3.5 Lesson: Assessment of Clients with Co-Occurring Disorders

Working with Resistance
Screening Co-Occurring Disorders

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Links to an external site.Research (De Weert-Van Oene et al., 2001) reveals that a working alliance between the counselor and client is one of the most important factors in retaining chemically dependent clients in treatment. Miller (2009) found that client engagement is the strongest predictor of short-term and long-term retention in addictions treatment.

"Highly resistant clients are experts at winning the client-therapist struggle. They are experts at making us feel incompetent." Aldo Pucci

Resistance

"A process of avoiding or diminishing the self-disclosing communication requested by the interviewer because of its capacity to make the interviewee uncomfortable or anxious.” (Pope, 1979, P. 74)
An active process that has the potential to become a fundamental obstacle to positive counseling.

Advice to the Counselor: Do's and Don'ts of Assessment for COD

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, including family members, persons who have treated the client previously, other mental health and substance abuse treatment providers, friends, significant others, probation officers as quickly as possible in the assessment process. (These other sources of information will henceforth be referred to as collaterals.)
Don't allow preconceptions about addiction to interfere with learning about what the client really needs (e.g., “All mental symptoms tend to be caused by addiction unless proven otherwise”). Co-occurring disorders are as likely to be underrecognized as over recognized. Assume initially that an established diagnosis and treatment regimen for mental illness is correct, and advise clients to continue with those recommendations until careful re-evaluation has taken place.
Do become familiar with the diagnostic criteria for common mental disorders, including personality disorders, and with the names and indications of common psychiatric medications. Become familiar with the criteria in your own State for determining who is a mental health priority client. Know the process for referring clients for mental health case management services or for collaborating with mental health treatment providers.
Don't assume that there is one correct treatment approach or program for any type of COD. The purpose of assessment is to collect information about multiple variables that will permit individualized treatment matching. It is particularly important to assess the stage of change for each problem and the client's level of ability to follow treatment recommendations.
Do become familiar with the specific role that your program or setting plays in delivering services related to COD in the wider context of the system of care. This allows you to have a clearer idea of what clients your program will best serve and helps you to facilitate access to other settings for clients who might be better served elsewhere.
Don't be afraid to admit when you don't know, either to the client or yourself. If you do not understand what is going on with a client, acknowledge that to the client, indicate that you will work with the client to find the answers, and then ask for help. Identify at least one supervisor who is knowledgeable about COD as a resource for asking questions.
Most important, do remember 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.

References

Substance Abuse and Mental Health Services Administration (US) (2005). Treatment Improvement Protocol (TIP) Series, No. 42. Center for Substance Abuse Treatment. Rockville (MD): SAMHSA

Sanders, M. (n.d.). Strategies for engaging difficult-to-reach, multi-problem clients with substance use disorders. Retrieved from http://www.onthemarkconsulting25.com/Documents/STRATEGIES%20FOR%20ENGAGING%20DIFFICULT.pdf

Screening and Basic Assessment for Co-Occurring Disorders (COD)

Clients with COD are best served when screening, assessment, and treatment planning are integrated, addressing both substance abuse and mental health disorders, each in the context of the other. Diagnostic certainty cannot be the basis for service planning and design, and the Co-Occurring Center for Excellence (COCE) encourages the use of a broad definition of COD based on client service needs. For example, some clients' mental health and substance abuse problems may not, at a given point in time, fully meet the criteria for diagnoses in categories from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition Text Revision (DSM- V-TR) (American Psychiatric Association, 2013). Nonetheless, they would be included in a broad definition of COD to allow responses to the real needs of consumers. The process of integrated screening, assessment, and treatment planning will vary depending on the information available at the time of initial contact with the client. The special challenge of screening, assessment, and treatment planning in COD is to explore, determine, and respond to the effects of two mutually interacting disorders. Because neither substance abuse nor mental illness should be considered primary for a person with COD (Lehman et al., 1998; Mueser et al., 2003), an existing diagnosis of mental illness or substance abuse is a point of departure only. The complexity of COD dictates that screening, assessment, and treatment planning cannot be bound by a rigid formula. Rather, the success of this process depends on the skills and creativity of the counselor in applying available procedures, tools, and laboratory tests and on the relationships established with the client and his or her intimates.

Screening, assessment, and treatment planning constitute three interrelated components of a process that, when properly executed, informs and guides the provision of appropriate, client-centered services to persons with co-occurring disorders (COD). Clients with COD are best served through an integrated screening, assessment, and treatment planning process that addresses both substance use and mental disorders, each in the context of the other. This paper discusses the purpose, appropriate staffing, protocols, methods, advantages and disadvantages, and processes for integrated screening, assessment, and treatment planning for persons with COD as well as systems issues and financing.

Figure 1 introduces the concept of Contact (see left-hand side of the figure), which refers to the fact that there is "no wrong door" through which a client can enter the COD system of care. The capacity for screening and the ability to recognize that some form of assistance is required should be available at any point in the service system (CSAT, 2000).

Except Source: US Department of Health & Human Services (2006). Screening, assessment, and treatment planning for persons with co-occurring disorders. Overview paper 2. Retrieved from https://store.samhsa.gov/shin/content/PHD1131/PHD1131.pdf

Reading Assignment

TIP 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders Links to an external site.

Chapter 4: Assessment (pages 65-100 and review Appendix pages 487 -512)