SRP for Clients with CD - Adapting the SRP Approach - Screening and Assessment

Excerpted from Structured Relapse Prevention: An Outpatient Counselling Approach.

• Adapting the SRP Approach
  • Introduction
  • Screening and Assessment
  • Treatment
  • Other Issues of CD-Adapted SRP
  • References
• PDF version of Adapting the SRP Approach

While there is no consensus about the best screening and assessment tools for people with concurrent disorders, the components of an integrated treatment process are addressed by Health Canada’s (2002) Best Practices document:

• identifying potential substance use and/or mental health problems by properly screening clients
• for those who screen positive, conducting a comprehensive assessment to investigate the nature and severity of the substance use and mental health problems, and exploring their interrelations
• for those who have been diagnosed as having concurrent substance use and mental health problems, providing treatment and support.

With respect to screening to identify people with potential concurrent disorders, the principles of best practice suggest “level 1 screening procedures,” where all people presenting in mental health services are screened for concurrent substance use problems (Health Canada, 2002). Level 1 screening procedures include asking a few key questions regarding substance use, being alert to social and clinical indicators that raise the clinician’s index of suspicion, and drawing on the judgment and experience of a case manager. These procedures are summarized below.

Asking a few key questions

By asking a few key questions regarding, for example, a client’s perception that others are concerned about his or her substance use, you can make better decisions about whether or not the client requires more intensive assessment of a potential concurrent substance use disorder. A Yes response to any one of the three following questions suggests that further investigation into the possibility of concurrent disorders is warranted:

• Have you ever had any problems related to your use of alcohol or other drugs?
• Has a relative, friend, doctor or other health worker been concerned about your drinking or other drug use, or suggested you cut down?
• Have you ever said to another person, “No, I don’t have an alcohol (or other drug) problem,” when, around the same time, you questioned yourself and felt, “Maybe I do have a problem”?

Do not rely only on client self-disclosure, because clients may minimize their problems. For this reason, additional screening procedures may be helpful.

Index of suspicion and clinical correlates

If it is not possible to ask questions, or if the quality of a self-report is in question, a number of behavioural, clinical and social indicators and consequences (the “index of suspicion”), can be considered; the presence of a number of items from this index may give cause for suspecting possible concurrent substance use difficulties. The index includes:

• new or unexplained mental health symptom relapses
• history of substance use
• unstable housing
• budgeting difficulties
• treatment compliance issues
• sexual acting out
• social isolation or difficulties
• violence or threats
• suicidal thoughts or attempts
• self-harm
• hygiene or health concerns
• legal problems
• cognitive impairments
• avoidance of disclosing mental health or substance use issues.

Along with the items above, be alert to what Mueser et al. (1992), in their work with clients with severe mental illness, have identified as various “clinical correlates” of substance use disorders:

• cigarette smoking (people who smoke are three to four times more likely to misuse substances)
• male
• younger
• lower education
• single or never married
• good premorbid social functioning
• family history of substance use problems
• history of childhood conduct disorder
• antisocial personality disorder
• higher affective symptoms (e.g., depression or suicidality)
• relationship problems
• job problems
• disrupted housing or other instability
• disruptive behaviour or violence
• non-compliance with treatment (e.g., medication not taken, missed appointments)
• legal problems
• physical symptoms (e.g., dilated pupils, sweats, shakes, smell)
• physical diagnoses (e.g., liver problems).

Given the high prevalence of comorbidity, you should make screening efforts routine, and “view concurrent disorders as the norm, NOT the exception” (Mueser et al., 1992). Accordingly, the use of an index of suspicion, and bringing this lens to interactions with clients, represents good clinical practice in both substance use and mental health settings.

Case manager judgement

Also useful is a case manager’s opinion and concern about the possibility of a substance use problem, since the case manager often has the benefit of a long-standing relationship with the client. Seeking this opinion can be as simple as asking the case manager, “Do you think the client has ever had a drinking or other drug problem? Would you say definitely, probably or not at all?”

Moving from screening to assessment

If the result of the screening procedures outlined above suggests concurrent disorders, you may find it helpful to complete a brief screening tool. The Dartmouth Assessment of Lifestyle Instrument (DALI) (Rosenberg et al., 1998) is the only tool that was explicitly developed as a screen for substance use disorders among people with severe mental illness (see http://dms.dartmouth.edu/prc/instruments/DALI.pdf).

With respect to diagnostic assessment, the most comprehensive option for such clients is a complete assessment for psychiatric and substance use disorders, per the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994). However, several barriers may preclude a complete psychiatric and substance use assessment, including limited resources, long waiting lists for treatment and limited CD-specialized programs and services. For a more complete review of CD screening and assessment considerations, issues and instruments, see Juan Negrete’s chapter, “Screening and Assessing for Concurrent Disorders” in Skinner (2005).

Return to the index of excerpts from Structured Relapse Prevention: An Outpatient Counselling Approach.

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