broad levels of care:

1. Level 0.5: Early Intervention

2. Level 1: Outpatient Treatment

3. Level 2: Intensive Outpatient/Partial Hospitalization Treatment

4. Level 3: Residential/Inpatient Treatment

5. Level 4: Medically Managed Intensive Inpatient Treatment.

Each level of care includes several layers of intensity. For example, Level 3.1 refers to “Clinically Managed Low-Intensity Residential Treatment” and Level 3.7 refers to “Medically Monitored Intensive Inpatient Services.” Clients are evaluated using the following dimensions to create a holistic, biopsychosocial assessment of an individual to be used for treatment planning:

· (1)

acute intoxication or withdrawal potential;

· (2)

biomedical conditions and complications;

· (3)

emotional, behavioral, or cognitive conditions and complications;

· (4)

readiness to change;

· (5)

relapse, continued use, or continued problem potential; and

· (6)

recovery/living environment.

An example of using these criteria will be presented in the next section on co-occurring disorders (COD).

A different classification system focused on the integration of substance abuse and mental health services was developed by the consensus panel for TIP 42 (CSAT, 2005) on Co-occurring Disorders. This system divides levels of care into basic, intermediate, advanced, or fully integrated, which describe the capability of programs to offer needed services for persons with COD. A basic program provides treatment for one disorder, but screens for the other disorder; an intermediate level focuses primarily on one disorder but also addresses some specific needs of the other (e.g., a counselor could provide motivational interviewing regarding substance use while holding medication management groups for psychiatric patients); an advanced level provides services for both disorders using an integrated perspective (e.g., adding interventions such as mutual self-help and relapse prevention groups to a mental health setting); and a fully integrated program is essentially a one-stop shop that actively provides treatment for both disorders by the same clinicians who are trained in psychopathology, assessment, and treatment strategies for both mental and substance use disorders, and the funding streams are fully integrated. The integration of services has become a high priority within the SAMHSA because of the advent of the Affordable Care Act and the need for community-based screening for health risk behaviors (see Chapter 4 on Co-occurring Disorders for more discussion of social issues and treatment strategies).

7-5Assessment of Persons with Co-Occurring Disorders (COD)

Integrated assessment is critical to understanding the interactions between mental illness and substance misuse. Substance misuse worsens the outcome of severe mental illness, and vice versa. Co-occurring mental health and substance use issues are so common with individuals who present for any kind of treatment, it is considered the norm, not the exception (Miller et al., 2011). National admissions data for substance abuse treatment facilities reveal that about one-third (32.5%) of the admissions had a psychiatric problem in addition to a substance use problem (SAMHSA, 2014). Chapter 4 presented the background on the social issues and preferred treatment options for people with COD; this section will focus on specific screening and assessment instruments.

When a client presents with potential COD, it may overwhelm the counselor because of the number of needs, the complexities in sorting out treatment options, and the disarray of most clients’ lives who find themselves in that situation. There are times practitioners will find themselves not knowing how to proceed. These are the times that the Center for Substance Abuse Treatment (2005) reminds us that “empathy and hope are the most valuable components of your work with a client. When in doubt about how to manage a client with COD, stay connected, be empathic and hopeful, and work with the client and the treatment team to try to figure out the best approach over time” (p. 67).

Working “over time” is a key component in the screening and assessment phase of clients with COD. The difficulties of sorting out whether mental health symptoms are independent or dependent on the use of substances may be revealed only over weeks and months of contact with the client. Chapter 4 discussed more about these complications in the section titled “The perils of differential diagnosis.” In this section we will confine ourselves to screening and assessment tools that will help answer “yes” or “no” to the general question, “Does the substance abuse (or mental health) client show signs of a possible mental health (or substance abuse problem)?”

There are certain prerequisites that are essential before a counselor can embark on screening and assessment for COD:

1. Be familiar with the diagnostic criteria for common mental disorders. In these times, when eligibility for many services depends on the client meeting certain DSM-5 criteria, it is critical for all practitioners in the helping professions to at least have a copy of the Pocket Guide to the DSM-5 Diagnostic Exam (Nussbaum, 2013). This is an easy to utilize desk copy that is about five pounds lighter than the complete DSM-5 and extremely helpful in finding plenty of details and criteria for each mental health diagnosis. For Internet enthusiasts, any diagnosis can be found through a Google search, but the options can be bewildering. A recent search of “schizophrenia” came up with 23,100,000 results.

2. Be familiar with the names and indications of common psychiatric medications and the potential interactions that many occur. The names and drugs are always changing, so it is best to use an Internet source to keep up with the latest psychotropic medications that are used. An excellent new free product, updated regularly, is the Behavioral Health Medications (BHMeds) APP found at http://www.attcnetworkorg. This APP covers substance use disorder and mental health medications, information on generic and brand names, their purpose, usual dose and frequency, side effects, potential for abuse and dependence, emergency conditions, and cautions. The BHMeds can also be downloaded free or a copy may be ordered for a nominal cost.

3. Understand the policies of your particular agency or helping context on the procedures for gathering information. For example, CSAT (2005) recommends that every effort be made to contact all parties, including family, probation officers, and treatment professionals who have worked with the person. However, practitioners at the Harm Reduction Therapy Center in San Francisco gather information from family and significant others only if the client wishes to do so, and then only with the client present (Little & Franskoviak, 2010).

4. Do not be afraid that you do not have all the answers. That is why we have supervisors! Identify at least one person who is a good source for possibilities and a sounding board for frustrations.

5. Know your community resources, in terms of who provides what in the ASAM levels of care, what level of programming is available for people with COD, and what mutual help organizations exist in your community that are helpful to people with a COD. It is especially important to know the options available for housing (and what the rules are regarding abstinence), medication and medical assistance, substance abuse and gambling treatment (and potential waiting lists), and other resources that could increase the client’s recovery capital (friends, churches, hobby groups, drop-in centers with activities, food pantries, etc.). Meuser and colleagues (2006) point out several areas that may need assessment: housing, case management needs for  severe mental illness , supported employment, family psycho education, social skills training, training of clients for illness management, and pharmacological treatment. Assessment needs to include both the strengths and limitations the client has in each area.

The search is still on for the development of a reliable and valid brief screening tool for COD (Jessup & Dibble, 2010). The common substance abuse screening tools mentioned previously are used with individuals with COD, including the CAGE and the AUDIT. In addition, the Simple Screening Instrument for Substance Abuse (SSI-SA) was developed by a consensus panel of experts for CSAT in 1994, using existing alcohol and drug screening tools. It is widely used either as an interview or self-administered, and it is one of the most common screening instruments used in correctional settings (CSAT, 2005). The SSI-SA is in the public domain, can be accessed in TIP 42 (CSAT 2005), and is reproduced in its entirety in Box 7.3. Of the 16 items, questions 1 and 15 are not scored, so the included scores range from 0 to 14. A score of 4 or more is the cut-off point that indicates a further full assessment is needed. A score of 2–3 indicates minimal risk.

Box 7.3

Simple Screening Instrument for Substance Abuse (SSI-SA) Self-Administered Form

Directions: The questions that follow are about your use of alcohol and other drugs. Your answers will be kept private. Mark the response that best fits for you. Answer the questions in terms of your experiences in the past 6 months.

During the last six months …

1. Have you used alcohol or other drugs? (such as wine, beer hard liquor, pot, coke, heroin or other opioids, uppers, downers, hallucinogens, or inhalants? (Yes/No)

2. Have you felt that you use too much alcohol or other drugs? (Yes/No)

3. Have you tried to cut down or quit drinking or using alcohol or other drugs? (Yes/No)

4. Have you gone to anyone for help because of your drinking or drug use? (Such as Alcoholics Anonymous, Narcotic Anonymous, Cocaine Anonymous, counselors, or a treatment program?) (Yes/No)

5. Have you had any health problems? For example, have you:

· _Had blackouts or other periods of memory loss?

· _Injured your head after drinking or using drugs?

· _Had convulsions, delirium tremens (“DTs”)?

· _Had hepatitis or other liver problems?

· _Felt sick, shaky, or depressed when you stopped?

· _Felt “coke bug” or a crawling feeling under the skin after you stopped using drugs?

· _Been injured after drinking or using?

· _Used needles to shoot drugs?

6. Has drinking or other drug use caused problems between you and your family or friends? (Yes/No)

7. Has your drinking or other drug use caused problems at school or at work? (Yes/No)

8. Have you been arrested or had other legal problems? (such as bouncing bad checks, driving while intoxicated, theft, or drug possession?) (Yes/No)

9. Have you lost your temper or gotten into arguments or fight while drinking or using other drugs? (Yes/No)

10. Are you needing to drink or use drugs more and more to get the effect you want? (Yes/No)

11. Do you spend a lot of time thinking about or trying to get alcohol or other drugs? (Yes/No)

12. When drinking or using drugs, are you more likely to do something you wouldn’t normally do, such as break rules, break the law, sell things that are important to you, or have unprotected sex with someone? (Yes/No)

13. Do you feel bad or guilty about your drinking or drug use? (Yes/No)

The next questions are about your lifetime experiences.

14. Have you ever had a drinking or other drug problem? (Yes/No)

15. Have any of your family members ever had a drinking or drug problem? (Yes/No)

16. Do you feel that you have a drinking or drug problem now? (Yes/No)

Source: CSAT, 2005, pp. 509–510.

Similarly, the Mental Health Screening Form-III (MHSF-III) is designed to screen for present or past symptoms of most of the main mental disorders (Carroll & McGinley, 2001). The authors have described it as a “rough screening device” because it asks only one question for each disorder, and if the client misunderstands the question or does not remember, the screen would produce a false negative (p. 31). Nevertheless, CSAT (2005) recommends it as an initial screen to be used in substance abuse or other settings to help identify clients who may have mental health problems. The screen is in the public domain and can be found on numerous Websites that include scoring directions, such as http://ecdc.syr.edu/wp-content/uploads/2013/06/mental_health_screening_form_iii.pdf. The MHSF-III has 18 questions, such as “Have you ever felt that people had something against you, without them necessarily saying so, or that someone or some group may be trying to influence your thoughts or behavior? Have you ever been depressed for weeks at a time, lost interest or pleasure in most activities, had trouble concentrating and making decisions, or thought about killing yourself?” The authors recommend the screen be given in interview format so that follow-up questions can be asked about any “yes” answers, such as “When did that happen?” “How long did it last?” and “Did that happen before, during, or after your use of (substance)?” It also includes a question about gambling: “Have you ever lost considerable sums of money through gambling or had problems at work, in school, with your family and friends because of gambling?”

The Comprehensive Addictions and Psychological Evaluation (CAAPE) is a practical tool for assessing co-occurring disorders all in one instrument (Hoffman, 2013). It can be used in a variety of settings, such as addiction treatment, prison and jail, and chronic pain clinics. The interview takes 30–45 minutes and covers alcohol/tobacco/drug use, depression, mania, panic/anxiety, PTSD, obsessive-compulsive disorder, psychosis, and a wide range of personality disorders (antisocial, paranoid, schizoid, borderline, etc.). Although there is thorough coverage of potential issues, there is not one question on gambling behavior. The CAAPE has been copyrighted and is not free of charge.

Because of the high co-occurrence of eating disorders and substance use disorders, it would help to screen all clients in addiction treatment for eating disorders. This can be done easily by incorporating a few questions into the substance abuse assessment, such as:

· (1)

Tell me about your use of over-the-counter and prescription laxatives, diuretics, and diet pills,

· (2)

Tell me about past hospitalizations and behavioral health treatment history,

· (3)

How long and how often do you exercise?

· (4)

Other than those we’ve discussed, are there any other health issues that concern you? (SAMHSA, 2011).

Clinicians can also use a standardized screening instrument such as the five-question SCOFF questionnaire:

1. Do you make yourself Sick (induce vomiting) because you feel uncomfortably full?

2. Do you worry you have lost Control over how much you eat?

3. Have you recently lost more than One stone (14 lbs) in a three-month period?

4. Do you believe yourself to be Fat when others say you are too thin?

5. Would you say that Food dominates your life?

Two or more “yes” responses indicate that an ED is likely (Morgan, Reid, & Lacy, 2000).

A client who has COD problems could be assessed as fitting any one of the ASAM levels, depending on how the client is evaluated in the different dimensions. For example, dimension three is the “emotional, behavioral, or cognitive conditions and complications” (Mee-Lee, Shulman, Fishman, Gastfriend, & Miller, Eds., 2013). There are five areas of risk that need evaluation within this dimension: suicide potential and level of lethality, the degree to which the emotional or behavioral factors interfere with recovery, social functioning, the ability for self-care, and a prediction of the patient’s likely response to treatment. Consideration of dimension three helps to determine what level would best fit the needs of the individual. For example, a person with co-occurring disorders, “Jane B” is illustrated in Box 7.4 (CSAT, 2005). In this example, because of the severity of her situation, one might leap to the conclusion that Jane needs Level 3 or 4 care. However, a more careful review shows us that although she is psychotic and homeless, she is not suicidal, homicidal, or unable to feed herself and find shelter. Therefore, Jane does not meet criteria for involuntary psychiatric treatment. Level 3 is not an option because she is completely unmotivated to accept voluntary mental health services, and she is probably too psychotic to participate in treatment at this point. Homelessness alone does not qualify a person for Level 3. The ASAM analysis would lead us to recommend starting with Level 1.5 intensive mental disorder case management. Of course, recommending this level of treatment does not make it happen. We should anticipate a long period of engagement, using strategies described in the next chapter, to build trust over time. We would hope that, in the months to come, Jane would begin to trust the case management team enough to accept small measures of help that would build over time. Thus, the ASAM criteria can be helpful in adjusting our own expectations to what is real and possible, as well as a system of treatment matching. Because it is a complex multidimensional assessment, the ASAM requires additional training to implement with accuracy. Opportunities for ASAM workshops are available through substance abuse treatment programs, college coursework, and Internet resources.

Box 7.4

Jane B.

The client is a 28-year-old single Caucasian female with a diagnosis of paranoid schizophrenia, alcohol dependence, crack cocaine dependence, and a history of multiple episodes of sexual victimization. Jane B. is homeless (living in a shelter), actively psychotic, and refuses to admit to a drug or alcohol problem. She has made frequent visits to the local emergency room for both mental health and medical complaints, but she refuses any follow-up treatment. Her main requests are for money and food, not treatment. Jane has been offered involvement in a housing program that does not require treatment engagement or sobriety but has refused due to paranoia regarding working with staff to help her in this setting. Jane B. refuses all medication due to her paranoia, but she does not appear to be acutely dangerous to herself or others.

Source: CSAT, 2005, p. 70.

7-6Screening and Assessment of Older Adults

The Baby Boomer generation is increasing the number of aging Americans, and along with it, an “epidemic of mental health and/or substance abuse disorders” (Friedman, 2013). There are about 5.6–8 million Americans 65 or older who have a mental health or substance use disorder, and by the year 2030, the number is estimated at 10.1–14.4 older Americans (Institute of Medicine, 2012). Unfortunately, we will fall far short in providing adequate care for our elders in several areas:

· (1)

not enough trained geriatric psychiatrists, nurses, psychologists, and social workers;

· (2)

not enough research to address the challenges of tailoring interventions to this age group; and

· (3)

not enough routine screening and assessment of elders for detection and early intervention of these problems (Wu & Blazer, 2013; Bartels, Pepin, & Gill, 2014).

In this section, we will address the third shortcoming.

Substance abuse problems are often misdiagnosed or not assessed at all in older adults. Attitudes that drinking and drugging are a young person’s problem may affect our willingness to screen and assess. Even when we do discuss alcohol and drug use with an older adult, they may not understand that small amounts of alcohol or drugs can be a problem. Because older clients are more sensitive to these substances and have less ability to metabolize them, the National Institute of Alcohol Abuse and Alcoholism (2015) recommends that healthy older adults (age 65 and older) drink no more than seven drinks a week (i.e., 12 oz. of beer, 5 oz. of wine at 12% alcohol, or a 1.5 oz. shot of hard liquor at 40% alcohol), and a maximum of three drinks on any occasion. Even a small amount of alcohol can put older adults at higher risks for falls, cause depression, and interact dangerously with other medications. Screening and assessment challenges with this age group include the possibility that  cognitive impairments  can make self-reporting on alcohol and drug use unreliable.

Standard forms, like diagnoses from the DSM-5, contain several items that are inappropriate for clients of advanced age (e.g., items concerning tolerance and legal and occupational consequences of substance misuse). Two well-known alcohol-screening devices that have been validated for use with older adults are the CAGE and the Geriatric MAST. The MAST-G (Michigan Alcoholism Screening Test—Geriatric Version) consists of 24 questions with special relevance to the elderly. Samples are: Does having a drink help you sleep? Did you find your drinking increased after someone close to you died? When you feel lonely, does having a drink help? The MAST-G can be downloaded for free at www.sbirttraining.com. The SMAST-G is the shorter form of 10 items. In addition to these screening questions, clinicians should also inquire about excessive sleeping, declines in personal grooming and hygiene, and withdrawal from family and social activities (Trevisan, 2014).

As with any other age group, drug and alcohol abuse can occur right alongside other psychiatric illnesses. The prevalence of co-occurring disorders in older adults is roughly estimated at between 21% and 66%, although the research literature is almost nonexistent in this area (Bogunovic, 2012; Wu and Blazer, 2013). About 25% of older adults have comorbid depression, and 10–15% have cognitive disorders and anxiety disorders (Bogunovic, 2012). Transportation problems, stigma, lack of trained professionals, cost and lack of screening and assessment can be formidable barriers to mental health treatment.

One effective screen for depression in older adults is the Short-Form Geriatric Depression Scale (GDS). The short GDS has 15 items, as opposed to the original 38 item Long Form GDS (Yesavage, Brink, Rose, Lum, Huang, Adey, & Leirer, 1983). It’s available for free downloading at http://web.stanford.edu/~yesavage/GDS.html and has an app available that will automatically calculate the results. A score greater than or equal to 6 indicates symptoms of depression. Clearly, integrating routine substance abuse screening into mainstream primary care settings is needed to improve early detection and intervention.

The REAP project is an example of a successful community based outreach program in rural New Hampshire that is tailored to address the needs of older adults at risk for mental health and alcohol use disorders (Pepin, Hoyt, Karatzas, & Bartels, 2014). The REAP program is a statewide educational, wellness, and brief mental health and substance misuse program for older adults that provide free services (up to five counseling sessions annually). Referrals to the program come from a variety of sources in the community: medical providers, mental health providers, and family and friends. Upon referral, a REAP counselor contacts the client for an initial assessment. Participants are screened using the Short-Form GDS and the SMAST-G as described above as well as identifying risk factors, protective factors, and collaboratively developing participant goals. Subsequent sessions are focused on education and supportive counseling, connecting participants to entitlement services or to primary care, specialty care, or mental health services. Of the participants screened, 4.47% screened positive for alcohol abuse only, 55.57% screened positive for depressive symptoms only, and 9.91% screened positive for both alcohol abuse and depressive symptoms. The program achieved the goal of helping a large number of older adults who experience psychiatric distress but would be left alone and struggling were it not for identifying them and steering them to appropriate help.

7-7Diagnosing Addiction Problems

Diagnosis is the process that determines whether a person meets certain predetermined criteria for substance abuse, dependence, or pathological gambling. Because there is no gold standard or physiological test for addiction, the criteria used by most U.S. clinicians to classify these disorders are behavioral standards set by the American Psychiatric Association’s (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM-5). International clinicians tend to use the International Classification of Diseases (ICD) from the World Health Organization. Both of these classification systems have evolved over time, with changes published approximately every 10 years. The most current change to the DSM-5 was published in 2013. For the first time, a nonsubstance disorder (gambling) is included in the substance-related and addictive disorders section because of the overlap in terms of etiology, biology, comorbidity, and treatment (Romanczuk-Seiferth, Brink, & Goudriaan, 2014). The substance use disorder in DSM-5 combines the DSM-IV categories of substance abuse and substance dependence into a single disorder measured on a continuum from mild to severe (APA, 2013).

Diagnosis alone does not determine how to proceed with treatment. The DSM-5 describes the behavioral manifestations of the problem, somewhat like a bird classification system that identifies red beak and blue feathers as the markers of a particular bird without saying how or why they got that way. However, a formal diagnosis, like all classification systems, serves several purposes:

· (1)

it helps clinicians talk to each other, using the same term to mean the same thing;

· (2)

it serves as the basis of eligibility for services and third-party reimbursement;

· (3)

it establishes the seriousness of the situation; and

· (4)

it can sometimes reassure the recipient of the diagnosis that he or she is not alone with the problem.

The downside of the DSM system is that it is subject to the political influence of the pharmaceutical industry, is deficit-focused, stresses individual deficiencies, and pays little attention to the issues of social injustice and equality that may cause or increase the symptom and problems (Anderson, Cowger, & Snively, 2009). When using the DSM, it is critical to be aware of these potential shortcomings and balance the assessment with strength-based practices.

A formal diagnosis is usually made by a physician, nurse practitioner, licensed psychologist, or licensed social worker, depending on the rules of the individual state and/or insurance company. The most common approach to diagnosing is through a clinical interview with the client, comparing current symptoms and behaviors to the criteria specified in the DSM-5 (Miller et al., 2011). There are also structured diagnostic interviews available that require specialized training, such as the Structured Clinical Interview for DSM-5 (SCID-5) (First, Williams, Karg, & Spitzer, 2016).

7-8Assessment and the Strength Perspective

Assessment is much more than a toolbox of screening questions and assessment instruments. We do not want to lose the forest (recovery) for the trees (identifying the deficits). To balance the tilt toward the deficit, we also need to assess client strengths and resources and bring them to the light of day. A person recovering from addiction needs all the support they can get for the long and lonely process of setting aside the addiction that used to be their best friend and dealing with “the wreckage of the past.” One woman in the Davis (2009) study on women who were recovering from problem gambling said, “Professional help helps you to get over the devastation of you going through shame, you going through guilt, you going through humiliation, you going through alienation from your family, your friends, and anybody that cares about you” (p. 128). A significant part of how we help people through such devastation is to build a relationship with them.

A good way to discover a person’s strengths and build a relationship is to focus on what is happening in the client’s life and what the client wants to be different. This may mean setting aside, for the time being, the need to gather specific intake, screening, and assessment information about the client and the presenting problems. Bill Miller tells the story of making a dramatic change in a treatment program he directed (Miller et al., 2011). Instead of the client’s first contact being with a clerk who directed the intake process of forms and questions, he changed the first contact to be with a senior counselor. He directed the counselor to start with this statement: “After a while I’m going to ask you some questions that we need to ask everyone, but right now I just want to know why you’re here, what’s happening in your life, and what you hope we might be able to do for you” (p. 75). Counselors spent the first part of the session hearing the client’s story, and when it came time to fill in the forms, they already knew most of the content. The results were a higher retention rate, and the clients wanted to stay with the person who did their intake. Clearly, a therapeutic relationship with the client had a better chance of building after these changes were made.

A guiding principle of strength-based practice is that clients are in charge of setting their own goals and deciding how to achieve them (Rapp & Lane, 2009). Thus, part of the assessment process is to discover what the goals may be that are important to the client. Focusing attention on what the client wants to see happen as a result of working together with the clinician, as in Miller’s example, sets up a partnership that is based on the assumption that people have invaluable information about their experience and lives (Weik, Krieder, & Chamberlain, 2009).

Some strength-based practitioners see assessment as a political activity (Anderson, Cowger, & Snively, 2009). When the assessment process focuses only on deficits, it can reinforce the politically conservative idea that individual deficits are the cause of human problems, not oppressive or mismanaged social systems. In the addiction field, it is common for the public to marginalize “crack mothers” or “gambling addicts” as flawed individuals, instead of looking deeper into the social conditions that generate unequal power, like poverty. When clinicians look at only what has gone wrong in the client’s life, they inadvertently reinforce the idea that the person is the problem, instead of the problem being the problem. The authors recommend several guidelines for a strength assessment, based on the understanding that there are multiple constructions of reality for each person, and that problem situations are forever changing. Some examples of their practical suggestions include (p. 186):

· When assessments are written, they should be written in simple English with a minimum of professional nomenclature so that it is clear to all involved. Whenever possible, use direct quotes to describe the problem and solutions.

· Support and validate the story. This requires belief that clients are basically trustworthy.

· Honor self-determination and help clients discover their own points of view, meanings, choices, and vision for the future.

· Move the assessment toward strengths, both intrapersonal (motivation, emotional strengths and ability to think clearly) and interpersonal (family networks, significant others, voluntary organizations, community groups, and public institutions).

· Discover uniqueness—find the unique situation the client is experiencing.

· Reach a mutual agreement on the assessment, stressing the importance of the individual’s understanding of the situation and their wants. The person can feel ownership only if the assessment is open and shared.

· Do not get caught up in the labels of a diagnosis. A diagnosis should never “totalize” a person’s identity and is not the only outcome of an assessment.

Specific questions that help to move the assessment toward strengths are imbedded in each of the models discussed in the next chapter. For example, a typical technique in motivational interviewing is to ask about what changes the client has successfully made in the past? What was the change? How did they do it? What barriers did they overcome to make the change? (Miller et al., 2011). A familiar line of questioning to clinicians using the solution-focused model is “exception questions,” that is, asking about times when the problem is absent or a little less intense, and finding out what is different about those times (Lee, 2010).

“Recovery capital” is another way to describe client strengths. This is a phrase frequently used in program initiatives that emphasize the need for a longer term approach to addiction recovery rather than an acute model of care (Groshkova, Best, & White, 2013). Recovery capital is generally understood to include the skills, resources, and strengths that a client can bring to bear for support in the recovery process. More specifically, an analysis of recovery capital would include the influence of the community a client lives in, social support systems, and the client’s commitment to those supports (Best, 2014). Instead assessing what’s wrong in the client’s life, an assessment of  recovery capital  is designed to capture the positive measures of personal and social resources. The level of intervention needed will depend on the balance of recovery capital and problem severity/complexity. For example, for people with high recovery capital and low problem severity, brief interventions of various types may be appropriate. An Assessment of Recovery Capital scale has been developed to quantify recovery capital (Groshkova, Best, & White, 2013), which can be found at www.williamwhitepapers.com/recovery_toolkit/. The client is asked to rate 35 items such as “I have personal transportation or access to public transportation,” “I have access to regular, nutritious meals,” and “I have access to On-line recovery support groups” (White, 2015). Subsequent conversation can be directed to areas that were highest scoring and lowest scoring, what the meaning of the scale is for the client, and goals/strategies for increasing recovery capital.

A foundation of clinical skills is needed to put strength-based assessment into practice. One of the most essential is the quality of empathy. Miller and colleagues (2011) found through a series of research studies that regardless of the intervention model, drinking outcomes were strongly predicted by the extent that the counselor practiced empathic, reflective listening during the treatment process. The more empathy, the more recovery. Using Carl Rogers’s definition, empathy is defined as “the ability to listen to your clients and accurately reflect back to them the essence and meaning of what they have said” (p. 50). Empathy requires the additional skill of reflective listening. Reflective listening is not just repeating what the client says, but making a responsive statement, based on your experience and what you have heard, as to what the person really meant. For example, a woman who is experiencing problems with gambling may say, “I don’t have any money to pay the rent, my food is running out, and I’m about to lose my job …” A reflective response might be, “So you’re really at the end of your rope and probably wondering if you should even be here.” Other foundation skills essential to strength-based assessment include the ability to ask open-ended questions, affirm the client’s experience, and make short summaries as the interview progresses. In motivational interviewing, these are called the OARS skills: open-ended questions, affirmations, reflections, and summaries (Miller et al., 2011).

Finally, a strength-based assessment rests on the elusive quality of hope. For some women in the problem gambling study (Davis, 2009), the turning point arrived and recovery began with the tiny kindling of hope by another person: a sense that they were not alone, they were not crazy, and they could, somehow, stop gambling. Hope can be kindled in a professional treatment context or an informal setting. For one woman, her hope began when a psychiatrist told her, “You’re not crazy, you just need Gamblers Anonymous!” Finding strengths in the upside-down world of the woman with gambling problems is a testament to hope. In what could be the standard for clinicians everywhere, a counselor of women problem gamblers describes her therapeutic stance as follows:

The women want good strategies from me, but this is not what I feel they demand most. They seem to want to know that I am there with them, to acknowledge that I see their pain and I am not afraid of them; that I can bear their stories and carry them, and that I will attend to them when they feel unworthy. I feel I am asked to testify to their survival; to help them see what I see: a person, deeply injured, and with great, unbelievable resilience. (Anonymous, 2003)

Chapter Review

7-9aSummary and Conclusion

Many tools are available to help the counselor and the client assess the likelihood of alcohol, drug, or gambling problems. Screening tools, as short as one question, can alert clinicians to the possibility of a problem behavior. More complex assessment tools help define the seriousness of the problem and the consequences of the behavior. A formal diagnosis can qualify the client for particular services and third-party payments. Levels of care classifications assist in treatment matching.

As the addiction field moves steadily in the direction of client-centered, strength-based practice, screening and assessment becomes a more collaborative process that honors clients’ meanings of their experience, their goals for the future, and their strengths as well as limitations. The traditional medical model, where the physician tests for symptoms, diagnosis the problem, and prescribes the solution, no longer prevails in the complex, multidimensional world of clients who are struggling with addiction. Instead, assessment is treated

· (1)

as part of the engagement process, where the emphasis is on listening deeply to the client and empathically reflecting their words and meanings;

· (2)

as part of the treatment process, where goals are established, maintained, and evaluated within the framework of what the client wants to be different; and

· (3)

as a mechanism for identifying not just problems but also client strengths and recovery capital to aid in the recovery process.

The next chapter will focus in depth on five different models of intervention (harm reduction, motivational interviewing, solution-focused, cognitive-behavioral, and trauma-based) that use different approaches and techniques to further strength-based, effective practices.

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