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Competency 3: Integrative Assessment of Co-Occurring Disorders

Skill 3A: Able to identify the purpose and the key components of a comprehensive assessment.

Per SAMHSA:

Screening is a process for evaluating the possible presence of a particular problem.

Assessments are a process for defining the nature of that problem, determining a diagnosis, and developing specific treatment recommendations for addressing the problem or diagnosis.

  • Understand that in some instances the information gathered in the screening may be used in the assessment and there may be overlap in the processes.
  • Understand that often an assessment is conducted by a trained professional who is either licensed or certified to provide mental-health and/or substance-use treatment services.
  • Understand that the purpose of an assessment is to collect, organize and interpret client information to develop mutually agreed goals that guide treatment.
  • Understand that an assessment establishes a baseline of signs, symptoms, and behavior to allow for ongoing monitoring of progress
  • Understand that conducting assessments throughout treatment informs engagement, alignment, and progress.
  • Understand that in addition to collecting information on mental-health and substance-use issues, an integrated assessment includes a “whole person” approach that incorporates the following bio-psychosocial factors that impact health:
    • Interpersonal
    • Developmental
    • Physical
    • Cultural
    • Behavioral
    • Spiritual
    • Lifestyle
  • Environmental/Social
  • Knowledgeable in how to structure an assessment and the pertinent bio-psychosocial questions to ask.
  • Understand that pertinent assessment information includes and may not be limited to:
    • Information across time.
    • Both strengths and limitations, and context.
    • Information from not only the individual but significant individuals
    • Mental health, substance use and interaction.
    • Motivation around changing for problems identified.

Skill 3B: Able to conduct a collaborative assessment that engages the individual throughout the process.

  • Knowledgeable of basic counseling skills such as active listening, reflecting, and summarization.
  • Understand the importance of conducting a person-centered assessment that elicits the individual’s:
    • Reason for entering (and staying in) treatment
    • Perception of issues
    • Priority problem areas
    • Desired outcomes
    • Ideas on how to accomplish goals
    • Strengths, capacities, and preferences.
  • Knowledge that a trauma history may impact the individual’s ability to fully engage in the assessment process.
  • Knowledge that stigma/shame may impact an individual’s ability to fully engage in the assessment process.
  • Understand cultural influences that affect the assessment process.
  • Understand the importance of revisiting certain questions as the counseling relationship progresses.
  • Understand the importance of identifying psychosocial issues that may need to be addressed to facilitate participation in treatment for things like basic needs, childcare, transportation, literacy.

Skill 3C: Able to collaborate with collaterals to gather additional information.

  • With the consent of the client, Understand the importance of conducting interviews with family members, significant others, and providers to generate a comprehensive assessment. Understand the barriers to receiving consent (shame, stigma) and the importance of revisiting permission over time.

Skill 3D: Able to assess for current mental-health and history of mental-health issues.

  • Understand the importance of obtaining a history of past mental symptoms, diagnoses, treatment (including response to / compliance with treatment), prescribed medications, and medication adherence.
  • Understand past attempts at change and relapse.
  • Understand family history of mental-health issues.
  • Knowledge of the risk factors (history of self-harm or violence, access to means of harm, and stressors) and protective factors to consider.
  • Understand the components of a mental status exam (appearance and behavior, mood and affect, speech, thought process, thought content, cognition, insight, and judgment).

Skill 3E: Within scope of practice and treatment setting, when a client screens positive for trauma-related symptoms, able to follow up with a more thorough assessment.

  • Understand that there is a greater likelihood of having individuals with co-occurring trauma then many other mental-health related symptoms and diagnoses.
  • Understand that for individuals with histories of traumatic life events who screen positive for possible trauma-related symptoms and disorders, a thorough assessment by a qualified individual is recommended to gather all relevant information necessary to understand the role of trauma in their lives.
  • Knowledge of the Adverse Childhood Experience (ACE) questionnaire, Life Stressor Checklist with interview, Brief Trauma Questionnaire, or similar tools.
  • Understand that the ideal follow up treatment would address trauma and other conditions.

Skill 3F: Able to assess for current and history of substance use.

  • Knowledge of current substance use (including prescriptions) and history of use.
  • Knowledgeable of the signs and symptoms of substance misuse.
  • Knowledge of intoxication, withdrawal symptoms, and history of withdrawal symptoms.
  • Familiar with Post-Acute Withdrawal Syndrome.
  • Understand severity of use and frequency, duration and amount of use.
  • Understand problems associated with use.
  • Understand patterns of high and low use.
  • Understand family history of substance misuse.
  • Understand the importance of obtaining a history of treatment, including response to / compliance with treatment, prescribed medications and medication adherence.
  • Understand past attempts at change and relapse.

Skill 3G: Able to assess for interaction of substance use and mental health.

  • Understand the relationship between current substance-use and mental-health symptoms and functioning.
  • Knowledge that the symptoms of intoxication and withdrawal may mirror or exacerbate symptoms of mood and anxiety disorders (more common) and psychotic disorders (less common). Often, symptoms of depression, anxiety, or other mental-health issues improve when the person stops using substances.
  • Familiar with the “teeter totter principal”- what goes up must come down—which is useful to predict what kind of symptoms might be caused by what substances. For example, acute withdrawal symptoms from physiological depressants such as alcohol and benzodiazepines are hyperactivity, elevated blood pressure, agitation, and anxiety (i.e., the shakes). On the other hand, those who “crash” from stimulants are tired, withdrawn, and depressed. Virtually any substance taken in very large quantities over a long enough period can lead to a psychotic state. (SAMHSA)
  • Understand that a timeline of symptoms must be completed to ensure an accurate assessment is made. This includes obtaining a history of past mental-health symptoms, diagnosis and treatment before the onset of substance use, and during periods of abstinence.
  • Understand the importance of continuing to evaluate and monitor mental-health symptoms and their relationship to abstinence or ongoing substance use overtime.

Skill 3H: Able to complete an individualized functional analysis of behaviors (positive and negative consequences of maladaptive behavior and adaptive behaviors).

  • Knowledge of sequences, triggers, positive and negative outcomes to behaviors.
  • Knowledge of internal and external stimuli (cognitive, behavioral, emotional, and environmental) and associated responses (positive or negative) that decrease, maintain or increase substance-use or mental-health symptoms.
  • Knowledgeable about tools and resources to complete a functional assessment.

Skill 3I: Able to assess an individual’s physical health status.

  • Understand that a thorough health assessment includes both a physical exam and taking a thorough health history.
  • Understand the importance of gathering information on current healthcare (including dental) providers, medical conditions, treatment, chronic disease management (diabetes, heart conditions), infectious disease (HIV/AIDS, TB Hepatitis C), medications, and physical disabilities.
  • Understand the importance of collecting information on past medications, medical hospitalizations, head injuries, and trauma.
  • Understand the importance of inquiring about healthy eating and physical activity.

Skill 3J: Based on the severity of symptoms an individual presents, able to identify what quadrant of care the individual belongs and the appropriate treatment setting.

  • Understand that co-occurring disorders can be thought of as being on a continuum of severity.
  • Familiar with the 4 quadrants of care which provides a conceptual framework that classifies individuals in four basic groups based on relative symptom severity.
  • Understand that the 4 Quadrants of Care also provides a basic framework for matching symptom severity with appropriate treatment settings.
    • Quadrant I: Less severe mental disorder/less severe substance disorder - Primary healthcare system
    • Quadrant II: More severe mental disorder/less severe substance disorder- Mental-health system.
    • Quadrant III: Less severe mental disorder/more severe substance disorder- Substance-use System
    • Quadrant IV: More severe mental disorder/more severe substance disorder - typically treated in: Psychiatric hospitals, emergency rooms, long-term residential programs.
    • Understand that regardless of the treatment setting, the best treatment interventions are integrated and appropriately match the stage of change an individual is in.

Skill 3K: Able to Determine the Level of Care

  • Familiar with Level of Care Instruments, such as the ASAM criteria, CASII (requires certification), and the LOCUS, which offer a comprehensive set of guidelines for placement, continued stay, and transfer/ discharge of individuals with additional and co-occurring conditions.
  • Understand that these tools utilize the assessment information, and the identified priorities and services, and establishes the intensity of services that should be provided.

Skill 3L: Able to identify diagnostic criteria for substance-use and mental-health disorders which must be verified by a licensed physician or other licensed practitioner.

  • Knowledge of the most recent DSM criteria for both substance-use and mental disorders.

Skill 3M: Able to assess the level of functioning across a variety of life domains.

  • Understand that substance-use and mental-health issues impair an individuals’ cognitive capacity, social skills, and other functional areas.
  • Understand the importance of eliciting information on current functioning across multiple domains such as:
    • Health Practices
    • Housing Stability and Maintenance
    • Communication
    • Safety
    • Managing Time
  • Familiar with functional assessment tools like the DLA20 and CANS.

Skill 3N: Ability to assess strengths and supports.

  • Understand the importance of eliciting hopes, goals, successes, supports and strengths.
  • Understand that individuals possess resources to solve their own problems.
  • Understand the importance of building upon strengths to help individuals resolve problems.
  • Knowledge of ways to elicit strengths, resources and supports.
  • Understand the importance of eliciting the following:
    • Talents, aspirations, skills.
    • Supportive relationships, peers, family, treatment, spiritual, self- help or others
    • Interpersonal strengths such as coping, problem solving, and communication skills
  • Management of their condition 

Skill 3O: Able to identify cultural and linguistic influences, needs and supports.

  • Understand the importance of identifying and exploring cultural, racial, ethnic, and gender identities.
  • Understand the importance of Understanding an individual’s beliefs about wellness and treatment.
  • Knowledge of immigration issues, poverty, racism, stereotyping, and powerlessness that certain groups face.

Skill 3P: Able to identify problem domains.

  • Understand that individuals with co- occurring disorders often have issues in multiple-life domains such as legal, housing, vocational, family, social, and financial.

Skill 3Q: Able to assess readiness for change per relevant area of concern.

  • Knowledge of the sequence of steps through which people pass in the change process: pre-contemplation, contemplation, preparation, action, maintenance, and relapse
  • Understand that each stage in the model represents a different level of readiness to make a change.
  • Knowledge of the statements and behaviors associated with each stage.