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WELCOME
• Good Morning
and Welcome
Introduction to
Washington State’s Process for the
Screening and Assessment of
Persons with Co-Occurring
Disorders
This training designed to meet
• Washington State RCW 71.05.027
• ESSB 5763
• TIP 42: Substance Abuse Treatment for
Persons with Co-Occurring Disorders
TIP Chapter 4: Assessment
• Module I
– Introduction to Screening of Persons with
potential Co-Occurring Disorders:
Overview and Focus on GAIN-SS
• Module II
– Screening and Assessment, Steps 1 - 2
• Module III
– Screening and Assessment Process:
Steps 3 - 4
Module I
Introduction to Screening and
Assessment of Persons with CoOccurring Disorders: Overview and
Focus on GAIN-SS
Module I Objectives
• Introduce TIP 42: Chapter 4 – Assessment
• Distinguish between screening and assessment
• The importance of screening across disciplines
• Introduction of the GAIN-SS for screening
12 Step Assessment Process
1: Engage the client
2: Identify & contact
collaterals to gather
additional information
7: Determine disability &
functional impairment
8: Identify strengths &
supports
3: Screen for & detect
COD
9: Identify cultural & linguistic
needs & supports
4: Determine quadrant &
locus of responsibility
10: Identify problem domains
5: Determine level of care
6: Determine diagnosis
11: Determine stage of change
12: Plan treatment
Screening
• Screening for COD seeks to answer a
“yes” or “no” question:
– Does the substance abuse client being
screened show signs of a possible mental
health problem?
OR
– Does the mental health client being screened
show signs of a possible substance abuse
problem?
GAIN-SS
• Global Appraisal of Individual Needs – Short
Screen
• Designed for use in general populations to quickly
and accurately identify who would have a disorder
on the full GAIN Assessment and rule out those
who would not
• Designed for self-administration
• Take 3 to 5 minutes to administer
Home Work Assignment
• Read TIP 42 Chapter 4
Module II
Introduction to Screening and Assessment
of Persons with Co-Occurring Disorders:
Screening and Assessment, Step 1 and
Step 2
Module II Objectives
• The importance of the “engagement” in
performing a good assessment
• Review Step 1: Engage the patient
• Review Step 2: Identify and contact
collaterals to gather information
COD Screening & Assessment
To what extent do you currently provide
COD Screening and Assessment and
what instruments if any, are you
currently utilizing?
Instrument Selection Criteria
(Hand Out Screening Tool)
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The screening instrument is sensitive.
The screening instrument is brief.
The screening instrument is low or no cost.
The screening instrument can be administered
and scored with little training.
The screening instrument is applicable to a
diverse range of people.
The screening instrument includes a question
about suicide.
GAIN-SS
• Fifteen - item instrument that screens for
internalizing disorders, externalizing
disorders, substance use disorders.
• Take 3 to 5 minutes to administer
• Meant to determine whether a mental
illness, chemical dependency or cooccurring, assessment is needed
GAIN-SS 3 Subscales
• Internal Disorder Screener (IDScr)
was designed to identify people experiencing
internalizing disorders such as depression, anxiety,
suicidal ideation, and acute/post traumatic stress
disorders
• External Disorder Screener (EDScr)
designed to identify persons experiencing externalizing
disorders such as attention deficit, hyperactivity,
conduct disorder, aggression/violence and other
externalizing behavioral problems
GAIN-SS 3 Subscales
• Substance Disorder Screener (SDScr)
designed to identify persons abusing or
dependent upon alcohol or other drugs
GAIN-SS Scoring
• If a person receives a score of 2 or more on any
of the GAIN-SS subscales, then that person
should be referred for either a mental health, or
chemical dependency assessment. The
screening score shall be noted in TARGET and
referrals shall be noted in the clinical record.
• If a referral is not made, documentation
supporting the decision should be made in the
record.
Screening+Assessment Tx Plan
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 comprehensive assessment serves as the basis
for an individualized treatment plan. The
treatment plan must be matched to individual
needs.
12 Step Assessment Process
• Please read page 71 in TIP 42 in your own
free time
• The purpose of the assessment process is to
develop a method for gathering information
in an organized manner that allows the
clinician to develop an appropriate
treatment plan or recommendation.
12 Step Assessment Process
1: Engage the client
2: Identify & contact
collaterals to gather
additional information
7: Determine disability &
functional impairment
8: Identify strengths &
supports
3: Screen for & detect
COD
9: Identify cultural & linguistic
needs & supports
4: Determine quadrant &
locus of responsibility
10: Identify problem domains
5: Determine level of care
6: Determine diagnosis
11: Determine stage of change
12: Plan treatment
Step 1: Engage the Client
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No “wrong door”
Empathic detachment
Person-centered assessment
Sensitivity to culture, gender, and sexual
orientation
• Trauma sensitivity
Universal access – No wrong door
• Individuals with COD may enter a range of
community service sites and that proactive efforts
are necessary to welcome them into treatment and
prevent them from falling through the cracks.
• The purpose of this assessment is not just to
determine whether the client fits in my program,
but to help the client figure out where he or she
fits in the system of care, and to help him or her
get there.
Empathic detachment
• Requires the assessing clinician to
acknowledge that the clinician and client
are working together to make decisions to
support the client’s best interest.
• Clinicians should be prepared to respond to
the individual needs of clients with COD
Person-centered assessment
• Emphasizes that the focus of initial contact is not
on filling out a form or answering several
questions or on establishing program fit.
• The focus of initial contact is on finding out what
the client wants, in terms of his or her perception
of the problem, what he or she wants to change,
and how he or she thinks that change will occur.
Sensitivity to culture, gender, and
sexual orientation
• Culture plays a significant role in
determining the client’s view of the problem
and the treatment.
• Cultural sensitivity also requires recognition
of one’s own cultural perspective and a
genuine spirit of inquiry into how cultural
factors influence the client’s request for
help.
Trauma sensitivity
• The high prevalence of trauma in
individuals with COD requires that the
clinician consider the possibility of a trauma
history even before the assessment begins.
12 Step Assessment Process
1: Engage the client
2: Identify & contact
collaterals to gather
additional information
7: Determine disability &
functional impairment
8: Identify strengths &
supports
3: Screen for & detect
COD
9: Identify cultural & linguistic
needs & supports
4: Determine quadrant &
locus of responsibility
10: Identify problem domains
5: Determine level of care
6: Determine diagnosis
11: Determine stage of change
12: Plan treatment
Step 2: Identify & Contact Collaterals
• Clients may be unable or unwilling to report
past or present circumstances accurately.
• It is recommended that all assessments
include routine procedures for identifying
and contacting any family and other
collaterals who may have useful
information.
• Client resistance to gathering this collateral
information is a clinical issue and needs to
be addressed motivationally as you would
any other form of client resistance.
• Although gathering collateral information
has been designated as Step 2, information
from collaterals is valuable as a supplement
to the client’s own report in all of the
assessment steps discussed.
Steps in the assessment
process are not always
sequential and may occur in
different order.
Home Work Assignment
• Read TIP 42 Chapter 4
Module III
Introduction to Screening and Assessment
of Persons with Co-Occurring Disorders:
Screening and Assessment, Step 3 and
Step 4
Module III Objectives
• Review Step 3: Screen for potential CoOccurring Disorders
• Review Step 4: Determine Quadrant and
Locus of Responsibility
Major Aims of the Assessment Process
• 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.
12 Step Assessment Process
1: Engage the client
2: Identify & contact
collaterals to gather
additional information
7: Determine disability &
functional impairment
8: Identify strengths &
supports
3: Screen for & detect
COD
9: Identify cultural & linguistic
needs & supports
4: Determine quadrant &
locus of responsibility
10: Identify problem domains
5: Determine level of care
6: Determine diagnosis
11: Determine stage of change
12: Plan treatment
Step 3: Screen for Co-Occurring
Disorders
Screen for:
• Acute safety risk
• Past and present mental health
symptoms/disorders
• Past and present substance abuse disorders
• Cognitive and learning deficits
• Past and present victimization and trauma
Safety Screening
• Safety screening requires that early in the
interview the clinician directly ask the client
(and anyone else providing information) if
the client has any immediate impulse to
engage in violent or self-injurious behavior
or is in any immediate danger from others.
– If the answer is yes, the clinician should obtain
more detailed information about the nature and
severity of the danger, and any other
information relevant to safety.
– If the client appears to be at some immediate
risk, the clinician should arrange for a more indepth risk assessment by a qualified clinician,
and the client should not be left alone or
unsupervised.
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Who in your agency is qualified to
provide suicide risk assessments?
What are their qualifications?
When are suicide risk assessments
completed and how often?
When and how is staff trained in
providing suicide risk assessments?
How is this suicide risk assessment
documented?
Knowing what questions to ask
does not automatically make one
qualified to provide a mental
health, substance abuse, or
suicide risk assessments.
Local agencies providing
Mental Health Screening,
Assessment and Treatment
• CWCMH – (Access)
• Yakima Valley Farm Workers Clinic
(Behavioral Health)
• Catholic Family Services
12 Step Assessment Process
1: Engage the client
2: Identify & contact
collaterals to gather
additional information
7: Determine disability &
functional impairment
8: Identify strengths &
supports
3: Screen for & detect
COD
9: Identify cultural & linguistic
needs & supports
4: Determine quadrant &
locus of responsibility
10: Identify problem domains
5: Determine level of care
6: Determine diagnosis
11: Determine stage of change
12: Plan treatment
Step 4: Determine Quadrant and
Locus of Responsibility
High Severity
Low Severity
III
Less severe
mental disorder/
more severe
substance
abuse disorder
Locus of care:
Substance abuse system
I
Less severe
mental disorder/
Less severe
substance abuse disorder
Locus of care:
Primary health care
settings
Mental Illness
IV
More severe
mental disorder/
more severe
substance
abuse disorder
Locus of care:
State hospitals,
jails/prisons,
emergency rooms, etc.
II
More severe
mental disorder/
less severe
substance
abuse disorder
Locus of care:
Mental health system
High Severity
TABLE OF CO-OCCURRING PSYCHIATRIC AND SUBSTANCE ABUSE RELATED SYMPTOMS
QUADRANT PLACEMENT FOR ADULTS
Washington State
LOW MH – HIGH CD
HIGH MH- HIGH-CD
Integration of services
Collaboration between systems
Eligible for public alcohol/drug services but not mental
health services
Low to Moderate Psychiatric Symptoms/Disorders
And
High Severity Substance Issues/Disorders
Eligible for public alcohol/drug and mental health
services
High Severity Psychiatric Symptoms/Disorders
And
High Severity Substance Issues/Disorders
Services provided in outpatient and inpatient chemical
dependency system
Services provided in specialized treatment
programs with cross-trained staff or multidisciplinary
teams
III
IV
LOW MH - LOW CD
Consultation between systems
Generally not eligible for public alcohol/drug or mental
health services
Low to Moderate Psychiatric Symptoms/Disorders
And
Low to Moderate Severity Substance
Issues/Disorders
HIGH MH – LOW CD
Collaboration between systems
Eligible for public mental health services but not
alcohol/drug services
High Severity Psychiatric Symptoms/Disorders
And
Low to Moderate Severity Substance
Issues/Disorders
Services provided in outpatient chemical dependency or Services provided in outpatient and inpatient mental
mental health system
health system
I
II
Special Note on GAF Score
• Many chemical dependency clients will have GAF
scores below 51.
• The impairment to work, family and judgment
from the dependency can easily produce a 35-45
score on the GAF.
• Using a GAF score below 51 out of context of CD
to determine more severe mental disorders would
result in a high MH quadrant placement for clients
impaired solely due to their chemical dependency.
GAF of 50
• “Serious symptoms (e.g., suicidal ideation,
severe obsession rituals, frequent
shoplifting) or any serious impairment in
social, occupational, or school functioning
(e.g., no friends, unable to keep a job)”.
• How might substance abuse impact these
symptoms?
Determination of SMI Status
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Respondent has a major disorder (such as
depression, psychosis, or manic episodes) and
meets at least one of these additional criteria:
Functional limitation that limits major life
activities, ability to work, or taking care of
personal needs such as bathing;
Mental health (MH) services use or desire for
MH services;
Danger to self or others;
Dependence, i.e., inability to support one's self
or provide for one's own medical care.
• To determine SMI status start by finding out if the
client is already receiving mental health priority
services (e.g., Do you have a mental health case
manager? Are you a client of Community/County
Mental Health?).
• If the client is not already a mental health client,
and their symptoms and behavior adversely affects
their ability to function within the structure of the
substance abuse agency, then it might be necessary
to arrange for referral for a more comprehensive
assessment.
Determination of Severity of
Substance Use Disorders
• The presence of active or unstable
substance dependence or serious substance
abuse (e.g., recurrent substance-induced
psychosis without meeting other criteria for
dependence) would identify the client as
being in which quadrant?
(Quadrant III or IV)
• The presence of less serious substance use
disorder (mild to moderate substance abuse;
substance dependence in full or partial
remission) identifies the client as being in
which quadrants?
(Quadrant I or II)
• Clients in Quadrant III who present in
substance abuse treatment settings are often
best managed by receiving care in the
addiction treatment setting, with
collaborative or consultative support from
mental health providers.
• Clients in Quadrant IV usually require
intensive intervention to stabilize and
determination of eligibility for mental
health services and appropriate locus of
continuing care.
Level of Care Instruments
ASAM PPC 2R - Dimensions
LOCUS - Dimensions
• Acute Intoxication and/or
Withdrawal Potential
• Risk of Harm
• Biomedical Conditions and
Complications
• Emotional, Behavioral, or
Cognitive Conditions and
Complications (includes risk)
• Readiness to Change
• Relapse, Continued Use, or
Continued Problem Potential
• Recovery/Living Environment
• Functionality
• Comorbidity (Medical,
Addictive, Psychiatric)
• Recovery Support and Stress
• Treatment Attitude and
Engagement
• Treatment History
Wrap up
• What is your Home Work Assignment?
• Any questions?
• http://www.chestnut.org/