An official website of the United States government
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Substance Use Disorder Treatment for People With Co-Occurring Disorders: Updated 2020 [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2020. (Treatment Improvement Protocol (TIP) Series, No. 42.)
Screening and assessment are central to identifying and treating clients with cooccurring disorders (CODs) in a manner that is timely, effective, and tailored to all of their needs. The assessment process helps fulfill a critical need, as most people with CODs receive either treatment for only one disorder or no treatment at all.
Most counseling professionals can initiate the screening process. Understanding why, whom, and when to screen and which validated tools to use are the keys to success.
The assessment process is a multifactor, biopsychosocial approach to determining which symptoms and diagnoses might be present and how to tailor decisions about treatment and follow-up care based on assessment results.
The 12 steps of assessment are designed to foster a thorough investigation of pertinent biopsychosocial factors contributing to, exacerbating, and mitigating the client's current symptomatology and functional status. At its core is the client's chronological history of past symptoms of substance use disorders (SUDs) or mental illness, as well as diagnosis, treatment, and impairment related to these issues. Counselors should get a detailed description of current strengths, supports, limitations, skill deficits, and cultural barriers. Identification of a client's stage of change and readiness to engage in services will inform treatment planning and optimize adherence and outcomes.
A serious treatment gap exists between the mental disorder and SUD needs of people with CODs and the number of people who actually receive services. According to the 2018 National Survey on Drug Use and Health, of the 9.2 million U.S. adults ages 1 8 and older who had CODs in the past year, more than 90 percent did not receive treatment for both disorders, and approximately 50 percent received no treatment at all (Center for Behavioral Health Statistics and Quality, 2019). Underlying these statistics is the failure of addiction and mental health professionals to adequately recognize CODs.
Screening and assessment are critical components of establishing diagnosis and getting people on the right path to treatment or other needed services. This chapter, whose audiences are counselors, other treatment/service providers, supervisors, and administrators, offers guidance to help addiction counselors understand the purpose and process for effective screening and assessment of clients for possible CODs. It has three parts:
An overview of the basic screening and assessment approach that should be a part of any program for clients with CODs
An outline of the 12 steps to an ideal complete screening and assessment, including some instruments that can be used in assessing CODs (see Appendix C for select screening tools)
A discussion of key considerations in treatment matching
Ideally, information needs to be collected continually and assessments revised and monitored as clients move through recovery. A comprehensive assessment, as described in the main section of this chapter, leads to improved treatment planning and this chapter aims to provide a model of the optimal process of evaluation for clients with CODs and to encourage the field to move toward this ideal. Nonetheless, the panel recognizes that not all agencies and providers have the resources to conduct immediate and thorough screenings. Therefore, the chapter provides a description of the initial screening and the basic or minimal assessment of CODs necessary for the initial treatment planning.
Note that medical problems (including physical disability and sexually transmitted diseases), cultural topics, gender-specific and sexual orientation matters, and legal concerns always must be addressed, whether basic or more comprehensive assessment is performed. The consensus panel assumes that appropriate procedures are in place to address these and other important areas that must be included in treatment planning. However, the focus of this chapter, in keeping with the purpose of this Treatment Improvement Protocol (TIP), is on screening and assessment for CODs.
This section provides an overview of the screening and basic assessment process for CODs. A basic assessment covers the key information required for treatment matching and treatment planning. Specifically, the basic assessment offers a structure for obtaining:
Demographic and historical information, established or probable diagnoses, and associated impairments.
General strengths and problem areas.
Stage of change or level of service needed for both substance misuse and mental illness.
Preliminary determination of the severity of CODs as a guide to final level of care determination.
In carrying out these processes, counselors should understand the limitations of their licensure or certification authority to diagnose or assess mental disorders. Generally, however, collecting screening and assessment information is a legitimate and legal activity even for unlicensed providers, as long as they do not use diagnostic labels as conclusions or opinions about the client. Information gathered in this way is needed to ensure that the client is placed in the most appropriate treatment setting (see the section “Step 5: Determine Level of Care”) and to assist in providing mental disorder and addiction care that addresses each disorder.
In addition, a number of circumstances that can affect validity and test responses may not be obvious to the beginning counselor, such as the manner in which instructions are given to the client, the setting where the screening or assessment takes place, privacy (or the lack thereof), and trust and rapport between the client and counselor. Throughout the process be sensitive to cultural context and to the different presentations of both SUDs and mental disorders that may occur in various cultures (see Chapter 5 of this TIP for more information about culturally sensitive care for clients with CODs). Detailed discussions of these important screening/assessment and cultural matters are beyond the scope of this TIP.
For more information on screening and assessment for CODs, see Screening and Assessment of Co-Occurring Disorders in the Justice System (Substance Abuse and Mental Health Services Administration [SAMHSA], 2015b). For information on cultural topics, see TIP 59, Improving Cultural Competence (SAMHSA, 2014a).
For the purposes of this TIP, screening is a formal process of testing to determine whether a client warrants further because of a co-occurring SUD or mental disorder. The screening process for CODs seeks to answer a “yes” or “no” question: Does the substance misuse (or mental disorder) client being screened show signs of a possible mental (or substance misuse) problem?
Although both screening and assessment are ways of gathering information about the client in order to better treat him or her, assessment differs from screening in that screening is a process for evaluating the possible presence of a particular problem and typically precedes assessment, whereas assessment is a process for defining the nature of that problem and developing specific treatment recommendations for addressing the problem. Thus, assessment is a more thorough and comprehensive process than screening.
ADVICE TO THE COUNSELOR: DOS AND DON'TS OF ASSESSMENT FOR CODs.
The consensus panel recommends that all clients presenting for SUD treatment, mental health services, or both be screened at least annually by SUD treatment and mental health services providers for past and present substance misuse and mental disorders. SUD treatment and mental health counselors should also screen clients who report experiencing or otherwise show signs or symptoms of an SUD or a mental disorder.
Counselors can conduct screening processes, if properly designed (see next paragraph), using their basic counseling skills. All counselors can be trained to screen for COD. There are seldom any legal or professional restraints on who can be trained to conduct a screening. Counselors should work with their program administrators to determine how often to screen, which tools to use, and who will perform the screening.
ADVICE TO THE COUNSELOR: KNOW THE BASICS OF SCREENING.
The purpose of screening is not necessarily to identify what kind of disorder the person might have or how serious it might be. Rather, screening determines whether further assessment is warranted. Screening processes always should define a protocol for determining which clients screen positive and for ensuring that those clients receive a thorough assessment. That is, a professionally designed screening process establishes precisely how any screening tools or questions are to be scored and indicates what constitutes scoring positive for a particular possible problem (often called “establishing cutoff scores”). The screening protocol details exactly what takes place after a client scores in the positive range and provides the necessary standard forms to be used to record the results of all later assessments and to document that each staff member has carried out his or her responsibilities in the process.
So, what can an SUD treatment or mental health counselor do to screen clients? Screening often entails having a client respond to a specific set of questions, scoring those questions according to the counselor's training, and then taking the next step in the process depending on the results and the design of the screening process. In SUD treatment or mental health service settings, every counselor or clinician who conducts intake or assessment should be able to screen for the most common CODs and know the protocol for obtaining COD assessment information and recommendations. For SUD treatment agencies instituting mental disorder screening or mental health service programs instituting substance misuse screening, see the section, “Assessment Step 3: Screen for and Detect COD.” Selected instruments from that section appear in this chapter and in Appendix C.
A basic assessment assessment consists of gathering key information and engaging clients in a process that enables counselors to understand clients’ readiness for change, problem areas, COD diagnoses, 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 written and oral exercises. The COD diagnosis is established by referral to a psychiatrist, clinical psychologist, or other qualified healthcare professional. Assessment of the client with CODs is an ongoing process that should be repeated over time to capture the changing nature of the client's status. Intake information includes:
Background—family, trauma history, history of domestic violence (as either a perpetrator or a victim), marital status, legal involvement and financial situation, health, education, housing status, strengths and resources, and employment.
Substance use—age of first use, primary substance(s) used (including alcohol), patterns of substance use, treatment episodes, and family history of substance use problems.
Mental illness—family history of mental illness; client history of mental illness, including diagnosis, hospitalization and other treatment; current symptoms and mental status; and medications and medication adherence.
In addition, the basic information can be augmented by some objective measurement (see “Step 3: Screen for and Detect COD” and Appendix C). 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 following text box highlights the role of instruments in assessment.
Careful attention to the characteristics of past episodes of substance misuse and abstinence with regard to mental disorder symptoms, impairments, diagnoses, and treatments can illuminate the role of substance misuse in maintaining, worsening, and interfering with the treatment of any mental disorder. Understanding a client's mental disorder symptoms and impairments that persist during periods of abstinence of 30 days or more can be useful, particularly in understanding what the client copes with even when the acute effects of substance misuse are not present. For any period of abstinence that lasts a month or longer, ask the client about mental health services, SUD treatment, or both.
If mental disorder symptoms (even suicidality or hallucinations) occur within 30 days of intoxication or withdrawal from the substance, symptoms may be substance induced. The best way to manage them is by maintaining abstinence from substances. Even if symptoms are substance induced, formal treatment strategies should be applied to help the client newly in recovery best manage the symptoms.
THE ROLE OF ASSESSMENT TOOLS.
Provider and client together should try to understand the specific effects that substances have had on mental disorder symptoms, including possible triggering of psychiatric symptoms through substance use. The consensus panel notes that many individuals with CODs have well-established diagnoses when they enter SUD treatment and encourages counselors to find out about any known diagnoses.
As part of basic assessment, assess clients’ mental health and SUD history by asking questions like:
“Tell me about your mental ‘ups and downs’. What is it like for you when things are worse? What is it like when things are better or stable?”
“How do you notice using alcohol (or whatever substance the client is misusing) affects your depression (or whichever mental disorder symptom the client is experiencing)?”
“What mental disorders have you been diagnosed with in the past? When was that, and what happened after you received the diagnosis?”
“What (mental disorder or substance misuse) treatment seemed to work best for you?”
“What treatment did you like or dislike? Why?”
ADVICE TO THE COUNSELOR: HOW TO MAKE THE ASSESSMENT PROCESS A SUCCESS.
This chapter is organized around 12 specific steps in the assessment process. Through these steps, the counselor seeks to:
Get a more detailed chronological history of mental symptoms, diagnosis, treatment, and impairment, particularly preceding substance misuse and during periods of extended abstinence.
Get a more detailed description of current strengths, supports, limitations, skill deficits, and cultural barriers related to following a recommended treatment regimen for a disorder or problem.
Determine stage of change for each problem and identify external contingencies that might help promote treatment adherence.
Assessment steps appear sequential, but some can occur simultaneously or in a different order, depending on the situation. Providers should identify and attend to acute safety needs, which often must be addressed before a more comprehensive assessment process can occur. Sometimes, however, components of the assessment process are essential to address clients’ specific safety needs. Furthermore, counselors should recognize that although 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 clients’ lives and mental status, counselors must actively seek current information rather than proceed on assumptions that might be no longer valid. Exhibit 3.1 lists general considerations for the assessment of clients with CODs.
EXHIBIT 3.1. Assessment Considerations for Clients With CODs.
The following section discusses the availability and utility of validated assessment tools to assist counselors in this process. A number of tools are required by various states for use in their SLID treatment systems (e.g., ASI, [McLellan et al., 1992]; American Association of Community Psychiatry - Level of Care Utilization System [LOCUS]). Particular attention will be given to the role of these tools in the COD assessment process, with suggested strategies for reducing duplication of effort when possible.
It is beyond the scope of this TIP to provide detailed instructions for administering the tools mentioned, but select information about cutoff scores is included in this chapter (and select measures are included in Appendix C). Basic information about each instrument is also given in this chapter, and readers can obtain more detailed information about administration and interpretation from the sources given for obtaining these instruments.
This discussion is directed toward providers working in SUD treatment settings, although many of the steps apply equally well to mental health clinicians in mental health service settings. At certain key points in the discussion, particular information relevant to mental health clinicians is identified and described.
Because addictions and mental disorders are complex conditions with multiple contributing factors, clinicians should conduct assessments using a biopsychosocial approach that thoroughly investigates clients’ history and current status in a holistic manner. “Biopsychosocial” in this context refers to a clinical philosophy and approach to care that seeks to understand clients and their experience through a medical, psychological, emotional, sociocultural, and socioeconomic lens. This is particularly important when assessing and treating CODs given that numerous determinants and exacerbating and mitigating factors may potentially be relevant to diagnosis, treatment planning, and outcomes. Biopsychosocial assessment is evidence based and the standard of care. It is comprehensive and widely addresses all aspects of clients’ lives that may be relevant to his or her symptoms and service needs.
By definition, a biopsychosocial assessment will rely on input from multidisciplinary team members including physicians and nurses (including psychiatric and mental health nurses [specialty practice registered nurses]); psychologists, psychiatrists, and other mental health professionals; social workers; and addiction counselors and other SUD treatment professionals. Addiction counselors will not be able to assess all biopsychosocial assessment areas (Exhibit 3.2) and will focus primarily on the psychological and social sources of information. Appendix C contains links to sample biopsychosocial assessment forms.
EXHIBIT 3.2. Biopsychosocial Sources of Information in the Assessment of CODs.
TWELVE STEPS IN THE ASSESSMENT PROCESS.
The first step in the assessment process is to engage the client in an empathie, welcoming manner and build rapport to facilitate open disclosure of information regarding mental illness, SUDs, and related concerns. The aim is to create a safe and nonjudgmental environment in which sensitive personal information may be discussed. Counselors should recognize that cultural matters, 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 topics therefore must be addressed sensitively at the outset and throughout the assessment process.
The consensus panel identified five key concepts that underlie effective engagement during initial clinical contact:
Universal access (“no wrong door”)
Empathie detachment
Person-centered assessment
Cultural sensitivity
Trauma-informed services
All staff, including SUD treatment providers and mental health clinicians, in any service setting need to develop competency in engaging and welcoming individuals with CODs. (See Chapter 5 for a discussion of working successfully with people who have CODs and establishing a therapeutic alliance.) Whereas engagement is presented here as the first necessary step for assessment to take place, in a larger sense engagement represents an ongoing concern of the counselor—to understand the client's experience and to keep him or her positive and engaged relative to the prospect of better health and recovery.
“No wrong door” refers to formal recognition by a service system that individuals with CODs may enter through a range of community service sites, that they are a high priority for engagement in treatment, and that proactive efforts are necessary to welcome them into treatment and prevent them from falling through the cracks. Addiction and mental health counselors are encouraged to identify individuals with CODs, welcome them into the service system, and initiate proactive efforts to help them access appropriate treatment in the system, regardless of their initial site of presentation. The recommended attitude counselors should embody is, “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.”
Empathie detachment requires the assessing clinician to:
Acknowledge that the provider and client are working together to make decisions to support the client's best interest.
Recognize that the provider cannot transform the client into a different person but can only support change that he or she is already making.
Maintain an empathie connection even if the client does not seem to fit into the provider's expectations, treatment categories, or preferred methods of working.
Providers should be prepared to demonstrate responsiveness to the requirements of treating clients with CODs. Counselors should be careful not to label mental disorder symptoms immediately as caused by addiction but instead should be comfortable with the strong possibility that a mental disorder may be present independently and encourage disclosure of information that will help clarify the meaning of any CODs for that client.
(See Chapter 4 for guidance on distinguishing independent mental disorders from substance-induced mental disorders.)
Person-centered assessments emphasize that the focus of initial contact is not on getting forms filled out or answering a battery of questions, or on establishing program fit. Instead the focus is on finding out what the client wants, seen from his or her perspective on the problem, what he or she wants to change, and how he or she thinks that change will occur.
Ewing, Austin, Diffin, and Grande (2015) developed an evidence-based practice tool for conducting person-centered assessment and planning with caregivers of palliative care patients. The framework and key approaches they propose could be generalized to other health issues—including mental illness and substance misuse—and offer useful guidance for ensuring assessment processes are focused on the client and his or her problems, goals, and needs. However, research is needed on the use of their framework in people with CODs.
An important component of a person-centered assessment is always recognizing the significant role of culture on a client's view of problems and treatments. Cultures differ significantly in their views of SUDs and mental disorders, which may affect how a client presents. Clients may participate in treatment cultures (mutual-support programs, Dual Recovery Self-Help, psychiatric rehabilitation) that also affect their view of treatment. Cultural sensitivity requires recognizing one's own cultural perspective and having a genuine spirit of inquiry into how cultural factors influence the clients’ requests for help.
During the assessment process, counselors should learn about clients’ sexual orientation and any gender identity matters, as part of understanding the clients’ personal identity, living situation, and relationships. Counselors should also be aware that clients often have family-related and other concerns that must be addressed to engage them in treatment, such as the need for child care.
For more information about culturally competent treatment, see Chapters 5 and 6 of this TIP as well as TIP 59, Improving Cultural Competence (SAMHSA, 2014a) and TIP 51, Substance Abuse Treatment: Addressing the Specific Needs of Women (SAMHSA, 2009c).
The high prevalence of trauma in individuals with CODs requires a clinician to consider the possibility of a trauma history even before beginning to assess the client. Trauma may include early childhood physical, sexual, or emotional abuse; experiences of rape or interpersonal violence as an adult; and traumatic experiences associated with political oppression, as might be the case in refugee or other immigrant populations. The approach to the client must be sensitive to the possibility that the client has suffered previous traumatic experiences that may interfere with his or her ability to trust the counselor. A clinician who observes guardedness on the part of the client should consider the possibility of trauma and try to promote safety in the interview by providing support and gentleness, rather than trying to “break through” evasiveness that might look like resistance or denial. All questioning should avoid “retraumatizing” the client.
See Chapter 4 for information about trauma-informed care. Chapter 6 for information on women's concerns in CODs, and TIP 57, Trauma-Informed Care in Behavioral Health Services (SAMHSA, 2014b).
Clients presenting for SUD treatment, particularly those who have current or past mental disorder symptoms, may be unable or unwilling to report past or present circumstances accurately. For this reason, all assessments should include routine procedures for identifying and contacting family and other collaterals (with clients’ permission) who may have useful information.
Information from collaterals is valuable as a supplement to the client's own report in all of the assessment steps listed in the remainder of this chapter. It is valuable particularly in evaluating the nature and severity of mental disorder symptoms when the client may be so impaired that he or she is unable to provide that information accurately. Note, however, that the process of seeking such information must be carried out strictly in accordance with applicable guidelines and laws regarding confidentiality1 and with the client's permission.
Confidentiality is governed by the federal “Confidentiality of Alcohol and Drug Abuse Patient Records” regulations (42 C.F.R. Part 2) and the federal “Standards for Privacy of Individually Identifiable Health Information” (45 C.F.R. Parts 160 and 1 64).
Because of the high prevalence of co-occurring mental disorders in SUD treatment settings, and because treatment outcomes for individuals with multiple problems improve if each problem is addressed specifically, the consensus panel recommends that:
SUD treatment providers screen all new clients for co-occurring mental disorders.
Mental disorder treatment providers screen all new clients for any substance misuse.
The type of screening will vary by setting. Substance misuse screening in mental disorder service 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 (i.e., SUDs and substance-induced mental disorders).
Mental disorder screening has four major components in SUD treatment settings:
Screen for acute safety risk, including for:
Suicide.
Violence to others.
Inability to care for oneself.
Risky behaviors.
Danger of physical or sexual victimization.
Screen for past and present mental illness symptoms and disorders.
Screen for cognitive and learning deficits.
Regardless of setting, screen all clients for past and present victimization and trauma.
Exhibit 3.3 lists recommended, validated screening tools across behavioral health service settings.
EXHIBIT 3.3. Recommended Screening Tools To Help Detect CODs.
Safety screening requires that, early in the interview, the provider specifically ask the client whether he or she has any immediate impulse to engage in violent or self-injurious behavior, or whether he or she is in any immediate danger from others. These questions should be asked directly of the client and of anyone else who is providing information. If the answer is yes, the provider should obtain more detailed information about the nature and severity of the danger, the client's ability to avoid the danger, the immediacy of the danger, what the client needs to do to be safe and feel safe, and any other information relevant to safety. Additional information can be gathered depending on counselor/staff training for crisis/emergency situations and the interventions appropriate to the treatment provider's particular setting and circumstances. Once this information is gathered, if it appears that the client is at immediate risk, the provider should arrange for a more indepth risk assessment by a mental health-trained clinician, and the client should not be left alone or unsupervised.
A variety of validated tools are available for screening for risk of suicide or other self-harm:
C-SSRS is a commonly used, well-supported tool to quickly assess suicidal ideation, behavior, and lethality in adult and adolescent populations (Posner et al., 2011). It is available in over 100 languages and has been used in many settings that serve people with CODs, including primary care, military hospitals, and the criminal justice system. Screeners can be selected based on the setting in which they are being used, the population being screened, and the language needed. Columbia University maintains versions of the C-SSRS at http://cssrs
SBQ-R (Osman et al., 2001) has demonstrated good reliability and validity in measuring past suicide attempts, frequency of suicidal ideation, previous suicidal communication, and likelihood of future suicide attempt in adults in inpatient and community settings (Batterham et al., 2015). For the full instrument with an overview and scoring instructions, see Exhibits 3.4 through 3.6, beginning on page 44.
Some systems use the LOCUS (Sowers, 2016) to determine level of care for both mental disorders and addiction. One dimension of LOCUS specifically provides guidance for scoring severity of risk of harm.
EXHIBIT 3.4. The Suicide Behaviors Questionnaire-Revised (SBQ-R) - Overview.
EXHIBIT 3.5. SBQ-R-Scoring.
For more indepth discussion of how to manage suicidal ideation and behaviors in clients seeking treatment for substance misuse, see Chapter 4 of this TIP as well as TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment (Center for Substance Abuse Treatment [CSAT], 2009).
No tool is definitive for safety screening. Providers and programs should use one of these tools only as a starting point, and then use more detailed questions to get all relevant information.
Providers should not underestimate risk because the client is actively using substances. For example, although people who are intoxicated might only seem to be making threats of self-harm (e.g., “I'm just going to go home and blow my head off if nobody around here can help me”), all statements about harming oneself or others must be taken seriously. Individuals who have suicidal or aggressive impulses when intoxicated may act on those impulses. Remember, alcohol and drug misuse are among the highest predictors of danger to self or others—even without any co-occurring mental disorder.
Determining whether and to what extent an intoxicated client may be suicidal requires a skilled mental health assessment, plus information from collaterals who know the client best. (See Chapter 4 for a more detailed discussion of suicidality in people with CODs.) In addition, remember that the vast majority of people who are misusing substances will experience at least transient symptoms of depression, anxiety, and other mental disorders. Moreover, even a skilled clinician may not be able to determine whether an intoxicated suicidal patient is making a serious threat of self-harm; however, safety is a critical and paramount concern.
If a client screens positive for suicide risk, counselors should conduct a suicide risk assessment to more thoroughly determine the client's potential for self-harm. No generally accepted and standardized suicide assessment has been shown to be reliable and valid, but most established suicide assessments contain similar elements. The assessment questions below are drawn from the National Institute of Mental Health's Ask Suicide-Screening Questions (ASQ) Toolkit (n.d.; https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/index.shtml).
Ask questions about the client's feelings about living, such as:
Ask questions about the client's feelings about living, such as:
“Do you ever wish you weren't alive?”
“Have you ever felt that your life wasn't worth living any longer?”
For people who endorse thoughts of suicide or self-harm questions, ask questions like:
“Do you have any thoughts of killing yourself now?”
“Do you have a plan for how you would kill yourself?”
“If you decided to kill yourself, how would you do it?”
For people who have tried to commit suicide in the past, ask:
“Why did you try to commit suicide? When was this? What were the circumstances? What did you do?”
“What happened after you tried to kill yourself?”
“Did you want to die?”
“Did you get medical or psychiatric treatment after? Was treatment offered to you? (If yes) How did that go for you?”
Also be sure to ask about other symptoms and factors that might increase or decrease risk of dying by suicide, such as:
“What are some reasons you would not kill yourself?”
“Do you know anyone who has killed themselves or tried to?”
“In the past few weeks, have you felt so sad or down that it was hard to do things you normally enjoy?”
“In the past few weeks, have you felt hopeless or as though things will never get better?”
“Do you often act without thinking?”
“Is there a trusted adult or other person you can talk to?”
“Are there any problems in your household that are hard to handle?”
The provider needs to determine, based on the client's assessment responses, whether the risk of imminent suicide is mild, moderate, or high. The provider must also determine to what degree the client is willing and able to follow through with a set of interventions to keep safe. Screening personnel should also assess whether suicidal feelings are transitory or reflect a chronic condition. Factors that may predispose a client toward suicide should also be considered in client evaluation. Vulnerable populations include (U.S. Department of Health and Human Services, 2012):
American Indians/Alaska Natives.
Individuals who have lost a loved one to suicide.
Individuals involved in the criminal justice system or child welfare system.
Individuals who engage in nonsuicidal self-injury (see Section III of DSM-5).
Individuals with a history of suicide attempts.
Individuals with debilitating physical conditions.
Individuals with mental disorders, SUDs, or both.
Individuals in the lesbian/gay/bisexual/transgender/questioning community.
Members of the armed forces and veterans.
Middle-aged and older men.
Asking people about thoughts of suicide does not make them more likely to try to kill themselves. On the contrary, asking about suicide displays a level of care and concern that can help people with suicidal thoughts and intentions open up and feel more receptive to help. Counselors should not avoid asking such questions out of fear that asking them will “put the idea” of suicide into their clients’ minds; this is simply not true.
Counselors should also be prepared to probe the client's likelihood of inflicting harm on another person. Specifically, counselors should ask questions that establish whether homicidal ideation, plans, means, access, and protective factors are present. Also ask about past experiences and future expectations. Questions can include the following:
“Have you had any thoughts of harming others?”
“Have you had any thoughts of harming anyone specific? Who?”
“If you decided to harm (name of person), how would you do it?”
“On a scale of 0 to 1 0, with 0 meaning ‘not likely at all,’ how likely are you to harm this person in the next week?”
“What reasons do you have to not harm this person? What might stop you from harming him/her?”
“What else could you do to deal with your anger (or name whatever other feelings the client reports feeling) instead of harming this person?”
“In the past, have you acted on thoughts of harming someone? What happened?”
“How might your life change if you harm this person? What might happen to you or to your family? What might happen to this person's family?”
“Would you be willing to agree to tell someone before you do this?”
“How confident are you in remaining sober over the next week? What can you do to increase the chances you will remain sober? (for example, use of 12-Step meetings, supports, or treatment).”
The U.S. Preventive Services Task Force (USPSTF) recommends that providers routinely screen all women of childbearing age for risk of intimate partner violence (USPSTF, 2016). Similarly, addiction counselors and mental health counselors should be vigilant for risk of victimization among female clients, although men too can and do experience intimate partner violence and should be screened if counselors suspect victimization.
The screener recommended for high sensitivity and specificity (Arkins, Begley, & Higgins, 2016; USPSTF, 2016) is called Humiliation, Afraid, Rape, and Kick. This four-question tool (which has been validated only for women) screens for emotional, physical, and sexual violence (Sohal, Eldridge, & Feder, 2007). See Appendix C for the tool.
Screening for past and present mental disorders accomplishes three goals:
To understand a client's history and, if the history is positive for a mental disorder, to alert the counselor and treatment team to the types of symptoms that may reappear so that the counselor, client, and staff can watch out for the emergence of any such symptoms.
To identify clients who may have a current mental disorder and need assessment to determine the nature of the disorder and an evaluation to plan for its treatment.
To determine the nature of the symptoms that may increase and decrease to help clients with current CODs monitor their symptoms—especially how the symptoms improve or worsen in response to medications, “slips” (i.e., substance use), and treatment interventions. For example, clients often need help seeing that the treatment goal of avoiding isolation improves their mood. So, when they call their sponsor and go to a meeting, they break the cycle of depressed mood, seclusion, dwelling on oneself and one's mood, increased depression, and other symptoms or consequences of depression.
Several screening, assessment, and treatment planning tools are available to assist the SUD treatment team (see Appendix C). Hundreds of assessment and treatment planning tools exist for assessment of specific disorders and for differential diagnosis and treatment planning. The National Institute on Alcohol Abuse and Alcoholism offers professional education materials that address screening and assessment for alcohol misuse, including links to several screening instruments (www.niaaa.nih.gov/publications/clinical-guides-and-manuals). A NIDA research report (NIDA, 2018a) provides broad background information on assessment processes pertinent to CODs and specific information on many mental disorders, treatment planning, and substance misuse tools. The mental health field contains a vast array of screening and assessment devices, and subfields are devoted primarily to the study and development of evaluative methods.
Almost all SAMHSATIPs, available online (https://store.samhsa.gov/series/tip-series-treatment-improvement-protocols-tips). have a section on assessment; many have appendixes with wholly reproduced assessment tools or information about locating such tools.
Advanced assessment techniques include assessment instruments for general and specific purposes and advanced guides to differential diagnosis. Most highpower assessment techniques center on a specific type of problem or set of symptoms, are typically lengthy, often require specific doctoral training to use, and can be difficult to adapt properly for some SUD treatment settings. For these reasons, such assessments are not included in this publication.
When using any of the wide array of tools that detect symptoms of mental disorders, counselors should bear in mind that symptoms of a mental disorder can be mimicked by substances. For example, hallucinogens may produce symptoms that resemble psychosis, and depression commonly occurs during withdrawal from many substances. Even with well-tested tools, distinguishing between a mental disorder and a substance-related disorder can be difficult without additional information such as the history and chronology of symptoms.
In addition to interpreting the results of such instruments in the broader context of what is known about the client's history, counselors are also reminded that retesting often is important, particularly to confirm diagnostic conclusions for clients who have used substances.
The next section briefly highlights some instruments available for mental disorder screening.
MHSF-III (Exhibit 3.7) has only 17 simple questions and is designed to screen for present or past symptoms of most major mental disorders (Carroll & McGinley, 2001). The MHSF-III was developed in an SUD treatment setting, and it has face validity— that is, if a knowledgeable diagnostician reads each item, it is clear that a “yes” would warrant further evaluation of the client for the mental disorder for which the item represents typical symptomatology. It has been used as a part of integrated behavioral health and physical health services (Chaple, Sacks, Randell, & Kang, 2016) and in behavioral health courts (Miller & Khey, 2016). The MHSF-III is reprinted in Appendix C.
EXHIBIT 3.7. Mental Health Screening Form-Ill.
The MHSF-III is only a screening device, because it asks only one question for each disorder for which it attempts to screen. If a client answers “no” because of a misunderstanding of the question or a momentary lapse in memory focus, the screen will produce a “false negative.” This means the client might have the mental disorder, but the screen falsely indicates that he or she probably does not have the disorder.
The MHSF-III is scored by totaling the “yes” responses (1 point each), for a maximum score of 17. A “yes” response to any of the items on questions 3 through 17 suggests that a qualified mental health specialist should be consulted to determine whether follow-up, including a diagnostic interview, is warranted.
Counselors should bear In mind that symptoms of substance misuse can mimic symptoms of mental disorders.
The Mini-International Neuropsychiatrie Interview (M.I.N.I.) is a simple tool that takes 15 to 30 minutes to administer and that covers 20 mental disorders and SUDs. Considerable validation research exists on the M.I.N.I. (Sheehan et al., 1998). However, a modified version of the M.I.N.I.—the Modified Mini Screen (MMS)—that contains only 22 items can be used to screen even more quickly for mental disorders in three diagnostic areas: mood disorders, anxiety disorders, and psychotic disorders. The MMS has been validated for use with adults in SUD treatment, social service, and criminal justice settinqs (Alexander, Layman, & Hauqland, 2013; SAMHSA, 2015b).
The ASI (McLellan et al., 1 992) does not screen for mental disorders and provides only a lowpower screen for generic mental health concerns. Use of the ASI ranges widely. Some SUD treatment programs use a scaleddown approach to gather basic information about a client's alcohol use; drug use; legal status; and employment, family/social, medical, and psychiatric status. Other programs use the ASI as an indepth assessment and treatment planning instrument, with a trained interviewer administering it and making complex judgments about the client's presentation and attitudes about and willingness to take the ASI. Counselors can be trained to make clinical judgments about how the client comes across, how genuine and legitimate the client's way of responding seems, whether there are any safety or selfharm concerns requiring further investigation, and where the client falls on a nine-point scale for each dimension.
With about 200 items, the ASI is a lowpower instrument with a broad range, covering the seven areas mentioned previously and requiring about 1 hour to complete. The continuing development of and research into the ASI includes training programs, computerization, and critical analyses. It is a public domain document that has been used widely for two decades. It has been found to be effective in predicting inpatient psychiatric admissions among people seeking SUD treatment (Drymalski & Nunley, 2016).
Among the major revisions to DSM-5 was the inclusion of a newly developed patient assessment tool to help providers screen for common mental disorders and symptoms needing treatment, including major depression, generalized anxiety, mania, somatic conditions, sleep disturbance, cognitive dysfunction, and substance misuse. The DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult contains 23 items that correspond to diagnostic categories in DSM-5 (e.g., depressive disorders, psychotic disorders) or to specific symptom domains (e.g., mania, anger, suicidal ideation).
Because the screener is included in DSM-5's Section III for “emerging measures,” meaning it requires further research before being implemented in routine clinical practice, little is known about its validation. No published studies to date have examined its use with COD populations. Nonetheless, the measure is worthy of consideration, especially in research settings. It is available online with scoring information (https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures#Disorder).
This section is intended primarily for counselors working in mental health service settings and suggests ways to screen clients for substance misuse.
Screening begins with inquiry about past and present substance use and related problems and disorders. If the client answers “yes” to having problems or a disorder, further assessment is warranted. If the client acknowledges a past substance problem but states that it is now resolved, assessment is still required. Careful exploration of what current strategies the individual is using to prevent relapse is warranted. Such information can help ensure that the individual continues to use those strategies while focusing on mental health services.
Screening for the presence of substance misuse involves four components, which are:
Substance misuse symptom checklists.
Substance misuse severity assessment.
Formal screening tools that work around denial.
Screening of urine, saliva, or hair samples.
Checklists address common categories of substances, problems associated with use for a given substance, and a history of meeting SUD criteria. Overly detailed checklists are unhelpful; they lose value as simple screening tools. Including misuse of over-the-counter medication (e.g., cold medications) and of prescribed medication is helpful.
Monitor the severity of an SUD (if present). This process can begin with simple questions about past or present diagnosis of an SUD and the client's experience of associated difficulties.
DSM-5 offers guidance on assessing SUD severity based on symptom count. Specifically, two to three symptoms would be considered a mild SUD, four or five a moderate SUD, and six or more a severe SUD (American Psychiatric Association [APA], 2013). Some programs may use formal SUD diagnostic tools; others use the ASI (McLellan et al., 1992) or similar instruments, even in the mental disorder service setting.
SCREENING AND INTOXICATION/WITH DRAWAL.
The AUDIT (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001) and its abbreviated version, the AUDIT-C (Bush, Kivlahan, McDonell, Fihn, & Bradley, 1998), have been validated for use in screening adults at risk for alcohol misuse (Dawson, Smith, Saha, Rubinsky, & Grant, 2012; Johnson, Lee, Vinson, & Seale, 2013). These instruments measure current alcohol use, drinking behaviors, and consequences of drinking. Cutoff scores suggesting hazardous alcohol use are 8 or higher on the AUDIT (Babor et al., 2001) and 3 or higher on the AUDIT-C for SUD or heavy drinking (Bush et al., 1998). Both measures are in Appendix C.
The CAGE-AID (Cut Down, Annoyed, Guilty, Eye-opener—Adapted to Include Drugs) is a variation of the four-question CAGE screener, which focuses solely on detecting alcohol misuse. The CAGE-AID instead screens for drug use and alcohol misuse. It is brief, valid, and reliable (Mdege & Lang, 2011), and recommended by the USPSTF and others for substance misuse screening, particularly in primary care populations (Halloran, 2013; Lanier & Ko, 2008). Respondents who endorse one or more items on the CAGE-AID should be considered for full assessment of substance misuse. The CAGE-AID is online at https://www.hiv.uw.edu/page/substance-use/cage-aid.
WHO's ASSIST tool (WHO ASSIST Working Group, 2002) is an effective measure for lifetime and current substance misuse, but its length and complex computer scoring system have hindered its widespread adoption. NIDA developed an abbreviated version called the NIDA-Modified ASSIST, which is recommended by APA for use with DSM-5 (NIDA, 2015) and is recommended for primary care as well as general medical populations (NIDA, 2012; Zgierska, Amaza, Brown, Mundt, & Fleming, 2014).
The NIDA-Modified ASSIST can be completed online (www.drugabuse.gov/nmassist/) or on paper. It opens with a Quick Screen to determine whether further assessment is warranted. If the client answers as at risk on the Quick Screen, the full NIDA-Modified ASSIST should be administered.
The DAST-10 (Skinner, 1982) is a moderately-to-highly reliable and valid measure that has been widely used in practice and research (Mdege & Lang, 2011; Yudko, Lozhkina, & Fouts, 2007). It assesses past-year use of substances other than alcohol and can be administered quickly. Scores of 3 or higher warrant consideration of further assessment for a possible SUD (Skinner, 1982). The DAST-10 can be accessed online (https://www.hiv.uw.edu/page/substance-use/dast-10).
The MAST (Selzer, 1 971) is a widely used self-report screening tool for problematic substance use. A systematic review of its psychometric properties suggests the MAST is moderate to robust in reliability and validity (Minnich, Erford, Bardhoshi, & Atalay, 2018).
This 25-item measure asks about lifetime alcohol use and consequences. It takes 8 to 10 minutes to complete. A score of 0 to 3 suggests no drinking problems. A score of 4 suggests early or moderate problems. A score of 5 or higher indicates problem drinking and warrants further assessment. See Appendix C for the measure.
Developed by CSAT, the SSI-SA (CSAT, 1994) screens for alcohol consumption and other substance use, preoccupation and loss of control, negative consequences of substance use, problem recognition, and tolerance and withdrawal. The SSI-SA has strong psychometric properties (Boothroyd, Peters, Armstrong, Rynearson-Moody, & Caudy, 2015) and includes items drawn from existing validated substance screeners, including the AUDIT, CAGE, DAST, and MAST. It is often used in criminal justice settings (SAMHSA, 2015b) but also has been found effective in hospital settings (Mdege & Lang, 2011). A score of 4 or higher is considered indicative of moderate to high risk of substance misuse and warrants further assessment (Boothroyd et al., 2015). See Appendix C for this instrument.
Trauma refers to an event or circumstance experienced, witnessed, or learned of by an individual that has a protracted, negative influence on his or her physical, emotional, psychological, social, spiritual, or functional well-being. Common traumatic events include childhood maltreatment (e.g., physical, sexual, or emotional abuse; neglect); being a victim of physical or sexual assault; experiencing a terrorist event, natural or man-made disaster, accident, fire, or mass casualty event; repeatedly being exposed to details of horrific or violent events (e.g., first responders seeing injured or dead victims, police officials repeatedly hearing details about child abuse); or learning that something extremely disturbing happened to a loved one or close friend (e.g., learning that your child has died).
Trauma is common in individuals with SUDs, mental disorders, or both, particularly women and military populations (Berenz & Coffey, 2012; Carter, Capone, & Short, 2011; Gilmore et al., 2016; Kline et al., 2014; Konkoly Thege et al., 2017; Mandavia, Robinson, Bradley, Ressler, & Powers, 2016; Mason & Du Mont, 2015; Palmer et al., 2016; Vest, Hoopsick, Homish, Daws, & Homish, 2018; Walsh, McLaughlin, Hamilton, & Keyes, 2017; see also Chapter 4 for more discussion).
To determine whether trauma screening is warranted, counselors can ask clients about past traumatizing events directly or use a structured tool, like the Adverse Childhood Experiences Study Score Calculator (available online at https://acestoohigh.com/got-your-ace-score/). In screening for a history of trauma or obtaining a preliminary diagnosis of PTSD, asking clients to describe traumatic events in detail can be traumatizing. Limit questioning to very brief and general questions, such as “Have you ever experienced childhood physical abuse? Sexual abuse? A serious accident? Violence or the threat of it? Have there been experiences in your life that were so traumatic they left you unable to cope with day-to-day life?”
To screen for PTSD, assuming the client has a positive trauma history, consider using these scales:
The Primary Care PTSD Screen for DSM-5 (Prins et al., 2015) and administration and scoring information are available online (www
The PTSD Checklist for DSM-5 (Weathers et al., 2013) and administration and scoring information are available online (https://www
See TIP 57, Trauma-Informed Care in Behavioral Health Services (SAMHSA, 2014b), for more indepth discussion of screening, assessment, and management of trauma in behavioral health populations. Valuable guidance about counseling people with CODs and trauma is in Chapter 7 of this TIP.
Quadrants of care (i.e., Four Quadrants Model) is a conceptual framework that classifies clients in four basic groups based on relative symptom severity, not diagnosis (Exhibit 3.8).
EXHIBIT 3.8. Level of Care Quadrants.
Quadrant assignment is based on the severity of the mental disorders and SUDs as follows:
Category/Quadrant I: This quadrant includes individuals with low-severity substance misuse and low-severity mental disorders. These low-severity individuals can be accommodated in intermediate outpatient settings of either mental disorder or chemical dependency programs, with consultation or collaboration between settings if needed. Alternatively, some people will be identified and managed in primary care settings with consultation from mental health service or SUD treatment providers.
Quadrant II: This quadrant includes individuals with high-severity mental disorders who are usually identified as priority clients within the mental health system and who also have low-severity SUDs (e.g., SUD in remission or partial remission). These individuals ordinarily receive continuing care in the mental health system and are likely to be well served in a variety of intermediate-level mental health programs using integrated case management.
Quadrant III: This quadrant includes individuals who have severe SUDs and low-or moderate-severity mental disorders. They are generally well accommodated in intermediate-level SLID treatment programs. In some cases, coordination and collaboration with affiliated mental health programs are needed to provide ongoing treatment of the mental disorders.
Quadrant IV: Quadrant IV has two subgroups. One includes people with serious, persistent mental illness (SPMI) who also have severe and unstable SUDs. The other includes people with severe and unstable SUDs and severe and unstable behavioral problems (e.g., violence, suicidality) who do not (yet) meet criteria for SPMI. These individuals require intensive, comprehensive, and integrated services for both their SUDs and mental disorders. The locus of treatment can be specialized residential SUD treatment programs such as modified therapeutic communities in state hospitals, jails, or even in settings that provide acute care such as emergency departments (EDs).
The quadrants of care were derived from a conference, the National Dialogue on Co-Occurring
Mental Health and Substance Abuse Disorders, supported by SAMHSA and two of its centers— CSAT and the Center for Mental Health Services— and co-sponsored by the National Association of State Mental Health Program Directors (NASMHPD) and the National Association of State Alcohol and Drug Abuse Directors (NASADAD). The quadrants of care model was originally developed by Ries (1993) and used by the State of New York (NASMHPD & NASADAD, 1999; see also Rosenthal, 1992). It has two distinct uses:
To help conceptualize an individual client's treatment and to guide improvements in system integration (for example, if the client has acute psychosis and is known to the treatment staff to have a history of alcohol use disorder (AUD), the client will clearly fall into Category IV—that is, severe mental disorder and severe SUD). However, the severity of the client's needs, diagnosis, symptoms, and impairments all determine level of care placement.
To guide improvements in systems integration, including efficient allocation of resources.
The model is considered valid, reliable, and feasible (McDonell et al., 2012), which is particularly beneficial for clients with CODs given that conditions tend to fluctuate over time, underscoring the need for a stable framework that can accurately classify individuals and capture their potential treatment needs throughout the course of their illnesses.
Step 2 will collect most information necessary to make this determination, but there will sometimes be additional nuances to consider. Certain states formally specify procedures for quadrant determination. In the absence of formal procedures, SUD treatment providers in any setting can follow Exhibit 3.8.
Every state mental health system has developed a set of specific criteria for determining who can be considered seriously mentally ill and therefore eligible to be considered a mental health priority client. These criteria are based on combinations of specific diagnoses, severity of disability, and duration of disability (usually 6 months to 1 year). Some require that the condition be independent of an SUD. These criteria are different for every state. It would be helpful for SUD treatment providers to obtain copies of the criteria for their own states, as well as copies of the specific procedures by which eligibility is established by their states’ mental health systems. By determining that a client might be eligible for consideration as a mental health priority client, the SUD treatment counselor can assist the client in accessing various services and benefits the client may not know are open to her or him.
To gauge SMI status, start by asking whether the client already gets mental health priority services (e.g., “Do you have a mental health case manager?” “Are you a Department of Mental Health client?”).
If the client already is a mental health client, then he or she will be assigned to quadrant II or IV. Contact the mental health case manager and establish collaboration to promote case management.
If the client is not already a mental health client but appears to be eligible, and the client and family are willing, arrange a referral for eligibility determination.
Clients who present in SUD treatment settings who look as if they might have SMI, but have not been so determined, should be considered to belong to quadrant IV.
For assistance in determining the severity of symptoms and disability, the SUD treatment provider can use the severity criteria listed in DSM-5. For disorders in which DSM-5 does not offer any guidance on determining severity, counselors can use Dimension 3 (Co-Morbidity) subscales in the LOCUS (see the section “Assessment Step 5: Determine Level of Care”), particularly the levels of severity of comorbidity and impairment/functionality.
Presence of active or unstable substance misuse or serious substance misuse as indicated by a DSM-5 severity rating of “severe” would identify the individual as being in quadrant III or IV. Less serious SUD (a DSM-5 severity rating of “mild” or “moderate”) identifies the individual as being in quadrant I or II.
If the client is determined to have SMI with a serious SUD, he or she falls in quadrant IV; those with SMI and a mild SUD fall in quadrant II. A client with a serious SUD who has mental disorder symptoms that do not constitute SMI falls into quadrant III. A client with mild to moderate mental disorder symptoms and a less serious SUD falls into quadrant I.
Clients in quadrant III who present in SUD treatment settings are often best managed by receiving care in the SUD treatment setting, with collaborative or consultative support from mental health providers. Individuals in quadrant IV usually require intensive intervention to stabilize and determine eligibility for mental health services and appropriate locus of continuing care. If they do not meet SMI criteria, once their more serious mental symptoms have stabilized and substance use is controlled initially, they begin to look like individuals in quadrant III, and can respond to similar services.
Note, however, that this discussion of quadrant determination is not validated by clinical research. It is merely a practical approach to adapting an existing framework for clinical use, in advance of more formal processes being developed, tested, and disseminated.
In many systems, the process of assessment stops largely after assessment Step 4 with the determination of placement. Some information from subsequent steps (especially Step 7) may be included in this initial process, but usually more indepth or detailed consideration of treatment needs may not occur until after “placement” in an actual treatment setting.
ASSESSMENT STEP 5—APPLICATION TO CASE EXAMPLES (JANE B.).
Client placement in the appropriate care setting for his or her needs is necessary to optimize treatment completion and desirable outcomes. Placing a client in a level of care is also often required by private and public payers (i.e., Medicaid) for authorization of mental health services or SUD treatment decisions. Thus, the availability of valid and reliable commonly used tools can not only help increase the odds of effective treatment matching but can help providers meet documentation requirements for reimbursement.
The LOCUS Adult Version 20 (Sowers, 2016) can be used as a systemwide level of care assessment instrument for either mental disorder service settings only or for both mental disorder service and SUD treatment settings. The LOCUS uses multiple dimensions of assessment, including:
Risk of harm.
Functional status.
Comorbidity (medical, addictive, psychiatric).
Recovery environment.
Treatment and recovery history.
Engagement and recovery status.
The LOCUS (Plakun, 2018) helps:
Determine a client's level of service needs.
Describe all levels of care, from short-term outpatient services to inpatient residential care.
Provide a quantified approach to defining level of care based on scores on its six dimensions.
LOCUS has a point system for each dimension that permits aggregate scoring to suggest level of service intensity. It permits level of care assessment for clients with mental disorders or SUDs only, as well as for those with CODs. It is highly correlated with the DSM-IV-TR Global Assessment of Functioning scale and has demonstrated good sensitivity in assessing severity of symptoms, particularly those that are psychiatric in nature (Thurber, Wilson, Realmuto, & Specker, 2018).
Determining the diagnosis can be a formidable clinical challenge in the assessment of CODs. Clinicians in both mental disorder services and SUD 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 misuse. Of course, substance misuse 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. Three guiding principles can help counselors thoroughly assess the client's current and past history of mental and substance-related symptoms and problems:
Conduct a thorough interview to establish past mental and SUD diagnoses and treatments.
Document all past diagnoses, including their relationship to certain time periods (e.g., just before the diagnosis, just after the diagnosis, during symptomatic phases) and events, symptoms, and levels of functioning during those time periods.
Determine the timing of mental disorder symptoms, particularly in relationship to periods of substance use and SUDs (e.g., during periods of abstinence, within 30 days of onset of an SUD).
Addiction counselors who want to improve their competencies to address CODs are urged to become conversant with the basic resource used to diagnose mental disorders, DSM5 (APA, 2013). Indepth discussion of what counselors need to know concerning DSM-5 diagnostic criteria, differential diagnosis, and management of mental disorders in the context of co-occurring addiction is in Chapter 4.
Diagnosis is established more by history than by current symptom presentation. This applies to both mental disorders and SUDs. The first step in determining the diagnosis is to determine whether the client has an established diagnosis or is receiving ongoing treatment for an established disorder. This information can be obtained by the counselor as part of the routine intake process. If there is evidence of a disorder but the diagnosis or treatment recommendations are unclear, the counselor should immediately begin the process of obtaining this information from collaterals. If there is a valid history of a mental disorder diagnosis at admission to SUD treatment, that diagnosis should be considered presumptively valid for initial treatment planning, and any existing stabilizing treatment should be maintained. In addition to confirming an established diagnosis, the client's history can provide insight into patterns that may emerge and add depth to knowledge of the client.
For example, if a client comes into the clinician's office and says she hears voices (whether or not she is sober currently), no diagnosis should be made on that basis alone. People hear voices for many reasons. They may be related to substance-related syndromes (e.g., substance-induced psychosis or hallucinosis, which is the experience of hearing voices that the client knows are not real, and that may say things that are distressing or attacking—particularly when the client has a history of trauma—but are not bizarre). With CODs, most causes will be independent of substance use (e.g., schizophrenia, schizoaffective disorder, affective disorder with psychosis or dissociative hallucinosis related to PTSD). Psychosis usually involves loss of ability to tell that the voices are not real and increased likelihood that they are bizarre in content. Methamphetamine psychosis is particularly confounding because it can mimic schizophrenia. Many clients with psychotic disorders will still hear voices when on medication, but the medication makes the voices less bizarre and helps clients know they are not real.
If clients state, for example, that they have heard voices, although not as much as they used to; have been abstinent for 4 years; have remembered to take medication most days, but may forget; and have had multiple hospitalizations for psychosis 10 years ago but none since, then they clearly have a diagnosis of psychotic illness (probably schizophrenia or schizoaffective disorder). Given their continuing symptoms while abstinent and on medication, it is quite possible that the diagnosis will persist.
Chapter 4 offers additional information about differential diagnosis.
Even though SUD treatment counselors may not be licensed to make a mental disorder diagnosis, they should document prior diagnoses and gather information related to current diagnoses.
Diagnoses established by history should not be changed at the point of initial assessment. If the clinician has a suspicion that a long-established diagnosis may be invalid, he or she needs to take time to gather additional information, consult with collaterals, get more careful and detailed history, and develop a better relationship with the client before recommending diagnostic réévaluation. The counselor should raise concerns related to diagnosis with the clinical supervisor or at a team meeting.
In many instances, no well-established mental disorder diagnosis exists, or multiple diagnoses confuse the picture. Even with an established diagnosis, gathering information to confirm that diagnosis is helpful. During initial assessment, SUD treatment counselors can gather data that can assist diagnosis, either by supporting the findings of the existing mental health assessment or by providing useful background information in the event a new mental health assessment is conducted. The key is not merely to gather lists of past and present symptoms but to connect those symptoms to periods in the client's life that are helpful in the diagnostic process—namely, before the onset of an SUD and during periods of abstinence (or very limited use) or after SUD onset and persisting for more than 30 days.
The clinician should determine whether mental disorder symptoms occur only when the client is using substances actively. Therefore, it is important to determine the nature and severity of the symptoms of the mental disorder when the SUD is stabilized. Note whether the client recently had a complete physical, including appropriate labs. Physical diseases can also present with or mimic mental disorders (e.g., hypothyroidism presenting with or like depression) and need to be identified and treated accordingly.
For diagnostic purposes, it is almost always necessary to tie mental disorder symptoms to specific periods of time in the client's history, in particular those times when an active SUD was not present.
Most SUD assessment tools do not require connection of mental disorder symptoms to substance use or abstinence. Mental disorder symptom information obtained from such tools can confuse counselors and make them feel that the whole process is not worth the effort. In fact, when clinicians seek information about mental disorder symptoms during periods of abstinence, such information is almost never part of traditional assessment forms. The mental disorder history and substance use history have in the past been collected separately and independently. As a result, the opportunity to evaluate interaction, which is the most important diagnostic information beyond the history, has routinely been lost. Newer and more detailed assessment tools overcome these historical and potentially misleading divisions.
The M.I.N.I. Plus (a more detailed version of the Mini-International Neuropsychiatrie Interview [Sheehan et al., 1998]) is structured to connect any identified symptoms to periods of abstinence. Clinicians can use this information to distinguish substance-induced mental disorders from independent mental disorders. The Timeline Follow-Back Method also is a valid and practical tool that can be used with individuals with substance misuse or CODs (Hjorthoj, Hjorthoj, & Nordentoft, 2012) to gather a detailed and comprehensive assessment of patterns of substance misuse beyond just quantity and frequency.
Consequently, the SUD treatment counselor can proceed in two ways:
Ask whether mental disorder symptoms or treatments identified in screening were present during periods of 30 days of abstinence
or longer, or were present before onset of substance use. (“Did this symptom or episode occur during a period when you were abstinent for at least 30 days?”)
Define with the client specific time periods when the SUD was in remission, and then get detailed information about mental disorder symptoms, diagnoses, impairments, and treatments during those periods of time. (“Can you recall a time when you were not using? Did these symptoms [or whatever the client has reported] occur during that period?”) This approach may yield more reliable information.
During this latter process, the counselor can use one of the medium-power symptom screening tools as a guide. Alternatively, the counselor can use the handy outlines of the DSM-5 criteria for common disorders (provided in Chapter 4) and inquire whether those criteria symptoms were met, whether they were diagnosed and treated, and if so, with what methods and how successfully. This information can suggest or support the accuracy of diagnoses. Documentation also can facilitate later diagnostic assessment by a mental health-trained clinician.
Determination of both current and baseline functional impairment contributes to identification of the need for case management 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 whether 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.
Current level of impairment is determined by assessing functional capabilities and deficits in each of the areas indicated in the following list. Similarly, baseline level of impairment is determined by identifying periods of extended abstinence and mental health stability (greater than 30 days) according to the methods described in the previous assessment step. 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 or herself 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 cognitive functioning? 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? Is there difficulty focusing, concentrating, and completing tasks?
Several freely available, reliable, well-validated tools measure functioning and impairment in clients with mental illness, substance misuse, or both (Gold, 2014; National Academies of Sciences, Engineering, and Medicine, 2016; Sanchez-Moreno, Martinez-Aran, & Vieta, 2017), including:
WHO Disability Assessment Schedule 2.0 ([WHODAS 2.0] Üstün & WHO, 2010;
www
Understanding and communicating.
Getting around (mobility).
Self-care.
Getting along with people (social and interpersonal functioning).
Life activities (home, academic, and occupational functioning).
Participation in society (participation in family, social, and community activities).
ASI (McLellan et al., 1992), a mental health screening tool that provides information about level of functioning for clients with SUDs. This is valuable when supplemented by interview information. (Note that the ASI also exists in an expanded version specifically for women, ASI-F [SAMHSA, 2009c].)
In a clinical interview, the counselor also should inquire about any current or past difficulties the client has had in learning or using relapse prevention skills, participating in mutual-support recovery programs, or obtaining medication or following medication regimens. In the same vein, the clinician may inquire about use of transportation, budgeting, self-care, and other related skills, and their effect on life functioning and treatment participation.
For individuals with CODs, impairment may be related to intellectual/cognitive ability or the mental disorder, which may exist in addition to the SUD. The clinician should establish level of intellectual/cognitive functioning in childhood, whether impairment persists, and if so, at what level, during the periods when substance use is in full or partial remission, just as in the previous discussion of diagnosis.
A specific tool to assess the need for capable-or enhanced-level services for people with CODs currently is not available. The consensus panel recommends a process of “practical assessment” that seeks to match the client's assessment (mental health, substance misuse, level of impairment) to the type of services needed. The individual may even be given trial tasks or assignments to determine in concert with the counselor if his or her performance meets the requirements of the program being considered.
ASAM criteria for COD-capable and - eligible programs are as follows (Mee-Lee, Shulman, Fishman, Gastfriend, & Miller 2013):
Co-occurring-capable (COC) programs in addiction treatment focus primarily on SUDs but can treat patients with subthreshold or diagnosable but stable mental disorders (Mee-Lee et al., 2013). Mental health services may be onsite or available by referral. COC programs in mental health are those that mainly focus on mental disorders but can treat patients with subthreshold or diagnosable but stable SUDs (Mee-Lee et al., 2013). Addiction counselors are onsite or available through referral.
Co-occurring-enhanced (COE) programs have more integrated addiction and mental health services and have staff who are trained to recognize the signs and symptoms of both disorders and are competent in providing integrated treatment for both mental disorders and SUDs at the same time.
Complexity-capable programs are designed to meet the needs of individuals (and their families) with multiple complex conditions that extend beyond just CODs. Physical and psychosocial conditions and treatment areas of focus often include chronic medical illnesses like HIV, trauma, legal matters, housing difficulties, criminal justice system involvement, unemployment, education concerns, childcare or parenting difficulties, and cognitive dysfunctions.
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 disorders or SUDs.
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 SUDs only. Questions might focus on:
Talents and interests.
Areas of educational interest and literacy; vocational skill, interest, and ability, such as 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 SUD 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.
ASSESSMENT STEP 8— APPLICATION TO CASE EXAMPLES PANE B.).
For individuals with SMI or substance misuse, the Individualized Placement and Support model of psychiatric rehabilitation has demonstrated that it is a cost-effective way to generate positive vocational and mental health outcomes compared with other models of vocational rehabilitation for this population, including improved rates of obtaining competitive employment, greater number of hours worked, increased wages, improvements in selfesteem and quality of life, and reductions in mental health service use (Drake, Bond, Goldman, Plogan, & Karakus, 2016; LePage et al., 2016). In this model, clients with disabilities who want to work may be placed in sheltered work activities based on strengths and preferences, even when actively using substances and inconsistently complying with medication regimens. In nonsheltered work activities, it is critical to remember that many employers have substance-free workplace policies.
Participating in ongoing jobs is valuable to selfesteem in itself and can generate the motivation to address mental disorders and substance misuse problems, as they appear to interfere specifically with work success. Taking advantage of educational and volunteer opportunities also may enhance self-esteem and is often a first step in securing employment.
Detailed cultural assessment is beyond the scope of this publication. Cultural assessment of individuals with CODs is not substantially different from cultural assessment for those with SUDs or mental disorders only, but some specific areas are worth addressing, such as:
Problems with literacy.
Not fitting into the treatment culture (SUD or mental health culture); conflict in treatment.
Cultural and linguistic service barriers.
ASSESSMENT STEP 9–APPLICATION TO CASE EXAMPLE (GEORGE T.).
To a certain degree, individuals with addiction and SMI may have difficulty fitting into existing treatment cultures. Many clients are aware of a variety of different attitudes toward their disorders that can affect relationships with others. Traditional culture carriers (parents, grandparents) may have different views of clients’ problems and the most appropriate treatment compared with peers. Individual clients may have positive or negative allegiance to a variety of peer or treatment cultures (e.g., mental health consumer movement, having mild or moderate severity mental disorders vs. SMI, 12-Step or dual recovery mutual support) based on past experience or on fears and concerns related to the mental disorder. Specific questions to explore with the client include:
“How are your substance use and mental health concerns defined by your parents? Peers? Other clients?”
“What do they think you should be doing to remedy these problems?”
“How do you decide which suqqestions to follow?”
“In what kinds of treatment settings do you feel most comfortable?”
“What do you think I (the counselor) should be doing to help you improve your situation?”
Cultural and linguistic barriers can compound access to COD treatment. The assessment process must address whether these barriers prevent access to care (e.g., the client reads or speaks only Spanish; the client is illiterate) and if so, determine options for providing more individualized intervention or for integrating intervention into naturalistic culturally and linguistically appropriate human service settings.
Chapter 5 describes components of culturally responsive services. Chapter 6 offers information about the needs of people of diverse racial/ethnic backgrounds with CODs and how counselors can help reduce treatment access and outcome disparities experienced by marginalized racial/ethnic groups.
Individuals with CODs may have difficulties in multiple life domains (e.g., medical, legal, vocational, family, social). The ASI can identify and quantify substance use-related problems across domains, to see which require attention. It is used most effectively as a component of a comprehensive assessment.
A comprehensive, biopsychosocial evaluation for individuals with CODs 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, SUD treatment, or both. 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 to obtain information.
A key evidence-based best practice for treatment matching clients with CODs is to match interventions not only to specific diagnoses but also to stage of change and stage of treatment for each disorder.
In SUD treatment settings, stage of change assessment usually involves determination of Prochaska and DiClemente Stages of Change: precontemplation, contemplation, preparation (or determination), action, maintenance, and relapse (Prochaska & DiClemente, 1992). This can involve using questionnaires such as the University of Rhode Island Change Assessment Scale (McConnaughy, Prochaska, & Velicer, 1983; available at https://habitslab.umbc.edu/urica/) or the Stages of Change Readiness and Treatment Eagerness Scale (Miller & Tonigan, 1996; available at https://casaa.unm.edu/inst/SOCRATESv8.pdf). Stage of change can be determined clinically by interviewing clients and evaluating their responses in the context of change. For example, one approach to stage of change identification is to ask clients, for each problem, to select the statement that most closely fits their view of that problem:
No problem, no interest in change, or both (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).
Stage of change assessment ideally will be applied separately to each mental disorder and to each SUD. For example, a client may be willing to take medication for a depressive disorder but unwilling to discuss trauma, or motivated to stop using cocaine but unwilling to consider alcohol as a problem.
For more indepth discussion of the stages of change and motivational enhancement, see TIP 35, Enhancing Motivation for Change in Substance Use Disorder Treatment (SAMHSA, 2019c).
A comprehensive assessment is the basis for an individualized treatment plan. Appropriate treatment plans and treatment interventions can be quite complex, depending on what might be discovered in each domain. No single, correct intervention or program exists for individuals with CODs. Rather, match appropriate treatment to individual needs per these multiple considerations.
The following case (Maria M.) illustrates how the noted factors help generate an integrated treatment plan that is appropriate to the needs and situation of a particular client.
ASSESSMENT STEP 12–APPLICATION TO CASE EXAMPLE (MARIA M.).
A major goal of the screening and assessment process is to ensure the client is matched with appropriate treatment. Acknowledging the overriding importance of this goal, this discussion of the process of clinical assessment for individuals with CODs begins with a fundamental statement of principle: Because clients with CODs are not all the same, program placements and treatment interventions should be matched individually to the needs of each client.
The ultimate purpose of the assessment process is to develop an appropriately individualized integrated treatment plan. In this model, the consensus panel recommends the following approach:
Treatment planning for individuals with CODs and associated problems should follow the principle of mental disorder dual (or multiple) primary treatment, in which a specific intervention is matched to each problem or diagnosis, as well as to stage of change and external contingencies. Exhibit 3.9 shows a sample treatment plan consisting of the problem, intervention, and goal.
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 problems related to the other disorder.
EXHIBIT 3.9. Sample Treatment Plan for Case Example George T.
These principles are best illustrated by using a case example to develop a sample treatment plan. For this purpose, the case example for George T. is used, incorporating the data gathered during assessment (Exhibit 3.9). The problem description presents various factors influencing the problem, including stage of change and client strengths. No specific person is recommended to carry out interventions proposed in the second column, as a range of professionals might carry out each intervention appropriately.
The consensus panel has reviewed research evidence and consensus clinical practice to identify factors critical to the process of matching clients to available treatment. Exhibit 3.10 lists these considerations.
EXHIBIT 3.10. Considerations in Treatment Matching.
Assessment is a systematic approach for behavioral health service providers to gather information that supports matched treatment plans for individuals with CODs. It is a required competency and a key component of the counselor-client relationship in which providers learn to better understand their clients; have opportunities to express genuine concern, hope, and empathy for long-term recovery; and help set the stage for effective treatment. Most of these activities are already a routine component of substance misuse-only assessment; the key additional element is attention to treatment requirements and stage of change for mental disorders, and the possible interference of mental disorder symptoms and disabilities (including personality disorder symptoms) in SUD treatment participation.
This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
Your browsing activity is empty.
Activity recording is turned off.
See more...
