James Fitzgerald Therapy PLLC

Substance Abuse and Mental Health Services Administration (SAMHSA)

Treatment Improvement Protocol Series # 42 (Updated 2020)

Substance Use Disorder Treatment for People With Co-Occurring Disorders

Chapter 3: Screening and Assessment of Co-Occurring Disorders 

KEY MESSAGES

• 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 fulfll 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 defcits, and cultural barriers. Identifcation 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 18 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:

1. An overview of the basic screening and assessment approach that should be a part of any program for clients with CODs
2. 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)
3. 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 feld 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-specifc 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

Screening and Basic Assessment of Co-Occurring Disorders

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. Specifcally, 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 co-occuring disorders as a guide to fnal level of care determination.

In carrying out these processes, counselors should understand the limitations of their licensure or certifcation 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 substance use disorders and mental health disorders that may occur in various cultures (see Chapter 5 of this TIP for more information about culturally sensitive care for clients with co-occurring disorders). 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 co-occurring disorders, 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).

Screening

A formal process of testing to determine whether a client warrants further treatment because of a co-occurring substance use disorder or mental health disorder. The screening process for co-occurring disorders seeks to answer a “yes” or “no” question: Does the substance misuse (or mental disorder) client being screened show signs of a possible mental health (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

• Do keep in mind that assessment is about getting to know a person with complex and individual needs. Tools alone cannot produce a comprehensive assessment.
• Do always make every effort to contact all involved parties, including family members, people who have treated the client previously, and probation offcers, as quickly as possible in the assessment process. (These other sources of information will henceforth be referred to as collaterals.)
• Don’t allow preconceptions about addiction to interfere with learning about what the client really needs. CODs are as likely to be underrecognized as overrecognized. Assume initially that an established diagnosis and treatment regimen for mental illness is correct, and advise clients to
  continue with those recommendations until careful reevaluation has taken place.
• Do become familiar with the diagnostic criteria for common mental disorders, including serious mental illness (SMI) (e.g., bipolar disorder, schizophrenia, other psychotic disorders). Also become familiar with the names and indications of common psychiatric medications and with the criteria in your own state for determining who is a mental disorder priority client. Know the process for referring clients for mental illness case management services or for collaborating with mental health services providers.
• Don’t assume there is one correct treatment approach or program for any type of COD. The purpose of assessment is to collect information on multiple variables, enabling individualized treatment matching. Assess stage of change for each problem and clients’ level of ability to follow treatment recommendations.
• Do get familiar with the specifc role your program plays in delivering services related to CODs in the wider context of the system of care. This allows you to have a clearer idea of what clients your program will best serve and helps you to facilitate access to other settings for clients who might be better served elsewhere.
• Don’t be afraid to admit when you don’t know, either to the client or yourself. If you do not understand what is going on with a client, acknowledge that to the client, indicate that you will work with the client to fnd the answers, and then ask for help. Identify at least one supervisor who is knowledgeable about CODs as a resource for asking questions.
• Most important, do remember that empathy and hope are the most valuable components of your work with a client. When in doubt about how to manage a client with COD, stay connected, be empathic and hopeful, and work with the client and the treatment team to try to fgure out the best approach over time.

The consensus panel recommends that all clients presenting for substance use disorder treatment, mental health services, or both be screened at least annually by substance use disorder treatment and mental health services providers for past and present substance misuse and mental disorders. Substance use disorder treatment and mental health counselors should also screen clients who report experiencing or otherwise show signs or symptoms of a substance use disorder or a mental health 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 co-occurring mental health disorders. 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

• What is screening? Screening is a simple process of determining whether more indepth assessment is needed, often consisting of asking the client basic “yes” or “no” questions.
• Who should conduct screening? Nearly any counselor can screen. Generally, no special training is required.
• When does screening take place? The consensus panel recommends that all SUD treatment clients and mental disorder treatment clients be screened for CODs at least annually. Screening is also needed when clients report or exhibit symptoms suggesting another disorder may be present.
• Where does screening occur? Screening can happen anywhere that services are offered.
• Why screen? Screening is a necessary frst step to ensure that clients receive the right diagnosis and treatment.
• How should screening be performed? A variety of easy-to-administer screening tools are available and are located or linked to throughout this chapter as well as in Appendix C.

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 defne 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 specifc 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.

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 qualifed 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 fnancial situation, health, education, housing status, strengths and resources, and employment.
• Substance use—age of frst 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.

The Complete Screening and Assessment Process

Considerations in Treatment Matching

Conclusion