Lesson 14: Screening and Assessment Strategies


Attention

The primary public health challenge of 2016 has been the opiate epidemic. Public health concerns change from year to year. Two years ago, it was Ebola. Whatever the challenge, Screening and Assessment are the beginning steps to dealing with the problem.

Click below view an Opioid Risk Tool as an example of a screening tool:

Link: https://www.drugabuse.gov/sites/default/files/files/OpioidRiskTool.pdf


Learning Outcomes

Upon completion of this lesson's material, students will

  • Understand the core functions of screening, assessment, case management and referral and how MHRT C's can help clients with co-occuring disorders.
  • Understand the importance of a non-confrontative, cooperative and consensual approach in helping clients to find and use services
  • Be able to enumerate your strengths and needs and to make a reasonable plan for growth and for seeking peer input and supervision

Teaching

Purpose of Screening

Image of magnifying glass looking at one figure in a line of figures.

Screening helps you identify cases for further assessment. Screening by itself is never adequate to determine the need for help or to make a treatment plan. If a screening is positive, the next step is to conduct a comprehensive assessment. If a screening is negative no further action is necessary. This assumes that the screening test is sensitive enough to catch most cases where the criterion is present (e.g. symptoms of Ebola, symptoms of drug or alcohol use, symptoms of hypertension, etc.) and specific enough to exclude most cases where the criterion is absent.

Here is a nice video on sensitivity and specificity:

 

If a test has low sensitivity, a positive result might not be very meaningful. For example if the base rate for mental disorders is 25% and your screening test only has a 15% sensitivity, you'd be better off just guessing that a person has a mental disorder 25% of the time rather than using the screening test.

If you absolutely don't want to miss a single case, then you look for high sensitivity (true positives) and don't worry about specificity (true negatives). You may wind up doing a lot of further assessment on people who don't have the problem, but when your screening test says they don't have the problem, you'll have greater confidence it is right.

EXAMPLE

A good example of a screening test for alcoholism that has been used for decades is the CAGE . One that is more recent and is used by DHHS to screen child protective referrals is the UNCOPE. Notice that the UNCOPE lists different levels of sensitivity and specificity for different score levels, different populations and different substances.

For example, alcohol abuse or dependence (or in DSM 5 terms, mild to severe AUD) has a sensitivity of 93 with 2 or more items and a specificity of 97. That means that it gets 93% true positives and 97% true negatives. These are high enough levels that the screener can be fairly sure that he or she has identified the case correctly for further assessment.

In Maine, if a child protective client (usually the parent who is suspected of abuse or neglect) has a score on the UNCOPE of 2 or higher, they are asked to go to a substance abuse professional for a full assessment which includes history, patterns of use of substances, urine testing, interview of collaterals, mental health assessment, as well as consideration of medical, social, educational, vocational and spiritual issues.

It is only with this kind of complete assessment that a person's need for treatment can be assessed and a reasonable treatment plan recommended. If this full assessment is positive, then DHHS will require the client to participate in treatment as a condition of reunification with their child (or if the child has not been taken as a condition for keeping their child).

Recently, Governor Lepage suggested requiring treatment for TANF recipients who were positive for Substance Dependence on the SASSI 3 (another screening test for substances). This reflected his misunderstanding of the use of screening tools. You should not make a diagnosis or a treatment plan based simply on a screening.

What reasonably might be required with a positive SASSI 3 is further assessment by a professional and treatment if warranted by that assessment.

But this kind of misunderstanding is common and as professionals we need to work with consumers and the general public to understand what screening is and why we do it.

Screening Tools

Keep in mind that these tools are for use by clinicians, not MHRT/Cs.

  • Ideally screening will simply be a tool in a wider discussion with the person about their life, what they want and need and what gives their life meaning and purpose.
  • Screening may provoke resistance: fear, anger. Work on keeping it helpful and empowering the person to take care. NO CONFRONTATION.
  • Can lead to Individualized Support Plan goals (for instance, learning more about healthy drinking or keeping track of how often and when s/he smokes cigarettes). These goals are preliminary to gather more information and help the consumer and providers determine whether there is a problem
  • One goal can be just keeping track of use and positive and negative outcomes (for example, if our client screens positive on the CAGE or UNCOPE, we may just agree to keep track of what happens when he or she takes a drink or smokes marijuana and whether that is truly what they want)
  • But treatment plan goals only come after a full assessment that identifies an issue as a problem
Screening can lead to referrals for more help: agreeing with the client to see their physician or a substance use professional.

Assessment

Assessment is a wide ranging investigation of the person's use of substances including medical, psychosocial, behavioral, legal, historical, familial, vocational, educational and spiritual domains.

  • Should consider every aspect of the person's life so as to put their use in perspective
  • The goal is to see the person as a human being and not just a case
  • Is best seen as a CONVERSATION that leads to a mutual plan with shared responsibilities
  • Opportunity for education and consciousness raising

One part of a substance assessment is looking at readiness for change and here the SOCRATES can be helpful. It assesses Recognition of the existence of a problem, Ambivalence about the need for change, and whether the person is currently Taking Steps for change. If for instance, the person is considered to have a problem by collaterals but doesn't recognize it her/himself, the MHRT/C may use Motivational Interviewing to raise consciousness. If the person is high on Ambivalence, they may already be in Contemplation and simply need help in considering pros and cons of continued use. If the person is high on Recognition and low on Ambivalence and Taking Steps, they may need help in Preparing a plan for Action.

MHRT/C Role

  • The MHRT/C serves both as a Community Support Worker who works with the client and their Individual Support Plan to achieve goals some of which may have to do with substance use
  •  And as a Case Manager who visualizes the beginning, middle and end of serving this person with this issue. For example, a client who has a drinking problem may need a substance use evaluation to begin with, treatment and support groups to improve and ongoing lifestyle changes to continue recovery. The Case Manager helps them find and use all of these services.
  • Engages with the client in ongoing treatment planning
  • Engages in coordination of all that the person needs to get where they want to be

figures pushing large puzzle pieces together

Referral

  • Helping the person to ask other workers to help
  • Need to have a comprehensive understanding of recovery and what a recovering person needs
  • Need to know your area and who and what is available for help
  • Here is a resource: 211 directory (just type in what service you are looking for, e.g. “food pantry” and it will give you a list of what is available)

When to Ask for Help

  • Know yourself! Strengths and needs. Skills and skill deficits. Personality and how your history and character may interact with your client's history and character.
  • Strengths needed by an MHRT/C: Good listener, see other's point of view, patient, stick-to-it, know your limits, have good self-care skills
  • Always keep it clear in your own mind that you are there to serve and when that's not going well you need to ask for help
  • We all need regular ongoing reality checks: peer interaction and supervision. Peer interaction especially helpful when you talk to more experienced workers who know the ropes. Also good for bouncing ideas around and for obtaining CONSENSUAL validation of thoughts and feelings about a case. Should have regular ongoing supervision both individual and group to make sure that you are following policies and regulations and really are doing what's best for the client. As humans we tend to be self-justifying and see our own side better than the other person's. Your supervisor can help you stay on track.
  • Developmental model of the worker: from neophyte to skilled helper. Your supervisor can help you objectively determine your strengths and needs. We need supervision even as as we develop our skills because everyone needs it to stay in perspective of doing what's best for the client and also doing effective self-care to prevent burnout and compassion fatigue.
  • Transference and Countertransference issues may arise when you are working with a client. It is important to understand what these are and seek supervision.

Keep Calm and Practice Self Care


Assessment

In this section you will find a list of the required Assessments that accompany this Lesson. The Lesson Discussions are designed for the ONLINE and HYBRID versions of this course. If you are not in an ONLINE or HYBRID version of this course you can ignore these instructions unless otherwise guided by your instructor.

Lesson 14 Quiz

  1. Explain your understanding of why every MHRT/C, no matter how experienced, needs regular supervision from a supervisor.
  2. Explain the concepts of “non-confrontative”, “conversation”, and “consensual” and why each of them are essential for an MHRT/C working with a co-cccuring disorders population.

Lesson 14 Discussion (for online class only)

This is a multi-part discussion question. Please provide answers to all parts.

  1. State where you believe you are in your development as a helper (beginner, advanced, expert) and why.
  2. Describe what your strengths and needs are.
  3. What parts of your understanding of the topics we have reviewed have changed?
  4. What have you learned about yourself?