CAS 454 midterm
The official diagnosis might look something like this
"Alcohol Use Disorder, Severe" or "Opiate Use Disorder, Moderate."
Which of the following is an example of Person-First Language?
"I think that your client is most likely a serious meth addict." "Dave, you are an alcoholic." "All of our clients here are addicts and alcoholics of some sort." Correct! "Suzy has an alcohol use disorder and is here seeking treatment."
Tarasoff v. Regents of the University of California
- 1976 - Therapist failed to inform a young woman and her parents of specific death threats made by a client - Poddar stalked Tarasoff bc she did not want a romantic relationship with him -Poddar was hospitalized for being a danger to himself and others, but eventually released - Tarasoff not informed and was murdered by Poddar - therapist failed to inform a young woman and her parents of a specific death threats made by client -therapist knew of Podarr's threats to kill Tarasoff and reported it to police but never warned Tarasoff -specific confidentiality was secondary to public's safety .
Jablonski by Pahls v. United United States States
- 1983 - Extended duty to warm to include the review of previous records that may indicate a history of violent behavior - Doctor did not warn clients gf of her bf's violent history - Kimball killed by Jablonski after his release -previous records of violent behavior -conducted risk assessment but didnt look at past with violence -when released, ended up killing his girlfriend
42 CFR Part 2
- 42 CFR = Code of Federal Regulations (commonly referred to as "Part 2") - The federal confidentiality laws that specifically pertain to alcohol & drug health information concerning services and clients.
Contemplation Stage
- Considering a change - Weighing pros and cons of change
Determination Stage
- in favor of change - Individuals in this stage appear to be ready and committed to action - Ambivalence isn't gone but is no longer a barrier
Action Stage
- individual is actively changing a negative behavior or adopting a new, healthy behavior - putting different strategies and practices to use
precontemplation stage
- stage of change in which people are unwilling to change their behavior - person is aware of problem and opportunity of which they may take advantage - Four R's: Reluctant, Rebellious, Resigned, Rationalizing
Confidentiality
-never put the name of the treatment center in the return address -don't identify yourself as an employee of a treatment center -avoid communicating by text, email, voicemails -avoid friending clients on facebook
master problem index
-prioritize the issues by numbering them -include the date of when a problem is entered -identify the source of the data -write an objective description of the problem: use client's own words when possible -include status of the problem: you know how you have been working towards those goals
exceptions of 42 CFR part 2
-signed release of information form-medical emergencies -threats or acts of harm to program staff and or facilities -reports child abuse or neglect -court ordered -disclosures to an outside agency that provides services to the program through a qualified service -research audit or evaluation
components of a consent to release information
1) The name of the patient 2) The name of the program making the disclosure 3) The purpose of the disclosure 4) Who is to receive the information 5) The information to be released (described as exactly and as narrowly as possible in light of the purpose of the release) 6) That the patient understands that he or she may revoke the consent at any time, except to the extent that action has been taken in reliance on it 7) That revocation may be oral as well as written 8) The date or condition upon which the consent expires, if it has not been revoked earlier 9) The date the consent form is signed 10) The signature of the patient
Know the DSM-5 criteria for substance use disorder
1. Substance is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control substance use. 3. A great deal of time is spent in activities necessary to obtain, use substance, or recover from its effects .4. Craving, or a strong desire or urge to use substance. 5. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of substance. 7. Important social, occupational, or recreational activities are given up or reduced because of substance use. 8. Recurrent substance use in situations in which it is physically hazardous. 9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by substance. 10. Tolerance 11. Withdrawal
The term "intervention" may seem strange but it is meant to indicate that this level of care is not providing treatment. Here are a couple of examples that might help:
1. a two-day drug and alcohol education class that provides basic education about the dangers of drinking/drugging and driving 2. a "victims impact panel" that includes presentations by victims of DUIs
Mild SUD
2-3 symptoms
Level II Intensive Outpatient / Partial Hospitalization
2. 1 Intensive Outpatient generally has nine or more hours of services per week, very often in a clinic or agency environment. 2.5 Partial Hospitalization otherwise known as "Partial Hospitalization" is for those who would benefit from greater than twenty hours of service per week but who do not need twenty-four-hour care and are still living at home. 20 hours / week Additional structure and exposure for clients who need it Intensive outpatient -more that 9 hours per week in clinic or agency Partial hospitalization -more than 20 hours a week -do not need 24 hour care and still live at home
Level III Residential / Inpatient Treatment
3.1 Clinically Managed Low Intensity Residential 3.3 Clinically Managed Population Specific High-Intensity Residential 3.5 Clinically Managed High Intensity Residential 3.7 Medically Monitored Intensive Inpatient 24 hour structured program Good for clients who need to be removed from toxic environment to get sober Residential/ Inpatient treatment -4 different types from low -intensity to high-intensity -client residing in facility that provides substance abuse programming -length of stay depends of severity
Moderate SUD
4-5 symptoms
Severe SUD
6 or more symptoms
Level I Outpatient Treatment
9+ Hours / Week Good for resistant clients who may be overwhelmed by other levels of care Outpatient services-least intensive -fewer than 9 hours per week -initial point of entry into treatment -step down from higher level of care that wasn't successful -increase client motivation
Pros of DSM-5
A "shortcut" for communication between and amongst professionals as anyone with sufficient training will recognize the symptoms and criteria used, and have a good idea about the client's condition. It may provide an "answer" to clients that helps to put their experiences into some context and remove shame and guilt from feeling weak and/or otherwise overly responsible. A more sharpened focus for what should be the goals of treatment by providing helpful boundaries to what clients are often experiencing as "boundary-less."
Which of the following is NOT an example of one of the exceptions listed by 42 CFR Part II for breaking confidentiality?
A client under the age of 18 shares stories of physical abuse by her parents. Correct!Answer A client threatens to vandalize their next door neighbor's house. A client signs a proper release of information form. A client passes out during an assessment and starts to have a seizure.
Dimension 1
Acute intoxication and/ or withdrawal potential-drugs can be life-threatening when in withdrawal One of the risks the ASAM seeks to mitigate relates to a client's physical health. One way it does this is by addressing risks related to intoxication and withdrawal in Dimension 1. Because many drugs are life-threatening when taken to excess, and some can be life-threatening when discontinued (especially in the first few days after cessation of use), Dimension 1 is particularly concerned with such data as date and time of last use, pattern of use (quantity and frequency), and so on. ASAM suggests referral and/or admittance into an inpatient setting with available medical services for a client who is determined as HIGH risk in Dimension 1. In cases of detox, the assessment of the client's condition is ongoing and after the appropriate care, she or he is referred to a level of treatment that matches the intensity and severity of their disorder. The detox process will ideally support the client's dignity and ease their discomfort through the withdrawal process.
Nevada Health Information Provider Performance System (NHIPPS)
All programs receiving state funding were required to use this assessment/database system, which tracked the client from the initial call to the end of a treatment episode (continuing care/aftercare). Few programs use the ASI because of the use of NHIPPS.
whats more appropriate? Amy is autistic or Amy has autism
Amy has autism its better to say counsellors help people with substance use disorders instead of saying they assist alcoholics and addicts
mental status exam
Appearance: What do you see? How is the client's dress—too much, too little, tattered? How is their grooming—fastidious, neglected? What is their posture like? Behavior: Does the client make or avoid eye contact? Is the eye contact that is made comfortable or too intense? Any unusual movements such as tics or tremors, incessant foot tapping, gum chewing? Speech: Is the client's rate of speech too fast or too slow? Is their response time delayed? Do they speak with a monotone or with emphasis? Volume too loud or soft? Mood: How does the client describe his or her own emotional state? Affect: What emotional clues do we see? For example, is the client's affect flat or blunted? Are they close to tears? Is their affect out-of-step with their mood—i.e., does the client smile while talking about how sad they are? Thought Process: Does the client's thought process seem coherent or disjointed? Are the thoughts expressed "normal" as evidenced by being related to one another in a linear fashion? Or, are the thoughts disorganized, disconnected, wild, or strange in other ways? Thought Content: What is the thematic content of the client's thoughts? Are their perceptual disturbances or hallucinations? Is the client preoccupied or fixated on certain topics? Cognition: How well is the client able to focus, attend, and concentrate? How intact is their memory, both short term and long term? Do they know where they are and why they are in your room? Can they recall the date? Insight/Judgment: Does the client exhibit awareness of his or her situation and its problems? Does the client seem able to understand how the choices they make and their behaviors affect themselves and others?
Referral Sources
As discussed earlier in this course, integrated treatment should be the goal of any program and/or provider. For this reason, it is important to record the name and contact information for any referral source that may have referred the client to treatment. As well, it will facilitate the sharing of information if there are the necessary Release of Information forms on file that have been signed by the client.
Employment History
As with educational history, obtaining a client's employment history can be helpful to better understand the client's strengths and limitations, as well how drugs and alcohol may have impacted his or her life. How many times have they been unable to hold a job due to using drugs? How many disciplinary actions and/or days of work have they missed? Does their employment history suggest, perhaps, a lack of accomplishment with frequent job changes that might be indicative of drug use? Not only may such information give an indication as to the severity of a client's drug and alcohol use, it may help to provide a sense for specifically targeted referrals and/or other interventions.
Medical History
Because health problems can derail even the most motivated of clients, it is important to get a thorough history of any known medical problems. It may even be helpful to recommend that a client see a doctor for a comprehensive physical examination. In such a way, we can make sure that clients have access to the needed medical resources to address any medical issues and to have the opportunity to be as healthful as possible. Such resources may not only be "reactionary" (i.e., recommending a client see a doctor to get their diabetes medication) but also "proactive" (i.e., recommending a client work with a dietician to learn how to make nutritious meals). Clients seeking residential treatment will be mandated to be tested for tuberculosis (TB), and should be offered voluntary HIV and hepatitis tests. However, many programs have to refer out for the hepatitis tests due to the cost for these tests.
Explain Posttraumatic Stress Disorder (PTSD)
Because many of our clients have experienced a traumatic event sometime in their past, it will not be uncommon for them to present with symptomology indicated PTSD. Such symptoms include recurrent and intrusive memories of the event that are distressing, heightened startle reflex, avoidance of possible triggers associated with the trauma, difficulty with sleep, and hypervigilance (same caveat as before: for a full list, refer to the DSM-5). Unless resolved, PTSD often persists such that those who experience PTSD are at heightened risk for continuing and/or resuming their use of substances in an effort to cope. It is important, therefore, for clinicians to be familiar with symptoms of PTSD and to make referrals to qualified mental health professionals who have received training in helping clients to resolve PTSD.
Dimension 2
Biomedical conditions and complications -medical problems a client may have -diabetes or high blood pressure/ chronic pain Dimension 2 looks at all other possible medical problems a client may have that will need to be addressed in order for them to be successful in treatment. Does the client have diabetes or high blood pressure? Is there a history of chronic pain? Is the client pregnant? All of these possible conditions have implications and possible impacts on a client's ability to be successful in treatment. These are the sorts of things with which Dimension 2 is concerned. If a client was determined to be at HIGH risk in Dimension 2 (meaning an immediate life-threatening condition is identified at assessment), then a referral and/or admittance to an inpatient setting wherein the needed medical services are available would be made.
screening tools
CAGE LIE-BETS
Screening tools
CAGE -have you ever felt you need to cut down on your drinking? -have people annoyed you by criticizing your drinking? -have you ever felt bad or guilty about your drinking? -have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover LIE BETS -90% effective 1. have you ever lied about your gambling? 2. Have the amounts of your bets increased?
Step 2: Welcoming the Client to the Assessment
Client Information Form (more in-depth than the initial contact form used internally by program staff) Informed Consent for Treatment (or, at the least, to the assessment) Consent for Release of Information (usually to specific individuals or agencies who have referred and/or required the client to seek the assessment) Financial Agreement Form (or, at the least, an acknowledgement of what responsibility, if any the client has towards paying for the assessment)
Additional assesment questions
Client Motivation: How motivated is the client for treatment? What are the primary motivators as identified by the client (i.e., external and/or internal)? Use of Free Time: How does the client keep engaged in his or her free time? Does the client have particular hobbies or activities in which they participate or would like to participate that do not involved drugs or alcohol? Client Strengths: What strengths does the client bring to his or her recovery that can be utilized towards treatment success? Client Barriers: What limitations, whether external or internal, might a client have that need to be addressed to optimize treatment success? Client Goals: What are the client's overall goals for his or her life? Special Needs: What, if any, special needs might a client have? For example, if a client is hard of hearing, they may need to rely more heavily on printed materials and videos with subtitles. Cultural Considerations: Does the client have a particular racial, ethnic, religious, sexual, or other identity that needs to be considered to ensure the client receives optimal treatment?
In regards to co-occurring disorders, which of the following is NOT true?
Compared to those without, those diagnosed with mood or anxiety disorders are about twice as likely to also have a substance use disorder. Those diagnosed with drug disorders have roughly twice the likelihood of also having a mood or anxiety disorder. Correct! Those with mental health disorders have zero chance of ever successfully addressing any substance use disorders they may have.
What is most true about diagnosing with the DSM-5?
Correct! "Diagnosing is part art, part science." If you think a disorder fits a client, then it probably does. When it comes to diagnosing, the more diagnoses you can identify, the better. It is based solely on a client's strengths because assessing a client's resilience is the number one concern of the DSM-5. It is based on objective and verifiable data.
Which of the following is NOT an example listed in the lecture notes of a possible risk for clients in treatment?
Correct! what is happening in other countries exposure to communicable illnesses realizing unpleasant truths about oneself losing or changing jobs
6 dimensions of ASAM
D1: Acute Intoxication and/or Withdrawal Potential D2: Biomedical Conditions and Complications D3: Emotional, Behavioral or Cognitive (EBC) Conditions and Complications D4: Readiness to Change D5: Relapse, Continued Use, or Continued Problem Potential D6: Recovery 6 Environment Rated on a level of no risk, low, mild, moderate, high, severe
Demographic Information
Demographic information includes all of the obvious things that an agency or program may need to know about clients, including how to contact them and more. This will include a client's name, birth date, gender identification, email and physical addresses, all known phone numbers and so forth. While much of the information collected is helpful for billing and other sundry things, it is also helpful for client follow-up and outreach should he or she go AWOL (absent without leave, or absent without notice) or otherwise miss a session. Available research is very clear that counselors and programs that initiate contact after a missed session have higher success rates than those that do not. It should be noted that many places/individual practitioners do not put a social security number in any charting. It may stay in the business office section only. Instead, a unique client identification number may be generated for tracking and confidentiality purposes.
Step 5: What is done with Information from the Assessment
Despite the version of the biopsychosocial form utilized, the information gathered will be used to assess the ASAM Criteria with an indication on the six dimensions of risk levels as Low, Medium, or High, and to the DSM-5 in a checklist format. As well, there will be an evaluation summary at the end of a client assessment. Oftentimes, agency forms will have checklists or spaces for all the information covered as far as alcohol/drug use history, family history, etc. is concerned. There are usually lines at the end of the form to put your conclusions, thoughts, and observations. This is where your counseling experience and instincts come into play and provide you with an opportunity to mention anything from the interview(s) that was not included anywhere else on the form. This is also where you write up your recommendations in a narrative format and any justifications you have for those recommendations that would not be apparent from the objective data.
DDCAT
Dual Diagnosis Capability in Addiction Treatment 1 to 5 scale
Duty to Warn
Duty to warn refers to the responsibility of a counselor or therapist to inform third parties or authorities if a client poses a threat to himself or herself or another identifiable individual. It is one of just a few instances where a therapist can breach client confidentiality. Normally, ethical guidelines require that therapists keep information revealed during meetings strictly private.
Educational History
Educational history may seem self-explanatory but obtaining the details of a client's progress through their education can provide a lot of information as to the client's strengths and limitations, as well how drugs and alcohol may have impacted his or her life. The kinds of things that could be helpful to know could include truancies and disciplinary referrals, whether a client was in special education and why, how far they got through school, and so on. Depending on what is learned, a client in treatment might benefit from a referral to a program to finish their high school diploma.
Dimension 3
Emotional, Behavioral, or Cognitive conditions and complications -emotional, behavioral, or cognitive disorders -co-occurring disorders -developmental ability that should be considered Dimension 3 shifts the focus from physical to psychological threats. These include all possible emotional, behavioral, and cognitive disorders that could occur along with the addiction—often referred to as co-occurring disorders. This is not to say that having a psychological or behavioral disorder is, in itself, a barrier to treatment; if properly treated through either medication or counseling (or other means), it may be no barrier at all. This dimension also attempts to get a sense of whether someone is cognitively impaired to the point where they may have a developmental ability that should be considered in the client's treatment planning. If a client was determined to be at HIGH risk in Dimension 3 (meaning he or she was actively suicidal and/or unable to keep oneself safe), then a referral and/or admittance to an inpatient setting wherein the needed psychological and medical services are available would be made.
T/F? Assessing a client's medical history is really not that important since a client always has the option of seeing someone about their medical issues on their own.
False
T/F? Research has proven that it doesn't matter how we refer to clients, just as long as we call them by their first names.
False
T/F? Sequential treatment has been proven to be far more effective at preventing relapse than either parallel or integrated treatment.
False
T/F? The best assessments are done by counselors straight out of school since it has been documented that they try harder due to feeling like they need to prove themselves.
False
T/F? The word "biopsychosocial" refers to someone who is overly social due to underlying biological and psychological needs.
False
Which of the following is recommended in the "Top Ten List of Practical Advice"
Following the adage, "Nothing about me without me," the assessment and treatment plan should be done with the client present.
ASAM: What is objectivity?
Gone are the days when counselors could make assessments "with their gut." The ASAM Criteria were developed to provide an objective perspective that counselors could utilize in evaluating their clients. It is now best practice to utilize such criteria.
estimations of risk—so someone who is actively suicidal, for example, would present as a
HIGH as in "high risk" in Dimension 3
Not Entering Treatment
In addition to the other myriad risks not included above that would be reviewed and/or discussed with clients, there is one other risk that is often overlooked: the risks associated with not entering treatment. Should clients decide not to enter into treatment, it is important that counselors help clients to understand the potential ramifications (i.e., continued personal misery, family tragedy, unemployment, homelessness, chronic and debilitating health conditions, death).
ASAM: What is Standardization?
In addition, the ASAM Criteria were developed so that there would be less discrepancy amongst different counselors as to what they were seeing, thus helping to facilitate a client being put into the correct level of care from the get-go.
Common required forms include:
Informed Consent for Treatment (if not already completed at assessment) Consent for Release of Information (for any others who may not have been acknowledged if done at the assessment) Financial Agreement Form (specifically for treatment, often times a sliding fee scale based on a client's ability to pay) Clients Acknowledgement Regarding Confidentiality Regulations Client Rights Form Client Grievance/Appeal Form Some treatment providers will have additional forms, such as: Right to Search Forms Emergency Medical Consent Forms Clothing and Personal Possession Inventory Form (inpatient and residential treatment) Physical Exam Results Form
Legal Status
It may go without stating, but many clients are referred for legal reasons related to drug- and alcohol-related infractions and charges. Knowing where they are at in the legal process—do they still have charges pending, are they currently on probation, or are they somewhere in-between—will help counselors to facilitate needed communication(s) with the needed authorities (assuming, again, a proper Release of Information has been signed). It was once thought that clients with external motivation fared worse than those who were internally motivated. Research says otherwise; according to the National Institute of Drug Abuse (NIDA), "Treatment does not need to be voluntary to be effective." Strong motivation can facilitate the treatment process. Sanctions or enticements in the family, employment setting, or criminal justice system can increase significantly both treatment entry and retention rates and the success of drug treatment interventions. Individuals who enter treatment under legal pressure have outcomes as favorable as those who enter treatment voluntarily." By finding a way to include such clients into treatment, it is possible to increase their motivation and receptivity to treatment.
Relationship Changes
It may seem obvious and not need to be said, but our clients exist within a web of relationships that include family and friends, acquaintances, employers, colleagues, and more. For a variety of reasons, some of these people may not be supportive of our clients' desire to quit using drugs and sober; indeed, they may actually work against and sabotage the efforts of our clients. Our clients need to know up-front that important relationships may need to be changed and/or given-up if they are to be successful with sobriety. This could mean, too, enduring feelings of loneliness, loss, and discomfort as clients give up old friends and work on making new ones. Again, our clients deserve to know this as they are considering whether to enter treatment.
Social History
Knowing how clients spend their free time is important. Do most or all of their friends drink and drug? Do they have any friends supportive of recovery? Do they have any hobbies or recreational activities which don't involve the use of alcohol or drugs? How do they relax when they are feeling stressed? As previously mentioned for other sections, knowing the answers to such questions can help programs and counselors to provide more targeted interventions to address any problems that might be identified.
Family History
Knowing the make-up of the client's family will be extremely helpful in ensuring the client receives all available resources and interventions with which to reinforce a family's strengths and compensate, if possible, for their limitations. Accordingly, we would like to know how the client defines "family" and who is included and their relationships with the client. As well, we would like to know how well everyone is getting along and what problems there might be, including whether family members are continuing to use drugs and/or drink alcohol, and/or otherwise may not be supportive of recovery.
someone who is willing and ready for treatment (i.e., in the "action" stage of change) would be considered
LOW as in "low risk" for Dimension 4
What are some examples of when confidential information is disclosed?
Legal instances where such information can be revealed include when it is necessary to provide professional services, when obtaining consultations from other professionals, to obtain payment for services, and to protect the client and other parties from potential harm.
levels of care from .5-IV
Level .5: Early Intervention Level I: Outpatient Treatment Level II: Intensive Outpatient / Partial Hospitalization Level III: Residential /Inpatient Treatment Level IV: Medically Managed Intensive Inpatient Treatment
goals
Measurable: progress toward goal can be monitored Attainable: not set outside a client's ability to attain them Time-limited: not open-ended Realistic: achievable given a client's available resources Specific: detailed a goal is the more affective
Addiction Severity Index (ASI)
Medical Status: How many times in your life have you been hospitalized for medical problems? Do you have any chronic medical problems that continue to interfere in your life? Are you taking any prescribed medication on a regular basis for a physical problem? How many days have you experienced any medical problems in the past 30 days? Employment and Support: What is your highest level of education completed? Do you have a valid driver/s license? How long was your longest full time job? Does someone contribute to your support in any way? What us your usual employment pattern in the past three years? Are you on welfare? How many people depend on you for the majority of their food, shelter, etc.? Alcohol and Drug Use: How many times have you used alcohol in the past 30 days? How many years in your life have you used alcohol in your lifetime? How many times have you used [name specific drug here: for example, heroin] in the past 30 days? How many years in your life have you used heroin in your lifetime? How do you take your heroin (what is the route of administration)? How long was your last period of voluntary abstinence from the primary substance with which you are having issues? How many times have you overdosed on drugs? How many times in your life have you received treatment for alcohol or drug problems? Legal Status: Did the criminal justice system prompt or suggest this admission? Are you on parole or probation? How many times in have you been arrested or charged with the following: shoplifting, probation violations, drug charges, etc.? Have you ever driven while intoxicated? How many months were you incarcerated in your life? How many times in the past thirty days have you engaged in illegal activities for profit? Family/Social Status: Have any of your blood-related relatives had what you would call a significant drinking, drug use, or psychiatric problem? What is your marital status? Are you satisfied with your current marital status? What have been your usual living arrangements in the past three years? Do you live with anyone who has a current alcohol problem or uses non-prescribed drugs? With whom do you spend most of your time? How many close friends do you have? Have you had significant periods in which you have experienced serious problems getting along with anyone in your family? Has anyone ever abused you emotionally, physically, or sexually? Psychiatric Status: How many times have you received treatment for any psychological or emotional problems in a hospital or inpatient setting? How many times have you received treatment as an outpatient/private patient? Have you had a significant period of time (that was not a direct result of alcohol/drug use) in which you have experienced depression, sadness, hopelessness, or loss of interest? Have you experienced hallucinations, or saw things or heard voices that others did not see/hear? Have you had a significant period of time (despite your alcohol and drug use) in which you have experienced thoughts of suicide or attempted suicide? Has a health care professional prescribed you medication for any psychological or emotional problems?
On Confidentiality
Never put the name of the treatment center in the return address on the envelope of a bill. This could alert the mail carrier and anyone living in the home that someone at that residence is in treatment. If you have to call the place of business of a client, never identify yourself as an employee of a treatment center. Think twice about communicating with clients by text, emailing, or leaving voicemails on phones. There are many technological issues to consider in order to ensure that third parties are not able to intercept these messages. The clients may also be using/sharing the same phones and/or computers with others. Think twice about "friending" clients on Facebook. This has additional ethical implications that will be covered later in this course but, related to this section's topic, doing so could compromise the confidentiality of our clients.
Current Income and Debt
Obtaining a client's current income and debt history is needed because a required part of accessing treatment is determining a client's ability to pay. Though they both may make the same amount of money annually, someone who has a several kids and no insurance will not be able to make the same level of payments as someone who is single with no other debt or obligations. State-certified and/or -funded agencies are required to provide services for those regardless of their ability to pay.
Which of the following statements is most true about the LIE-BETS tool?
One of its questions is, "If you weren't going to lie, what would you say about your gambling?" It is a very difficult screening tool to remember; however, when used correctly it can help to determine whether someone is lying to the clinician. One of its questions is, "Have you ever bet on something other than gambling?" Correct! With just two questions, it is 90 percent effective at detecting the likely presence of a gambling disorder.
Explain Opioid Treatment Programs
Opioid Treatment Programs (OTP), Office-Based Opioid Treatment (OBOT), and Opioid Treatment Services (OTS) are essentially synonymous terms and listed as separate levels of care. Rather than considering these to be separate levels of care as it may appear in the manual, it is better to think of OPT, OBOT, and OTS as services that offered concurrent with other levels of care, oftentimes Level I services. Such services are used with clients who are opiate dependent (e.g., oxycontin, heroin).
Which is not currently a diagnosis within the DSM-5?
Post-Traumatic Disorder Anxiety Correct! Transupsetness Disorder Depression
Know how to take client information, do an ASAM severity rating, place in a treatment level, diagnosis for a substance-related disorder, and formulate a master problem index.
Prioritize the issues by numbering them. This makes it easy to reference the problems when treatment planning or documenting them in case notes. It also helps to create a common frame of reference for all treatment staff—i.e., all staff know what is meant by "Problem number one." Also, keep in mind that the problem numbers are not listed in order of priority, only in order of when they were identified. Those identified earlier in treatment will have lower numbers than those identified later. Include the date of when a problem is entered on the list. Keep in mind that a problem list is not a static, fixed list. It is a living, breathing document and new problems may be added at any time while a client is in treatment. Identify the source of the data. Write an objective description of the problem. Use the client's own words when possible. Include the status of the problem. This is a way of flagging which problems are currently being addressed in treatment (i.e., "active"), which are being deferred to later (i.e., "deferred"), which have been referred for outside services or interventions (i.e., "referred), and which have been successfully addressed (i.e., "resolved").
7 Factors in scoring a treatment center dual diagnosis capability
Program Structure Program Milieu Clinical Process: Assessment Clinical Process: Treatment Continuity of Care Staffing Training
DDCAT toolkit
Program Structure: This domain examines whether the purpose and structure of an organization or program is in alignment with and supportive of providing integrated treatment. Program Milieu: The focus of this domain is whether there are overt signs and expectations that support clients to receive treatment for both of their disorders. Clinical Process—Assessment: The concern of this domain is seen in questions such as, "Is routine screening done for mental health symptoms?" And, "Are both mental health and substance use diagnoses made and documented?" Clinical Process—Treatment: This domain concerns itself with whether treatment plans are created that address both mental health and substance use disorders, as well as whether other treatment-oriented processes are in place to support both. Continuity of Care: As with the previous domains, this domain essentially addresses whether continuity of treatment strategies and interventions address both disorders. Staffing: As expected, this domain evaluates the composition of program staff and/or available resources to effectively treat co-occurring disorders. Training: Related to the previous domain, this domain measures how supported staff have been through their training to effectively work with co-occurring disorders in an integrated fashion.
Dimension 4
Readiness to change -how willing client is to engage in treatment -if they understand how much the drug is affecting them -if they have any skills that will help them with recovery Dimension 4 is the first of the six that does not deal directly with assessing possible organismic threats at either a physical or a psychological level. Instead, it is assessing how willing a client is to engage in treatment, how much he or she wants to make the needed changes, and how much he or she understands how much his or her drug use is contributing to negative consequences in his or her life. This dimension directly reflects Prochaska and DiClemente's Transtheoretical Model of Stages of Change, in that it isconsidered an important variable in the likely success of treatment explains why "Readiness to Change" has its own dimension.
Dimension 6
Recovery/ Living Environment -possible external supports or lack thereof -do they live near liquor stores or where drugs are readily available -steady work, go to school, church Lastly, Dimension 6 examines the possible external supports (or lack thereof) that a client may have. Does she or he have stable housing? Adequate food? Transportation? Do they live in a drug-infested neighborhood or with actively using family members? Do they live near liquor stores? Are their friends supportive of their abstinence or do most of them use? Do they have steady work, go to school, go to church, and/or have childcare, etc.?
Dimension 5
Relapse, continued use or continued problem potential -internal skill set for being able to prevent relapse or discontinue use -periods of abstinence Dimension 5 specifically assesses a client's internal skill set for being able to prevent relapse and or discontinue their use. In other words, we are looking at whether a client has ever exhibited (perhaps through periods of abstinence and/or reduced use) the use of skills and information that would allow him or her to reduce, stop, and/or refrain from using. This dimension also encourages the counselor to take the client's mental health issues and developmental level into consideration.
Level IV Medically Managed Intensive Inpatient treatment
Reserved for clients with most acute detox, intox, medical, and/or mental health needs Typically a short term treatment until client is stable to move to Level III Medically managed intensive inpatient treatment-hospital setting -so severe they require 24 hr/ day -high in dimension 1-3 -overdoes -injury/ death from other medical conditions -suicidality
Level . 5 Early Intervention
Services for specific individuals who, for a known reason, are at risk of developing substance‐ related problems Individual may not meet the diagnostic criteria for a substance use or addictive disorder Early intervention -shows few if any risk factors -low in all risk dimensions -2 day drug and alcohol class . -"victims impact panel"
specific exceptions to confidentiality in 42 CFR, Part 2
Signed release of information form: As just discussed, a proper signed release of information form would authorize information to be shared with designated parties. Medical emergencies: If a client needed immediate medical attention, only reveal as much information as necessary to the hospital or physician. Threats or acts of harm to program staff and/or facilities: If clients make threats or acts of harm to program staff and/or facilities, then confidentiality may be broken. Again, only the minimum amount of information necessary would be shared with law enforcement. Reports of child abuse or neglect: Though not directly stated as such, 42 CFR Part II does require providers to follow state laws with regards to reporting child abuse or neglect. Since all states require the reporting of child abuse or neglect, program staff would be able to break confidentiality to make such reports. Court order with a subpoena: Both must be present in order to compel disclosure. A court order is not enough, nor is a subpoena. Internal program communications: It is expected that all treatment staff at an agency will communicate and share information through both written (i.e., a client's file) and oral communications. Communications that do not disclose client-identifying information: When writing grants, for example, it would be permissible to use numbers of clients and information about the services but never reveal anything specific about an individual client. Disclosures to an outside agency that provides services to the program through a Qualified Service Organization Agreement (QSOA): As an example, a treatment agency might have an outside accounting firm that is conducting a financial audit sign a QSOA. Research, audit, or evaluation: For example, the Substance Abuse Prevention and Treatment Agency (SAPTA) in Nevada needs reports and data so that the treatment center can continue to receive funding.
What is a Co-occuring disorder?
Simply enough, it means that someone has both a substance use disorder as well as the presence of at least one mental health disorder. Another term that is often used to describe those with co-occurring disorder is to say that they have a "dual diagnosis."
Explain Depression
Some examples of these criteria include depressed mood, loss of interest in formerly pleasurable activities, thoughts of worthlessness, difficulty in thinking, and thoughts of death or suicide (for a complete list, refer to a copy of the DSM-5). When assessing any of our clients, it is important that we also do a thorough screen for suicidality, a person's likelihood towards suicide. There are a variety of screens out there but the best ones are direct—do you currently feel suicidal? Have you ever felt suicidal? If so, when? Do you currently have a plan for committing suicide—means, timeframe, etc.? It is important to do this for all clients seeking substance abuse treatment, not just those with histories of depression, as emotions can be intensified and/or blunted when learning to live without such substances. And while I have learned that clients who experience depression frequently feel "heavy"—i.e., there moods are somber, there is little joy—I have also learned not to discount other ways in which people with depression may present in their counseling session. For example, it is not uncommon for folks who have resolved and planned to commit suicide to present with an increase an affect and a reduction in depressive symptoms.
Explain Anxiety
Some examples of these criteria include excessive anxiety or worry, difficulty controlling or living with the anxiety or worry, irritability, difficulty sleeping, and restlessness (again for a complete list, refer to a copy of the DSM-5). It has been my experience that clients with anxiety will have a hard time being present with me (or in a group) while doing counseling because concentrating is difficult for them. As well, there are often similarities to depression in that such clients will present with a blank and blunted affect indicating difficulty in being fully open to life experiences and emotions, reduced motivation, and difficulty in following-through with setting or achieving goals. Indeed, so common is it for clients to experience both anxiety and depression that they are frequently referred to as being "two sides of the same coin."
Which of the following components/statements of a fictional treatment plan would be better off revised?
Strategy/Method/Intervention: "I will go to a detox center by the end of this week." Objective: "I will be alcohol and drug free in 30 days." Problem Statement: "I need treatment." Goal: "I want to live life free from alcohol and other drugs."
Duty to Warn cases
Tarasoff v. Regents of the Uni of California (1976) Jablonski by Pahls v. United United States States (1983)
ASAM: Uniform Language?
The ASAM Criteria also help to ensure that counselors across the substance abuse treatment spectrum are utilizing the same terms and that they mean the same things. Thus, "residential" and "outpatient" care have two distinctly different meanings. Also, when counselors from different agencies that both utilize ASAM criteria discuss the six dimensions, they are talking the same language.
ASAM: Continuum of Care?
The ASAM Criteria provide the framework for counselors to conceptualize when it is necessary or time to move their clients up and down the levels of care so that they are receiving the services appropriate to their needs.
who determines how and when confidential information can be disclosed?
The American Psychological Association's Ethical Principles of Psychologists and Code of Conduct These ethical guidelines suggest that private information can only be disclosed with permission of the individual or as permitted by the law.
Biopsychosocial Assessment
The counselor needs to ask close-ended questions in order to elicit the needed detail and information from the client. a counselor is going to evaluate and investigate all relevant domains (biological, psychological, and social) that may have some bearing on who the client is and what their issues are. Another way of thinking about the word "biopsychosocial" is this: we are going to do a comprehensive assessment that includes any information that might be pertinent to what a client is experiencing.
Termination Stage
The ending of a client-agency relationship.
Step 1: First Contact and Screening
The first contact that many potential clients will have with a treatment center is through an initial phone call or by walking into the facility. In this initial contact, it is common for facility staff to screen the potential clients to ensure that the clients are appropriate for the facility and vice-versa. In other words, they want to make sure that any potential clients will benefit from services provided by the facility. Some facilities specialize in treating only specific addictions (i.e., medication-assisted treatment facilities that provide methadone and suboxone commonly treat only those that have opioid use disorders) or populations (i.e., some treatment centers specialize in treating only women and their children). Such screenings are not necessarily very "deep" in that they don't explore the why's or the how's of a potential client's use—this would be covered in a more thorough assessment or evaluation that would come later—but, by design, are more typically broad and surface-oriented.
ASAM: Treatment Compliance?
The hope here is that if clients are best matched with the appropriate level and kind of care, they will be more likely to engage and be successful in therapy.
Maintenance Stage
The maintenance stage is reached when people have successfully sustained the changed behaviour over a relatively long period of time
integrated treatment
The most effective of all treatment modalities the substance abuse and mental health conditions are addressed concurrently and case management is utilized as a strategy to ensure continuity of treatment. This has all sorts of benefits in regards to the clients' care ensuring that members of the treatment team are on the same page so that any care provided is more intentional, consistent, and, well, more integrated.
Disclosing Information about a Client
The release of information form MUST have all nine parts in order to be valid. Also, this form authorizes disclosure but does not compel disclosure. It may not be in the best interest of the client to release certain types of information to certain parties. For example: a client's attorney may be requesting information but that does not mandate that the treatment center has to release the information. Releases are often signed by the client so information can be shared with any number of parties including parents/guardians, spouse/significant other, family members, employer or EAP, social worker, school counselor, therapist, other treatment centers, probation/parole officer, insurance company, collection agency, physician, vocational rehabilitation counselor, etc. Clients have the right to not sign a release, as well to revoke a release.
Employment Changes
There are many times when drinking and or using drugs is an accepted or even encourage part of the work lives of our clients. It may be trucking companies who look the other way while their employees use amphetamines to work long hours, bartenders surrounded by alcohol (and more), or white collar executives expected to wine-and-dine potential clients. Clients need to know that changes in employment may need to be considered if they are to be successful.
Exposure to Communicable Diseases
This won't necessarily come as a surprise to many of the clients, but it will for some. Because many of the clients will be working in settings (i.e., group treatment, residential centers) in which they will come into contact with other clients, they need to know that there is an elevated risk for TB, HIV, and hepatitis. This higher incidence is related to the unhealthy life choices that many of the clients were making for so long including ignoring their health needs, using contaminated needles, having unsafe sex, and more. Again, not only do potential clients deserve to know this but good centers will provide education and strategies so that clients can diminish the likelihood of contracting these diseases.
Exposure to Other Clients
Though the (hopefully) majority of interactions our clients have with other clients will be positive, prospective clients need to know that not all of the other clients will necessarily have their best interests at heart. As such, they should be provided information about this reality and what it means (i.e., broken confidences, financial and sexual exploitation).
Personal Changes
Though the goals our clients are seeking for positive changes in their lives are worth working for, the act of working towards these goals will likely still be stressful. In addition, as clients develop new strengths, confront old demons, and discover new ways of being in the world, their sense of who they are will shift. Again, though this may be a net positive, any change—whether positive or negative—is experienced as stressful.
T/F? A counselor should be careful not interpret judgments as facts.
True
T/F? In treatment planning, the statement written for the "Objective" is more narrowly and specifically written than the broader "Goal" statement.
True
T/F? Informed consent means sharing with a client at intake all of the potential rewards and risks from entering treatment.
True
T/F? It is important to develop and pay attention to your "sixth sense" as a clinician.
True
what SBIRT refers to and entails
Used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment. Brief Intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change. Referral to Treatment provides those identified as needing more extensive treatment with access to specialty care -Screening, Brief Intervention, and Referral to Treatment -used by non-substance abuse professionals -5 minute interview -motivation
Step 4: At the End of the Assessment
When the client interview is completed, it is recommended that the counselor share with the client what can be expected. Depending on agency protocol and policy, the counselor might feel comfortable sharing their initial clinical impressions and thoughts regarding possible treatment recommendations. If there is more to the assessment (i.e., waiting on reports from other sources, need to consult with a supervisor or other members of the agency's clinical team) the assessment counselor would inform the client of these and how they would be incorporated into the assessment. Timeframes and methods for reporting results of the assessment with both the client and any referral sources would also be shared.
Which of the following is NOT in the list of things covered in a Mental Status Exam?
Whether a client's thoughts are coherent Correct! Making sure that if a client follows sports that they are able to identify his/her favorite team How close to tears a client might be while relating a story from their past Style of dress and attention to grooming
One way of assessing a treatment program's level of service integration is by using the DDCAT Toolkit. Which of the following is one of the domains the Toolkit specifically evaluates?
Whether there are outside supporters who provide crucial political and/or marketing support of the program. How a program secures and sustains its funding of services. Where the program is located—i.e., whether it is located on a busy street or on a sleepy country lane. Correct! The quality and quantity of available staff to offer needed resources and approaches to treat both co-occurring disorders.
what is the "sixth sense"
With time and experience, good clinicians will develop a sixth sense, a reflex if you will, that will help to ensure their "alarm bells" ring when something seems out of place. Oftentimes, this initial impression is more felt and sensed than something that can be put into words. When this happens, good clinicians will use such impressions as a guide for their work with the client. Sometimes the impressions are confirmed and sometimes they are not, so it is important not to prejudge what counselors may be seeing or feeling. Counselors should be familiar with the procedures at their facility for communicating their impressions or concerns—perhaps it is expected that drug and alcohol counselors will flag any anomalies for review by their supervisors—so that they can be appropriately responded and attended to. One such example of when we must be cautious is when clients have been actively using alcohol or drugs and are under the influence or in withdrawal. Delusional, aggressive, and withdrawn behavior can be caused by a variety of drugs, as can anxiety and depression. Lest something is missed, this is why it is so important that assessments of such clients are done thoroughly and completely. When such symptoms are truly caused by drug and alcohol use, it is not uncommon to see rapid improvement in mood and functioning over time as clients become clean and sober.
Substance Abuse Subtle Screening Inventory (SASSI)
accuracy rate of over 90 percent. The SASSI helps assessment counselors by providing additional information for their assessments, providing additional motivation for a client who may be experiencing ambivalence towards treatment, and more.
informed consent
an ethical principle that research participants be told enough to enable them to choose whether they wish to participate -relationship changes -employment changes -personal changes-exposure to communicable diseases -exposure to other clients-not entering treatment
Which of the following is NOT one of the diagnostic criteria for pathological gambling?
asking others for money to cover losses constant thoughts about betting Correct! connecting with other gamblers to increase the odds of winning inability to feel a sense of calmness
Counselors use what when person first language is not used
blame
what is the mental status exam?
does not provide a diagnosis but simply assists counselors in identifying any unusual behaviors that could necessitate additional resources To put this another way, the MSE is to mental health what a traditional physical exam is to physical health.
T/F? It is best to use already-created generic treatment plan templates when working with clients as these have been tried-and-tested and will increase the likelihood of the success of our clients.
false
T/F? Writing good treatment plans is easy.
false
Co-occurring (dual diagnosis) material
having both a mental health disorder along with a substance abuse disorder -those diagnosed with mood or anxiety disorders are twice as likely to also have a substance use disorder and vice versa -out of adults with substance abuse disorder, 40% have co-occurring mental health disorder
sequential treatment
is treating one disorder then the other rather that treating both at the same time
why should a counselor not label their client?
it is important that clinicians not "label" their clients as alcoholics, addicts, junkies, etc. Labels can become self-fulfilling prophecies and increase the likelihood that clinician will see a "disease" before seeing the person.
Which of the following is NOT part of the Addiction Severity Index?
legal status medical status psychiatric status Correct! environmental status
Out of all adults with a substance use disorder
more than 40 percent have a co-occurring mental health disorder.
language changes what?
perception
Gambling addiction has been linked to
physical health issues such as obesity, high blood pressure, insomnia, and cardiac and intestinal disorders (Desai, Desai, and Potenza, 2007, Levens, et al. 2005). It has also been linked to depression, anxiety, substance abuse, attention deficits, personality disorders, and suicidal activities (Petry, Stinson, and Grant, 2005). As quoted by Rena Nora (2007), "Approximately 20 percent of patients in treatment for Pathological Gambling have been involved in a suicidal gesture, attempt, or have completed the act."
Prochaska and DiClemente's model of the Stages of Change
precontemplation contemplation determination action maintenance termination
the diagnostic criteria for pathological gambling include the following:
preoccupation with gambling increasing amounts of money being wagered feelings of loss of control feelings of restlessness and irritability gambling as a form of "escape" gambling to "chase losses" lying committing illegal acts losing relationships seeking bailouts
Person 1st Language
putting the person before the disability/disorder prevents from placing labels on individuals evolved from the disability movement and is an empowering way of acknowledging the person first and the disability second. -save client's dignity and help counselor conceptualize client -came from disability movement
objective
refines goal and makes it more specified
When working with a client on their treatment plan, a counselor should NOT
stay flexible when crafting a treatment plan. Part of the problem for clients with substance abuse issues is that they've had too MUCH freedom. Better for treatment plans to be rigid. use the client's words when writing parts of the treatment plan. It is just pure laziness on the part of a counselor not to translate what the client is saying into the appropriate clinical jargon use the client's input in considering what should go into the program. The whole reason a client is in treatment is because they haven't been able to be successful in treatment on her own. *make things as difficult as possible. When a treatment plan is written with more steps or more words than needed, it makes it more difficult for clients to follow.
LIE-BETS
the LIE-BETS tool has a more than 90 percent effectiveness rate if a person answers yes to either question indicating the presence of a possible gambling problem. It is uncommon for any screening tool, much less one with just two questions, to have demonstrated such efficacy.
dual diagnosis
the client with both substance abuse and another psychiatric disorder
Within the ASAM framework, the term "Level of Care" refers to
the intensity of services offered by a facility. The higher the level of care, the more consistent the delivery of services. For example, Level I refers to "outpatient" care which may only be offered 1 day per week while Level III refers to "inpatient" care which is often includes services offered throughout the day and the week.
Cons of DSM-5
the use of diagnosis means putting labels on the experiences clients are experiencing, and these labels can negatively influence a clinician's ability to work with their clients. At its most extreme, labels may be used so automatically and thoughtlessly that a client's individuality is completely subsumed. No longer is the client a person with a name, instead he is the "paranoid schizophrenic." Needless to say, clinicians must be careful to guard against the possible corrosion that can come from such labels, and make sure to stay open to all possible sources of information that may clarify a client's diagnosis.
the words addict and alcoholic...
the words addict and alcoholic are used to refer generally to individuals who have difficulties with drugs and alcohol. These are imprecise terms that mean different things to different people. For some, they are an important tool for sobriety (12 step programs), For others they are pejorative (negative connotations)
details clients have a right to know include:
treatment modalities (i.e., individual, group, role-playing, theoretical orientation) utilized by a particular agency staff qualifications and training rights to confidentiality including when confidentiality may be broken costs associated with treatment how to file a grievance if a client feels they are not being treated fairly agency/program rules expected frequency and length of treatment In other words, clients have the right to expect full disclosure for any treatment in which they agree to provide their consent. To provide anything less is to fall short of what is expected as professionals.
parallel treatment
treatment provided at the same
Compared to those without, those diagnosed with mood or anxiety disorders are about
twice as likely to also have a substance use disorder.
Those diagnosed with drug disorders have roughly
twice the likelihood of also having a mood or anxiety disorder.
Dual Diagnosis Capable program
which can accommodate relatively stable mental health problems
Dual Diagnosis Enhanced programs
which can treat clients with more unstable or severe mental disorders.
what are the specifics of legal duty to warn
• A therapist is required to breach confidentiality if the client poses an imminent threat to either himself, the therapist, or a third party. • The necessary information must be divulged to someone who is capable of taking action to reduce the threat. • In most cases, the person who is in danger and law enforcement would be notified.
