Assessment & Screening

Aspects of Recovery: Assessments

Screening & Assessments

While both screening and assessment are ways of gathering information about the client in order to better treat him, assessment differs from screening in the following way:

  • Screening is a process for evaluating the possible presence of a particular problem.

  • Assessment is a process for defining the nature of that problem and developing specific treatment recommendations for addressing the problem.

A screening assessment is generally completed by phone upon the initial contact and includes obtaining general information about the person, including name and contact information, age, insurance information for billing, social security number, date of birth, and the person’s reasons for seeking help at this time.  With this information, insurance payment and qualification for treatment is determined, and the assessment to determine the type of treatment may be scheduled.  

A basic assessment consists of gathering key information and engaging in a process with the client that enables the counselor to understand the client’s readiness for change, problem areas, COD diagnosis(co-occurring disorders), disabilities, and strengths.

An assessment typically involves a clinical examination of the functioning and well-being of the client and includes a number of tests and may include written and oral exercises.

A COD diagnosis is established by referral to a psychiatrist, clinical psychologist, or other qualified healthcare professional. Assessment of the client with COD is an ongoing process that should be repeated overtime to capture the changing nature of the client’s status. 

Intake information consists of

  1. 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
  2. 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
  3. 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

In addition, the basic information can be augmented by some objective measurement, such as that provided in the University of Rhode Island Change Assessment Scale (URICA) (McConnaughy et al. 1983), Addiction Severity Index (ASI) (McLellan et al. 1992), the Mental Health Screening Form-III (Carroll and McGinley 2001), and the Symptom Distress Scale (SDS) (McCorkle and Young 1978).  Most treatment facilities have incorporated their own versions, which are documented and stored in an electronic health record.

It is essential for treatment planning that the counselor organize the collected information in a way that helps identify established mental disorder diagnoses and current treatment. The text box below highlights the role of instruments in the assessment process.

There are 12 specific steps in the assessment process.

Step 1: Engage the person

  • The first step in the assessment process is to engage the client in an empathic, welcoming manner and build a rapport to facilitate open disclosure of information regarding mental health problems, substance use disorders, and related issues. The aim is to create a safe and non-judgmental environment in which sensitive personal issues may be discussed. Counselors should recognize that cultural issues, including the use of the client’s preferred language, play a role in creating a sense of safety and promote accurate understanding of the client’s situation and options. Such issues therefore must be addressed sensitively at the outset and throughout the assessment process.

Step 2: Identify and contact collaterals (family, friends, other providers) to gather additional information where possible

  • Clients presenting for substance abuse treatment, particularly those who have current or past mental health symptoms, may be unable or unwilling to report past or present circumstances accurately. For this reason, it is recommended that all assessments include routine procedures for identifying and contacting any family and other collaterals who may have useful information to provide. Information from collaterals is valuable as a supplement to the client’s own report in all of the assessment steps listed 

Step 3: Screen for and detect COD (co-occurring disorders)

  • Because of the high prevalence of co-occurring mental disorders in substance abuse treatment settings, and because treatment outcomes for individuals with multiple problems improve if each problem is addressed specifically, the consensus panel recommends that

    • All individuals presenting for substance abuse treatment should be screened routinely for co-occurring mental disorders.

    • All individuals presenting for treatment for a mental disorder should be screened routinely for any substance use disorder.

  • The content of the screening will vary upon the setting. Substance abuse screening in mental health settings should

    • Screen for acute safety risk related to serious intoxication or withdrawal

    • Screen for past and present substance use, substance-related problems, and substance-related disorders

  • Mental health screening has four major components in substance abuse treatment settings:

    • Screen for acute safety risk: suicide, violence, inability to care for oneself, HIV and hepatitis C virus risky behaviors, and danger of physical or sexual victimization

    • Screen for past and present mental health symptoms and disorders

    • Screen for cognitive and learning deficits

    • Regardless of the setting, all clients should be screened for past and present victimization and trauma.

Step 4: Determine quadrant and locus of responsibility

  • Determination of quadrant assignment is based on the severity of the mental and substance use disorders  Most of the information needed for this determination will have been acquired during step 2, but there are a few added nuances.

Step 5: Determine level of care

  • The use of the ASAM PPC-2R provides a mechanism for an organized assessment of individuals presenting for substance use disorder treatment to determine appropriate placement in “level of care.” This process involves consideration of six dimensions of assessment:

    • Dimension 1: Acute Intoxication and/or Withdrawal Potential

    • Dimension 2: Biomedical Conditions and Complications

    • Dimension 3: Emotional, Behavioral, or Cognitive Conditions and Complications

    • Dimension 4: Readiness to Change

    • Dimension 5: Relapse, Continued Use, or Continued Problem Potential

    • Dimension 6: Recovery/Living Environment

Step 6: Determine diagnosis(es)

  • Determining the diagnosis can be a formidable clinical challenge in the assessment of COD. Clinicians in both mental health services and substance abuse treatment settings recognize that it can be impossible to establish a firm diagnosis when confronted with the mixed presentation of mental symptoms and ongoing substance abuse. Of course, substance abuse contributes to the emergence or severity of mental symptoms and therefore confounds the diagnostic picture. Therefore, this step often includes dealing with confusing diagnostic presentations.

Step 7: Determine disability and functional impairment

  • Determination of both current and baseline functional impairment contributes to identification of the need for case management and/or higher levels of support. This step also relates to the determination of level of care requirements. Assessment of current cognitive capacity, social skills, and other functional abilities also is necessary to determine if there are deficits that may require modification in the treatment protocols of relapse prevention efforts or recovery programs. For example, the counselor might inquire about past participation in special education or related testing.

  • The clinician determines:

    • 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, through what means? If not, is the client disabled, or dependent on others for financial support?

    • 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 disability? Are there cognitive or memory impairments that impede learning? Is the client limited in ability to read, write, or understand? Are there difficulties with focusing, concentrating, and completing tasks?

Step 8: Identify strengths and supports

  • All assessment must include some specific attention to the individual’s current strengths, skills, and supports, both in relation to general life functioning, and in relation to his or her ability to manage either mental or substance use disorders. This often provides a more positive approach to treatment engagement than does focusing exclusively on deficits that need to be corrected. This is no less true for individuals with serious mental disorders than it is for people with substance use disorders only.  Questions might focus on

    • 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 and linguistic needs and supports

  • As noted above, detailed cultural assessment of individuals with substance use disorders is beyond the scope of this chapter. Cultural assessment of individuals with COD is not substantially different from cultural assessment for individuals with substance abuse or mental disorders only, but there are some specific issues that are worth addressing. These include

    • 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

Step 10: Identify problem domains

  • A comprehensive evaluation for individuals with COD requires clarifying how each disorder interacts with the problems in each domain, as well as identifying contingencies that might promote treatment adherence for mental health and/or substance abuse treatment. Information about others who might assist in the implementation of such contingencies (e.g., probation officers, family, friends) needs to be gathered, including appropriate releases of information.

Step 11: Determine stage of change

  • A key evidence-based best practice for treatment matching of individuals with COD in both substance abuse treatment and mental health services settings is the following:

    • For each disorder or problem, interventions have to be matched not only to specific diagnosis, but also to stage of change; the interventions also should be consistent with the stage of treatment for each disorder.

  • For each problem, the counselor chooses a statement that most closely fits the client’s view of that problem:

    • No problem and/or no interest in change (Precontemplation)

    • Might be a problem; might consider change (Contemplation)

    • Definitely a problem; getting ready to change (Preparation)

    • Actively working on changing, even if slowly (Action)

    • Has achieved stability, and is trying to maintain (Maintenance)

Step 12: Plan treatment

  • The ultimate purpose of the assessment process is to develop an appropriately individualized integrated treatment plan. is recommended using  the following approach:

    • Treatment planning for individuals with COD and associated problems should be designed according to the principle of mental disorder dual (or multiple) primary treatment, where 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. 

    • Integrated treatment planning involves helping the client to make the best possible treatment choices for each disorder and adhere to that treatment consistently. At the same time, the counselor needs to help the client adjust the recommended treatment strategies for each disorder as needed in order to take into account issues related to the other disorder.

The assessment process described above is a systematic approach for substance abuse treatment clinicians (and mental health clinicians) to gather the information needed to develop appropriately matched treatment plans for individuals with COD. This process can take anywhere from 2-4 hours, and out-of-pocket costs without insurance range between $150.00 – 250.00; health care professionals, DOT, or FAA employees may expect to pay significantly more.

Although the steps appear sequential, in fact, some of them could occur simultaneously or in a different order, depending on the situation. It is particularly important to identify and attend to any acute safety needs, which often have to be addressed before a more comprehensive assessment process can occur. Sometimes, however, components of the assessment process are essential to address the client’s specific safety needs. For example, if a person is homeless, more information on that person’s mental status, resources, and overall situation is required to address that priority appropriately.

Finally, it must be recognized that while the assessment seeks to identify individual needs and vulnerabilities as quickly as possible to initiate appropriate treatment, assessment is an ongoing process: As treatment proceeds and as other changes occur in the client’s life and mental status, counselors must actively seek current information rather than proceed on assumptions that might be no longer valid.

www.ncbi.nlm.nih.gov

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