Hello everyone and welcome back. In our last section we talked about a variety of psychoactive drugs. In this section we begin discussing screening and assessment. Before we begin to talking about actual diagnostic instruments we use for screening and assessment we first need to look at issues associated to screening and assessment. Let's begin by going to slide two.

The first thing one needs to know before using any kind of screening and assessment is that you need to know what the instrument was designed for. That is, you need to know the strength of each instrument and the weakness or limitations of the instrument. More importantly you need to be trained on the use of the instrument. It is also very important to practice using the instrument before you try using it with a client. Now, all of these things may seem straightforward but many individuals in all sorts of treatment settings whether it is in psychological treatment setting, criminal justice system, or in addictions don't always know this stuff before administering an instrument. Consequently, they make mistakes; they draw wrong conclusion, etc.

In addition to training issues there are a wide variety of community issues that one also needs to examine when using screenings, assessments, whatever. Classic example is what is the location of the clinic? Is the clinic located on the outside of town where no one can get access to even on a bus? Or, is the clinic easily accessible for everyone? Does it have adequate parking, etc? In addition, what are the community resources available if one diagnoses a person with some kind of disorder? Do you have governmental agencies available? Private agencies? Are there public or private providers? What are the referral resources that one may use or draw upon when one identifies certain problems? In addition to that, are there even resources even available? Are they affordable? For example, if one lives in Boise where there are a wide variety of treatment providers, government resources, private groups, etc. One is going to have an easier time placing the client once they have been diagnosed. On the other hand if one works in a rural communities and there are no resources on hand, or even providers, and if there are providers they may not even be affordable, then the options one has when one has diagnosed a client are very much different.

There are also a wide variety of treatment facility issues that one needs to consider when doing a screening or assessment. Many, many things or items that we overlook can have a direct impact on the test that one administers. I have listed some of these. A classic example is room temperature. Is it too hot? Or too cold? Is the client comfortable or are they uncomfortable? The noise is there a jackhammer going on outside the building or is there a lot of noise going on inside the agency? All of these things inhibit the client’s responses. The lighting; is it too dark, or is it bright and cheery, or is it like the sun outside? The persons voice; the therapists voice should be nice and pleasant so it does not set the client to be very defensive. On the other hand, the therapist’s voice should not be very loud or a squeaky voice because they can become very disturbing as well. The room set up; is it pleasant? Can the client feel comfortable? Also, the layout of the clinic. Is the client easily observable from the outside windows, or is the client feeling secure so others do not know the client is even there? And finally, how does the staff relate to your clients? Do they relate to them like numbers or like they are the scum of the Earth or whatever. Or are they pleasant and treat them with respect?

There are also a wide variety of counselor and client issues. The anxiety that the client experiences when they come into the room is very normal. It is very, very important for the therapist to put the client at ease. Is the client motivated to do well or to do poorly? These may be related to legal consequences the client may actually have. The attention of the client and the attention of the therapist, is the therapist always looking at their watch? Are they looking around the room or are they actually listening to the client and to what they have to say? The fatigue by the client or of the clinician, both of these can influence the results. Nods of the head by the clinician when the examinee is on the right track or a frown or blank stare when they are not can also change the results of what the client is saying.

In addition to that there are a wide variety of scoring issues that need to be considered when doing any kind of screening or assessment. Unless an assessment is scored by a machine there is always some judgment required to score a test. Even if you follow the guidelines these can change the results. However, following the guidelines when you are not using a machine scoring can reduce the potential judgment errors that one has and you can get a very good result.

False positives and false negatives are also very important when assessing any kind of client and using any kind of instrument. A false positive indicates when the client does not really have a problem but they are incorrectly identified as having a problem. A false negative is when the subject or client has a problem but is incorrectly identified as not having a problem. Both of these can have major problems when presenting to a judge or whatever. And it is very important for the therapist to know what the false positive and false negatives rates are with any kind of instrument.

Now there is one aspect that I really need to harp upon before we begin to talk about a variety of instruments and that is this, as shown on slide eight. Screening does not equal assessment. Screening instruments are used for something different than assessment instruments. So what are screening instruments supposed to do?

As we can see on slide nine, screenings should be able to be done in a variety of settings and at a paraprofessional level. It should be quick, taking about fifteen to thirty minutes maximum. But, ten to fifteen minutes for adolescents. It should be very easy, it should be very inexpensive, and the instruments one uses should have high validity and high reliability. The instruments one uses from a psychological perspective or from a counseling perspective also can be incorporated with other tests such as liver functioning tests performed by physicians.

Screening results as seen in slide ten are only designed for one thing; to determine if more information is needed. The screening does not establish a diagnosis and screening instruments are not designed to develop a diagnosis.

Screening instruments as seen in slide eleven need to have high reliability and high validity. They must be guided by how the instrument was developed and normed. That is, what type of setting was the instrument developed for? What was the instruments intended purpose?

Assessment as seen is slide twelve, is totally different from screening. It is a longer process and uses multiple data sources. It uses liver functioning tests, a wide variety of psychological standardized instruments, it may include significant others such as family and friends. It may include employers, teachers, etc. And, an assessment must always, always, always include an interview; however this sometimes does not occur.

Assessments are designed as seen in slide thirteen to determine who needs treatment. They are also used to determine basically, substance abuse, dependence or severity so a person can be accurately placed in treatment using ASAM criteria which we will talk about in a little while. The assessment needs to be comprehensive so the provider can develop a /DSM/ diagnosis that is very accurate. It must also provide clues and indicators that some other psychological or psychiatric problem may be present.

Now there are a wide variety of approaches to assessment and some of these are listed on slide fourteen. For example, your assessment can include a structured interview, it can include self-report information, and it can include questionnaires or instruments that the client fills out. In can include laboratory tests or interviews with others and it can include a lot of collateral information obtained by employers or law enforcement personnel.

Basically assessment results should include a variety of things. It should include test results, the /DSM/ diagnosis that one develops, other non-standard impressions the counselor may have, factors that may contribute to a disorder, the client strengths and this is especially true for adolescents and some kind of plan for action both immediate and the long-term

Now there is a gold standard for every assessment that one does and that is this, and shown in slide sixteen, whatever assessment diagnosis you develop must be able to stand up in court. This is especially important with youth, individuals referred by the criminal justice system, or with individuals with co-existing disorders.

Often times though, assessments cannot stand up in court. Why? As we see in slide seventeen, sometimes instruments have poor reliability or validity, or the assessment was not very comprehensive, and that allows attorneys to get people into treatment when they actually did not need it and vice versa. It can also be used as an extenuating circumstance that is....The ____ made me do it!” alcohol, cocaine, whatever it may be. So your assessment is very, very important.

Assessments should basically identify individuals who are experiencing problems and whatever stage of dependence they are at. It should assess the full spectrum of problems for which treatment is needed.
It should have an appropriate intervention. It should involve significant others as needed. It should evaluate the effectiveness of the particular intervention as the client is going through treatment. And finally, it should also identify the client strengths as well as problems.

Now there is one aspect of client diagnosis that one needs to include and is located on slide nineteen, and that is a /DSM/ IV diagnosis. The /DSM/IV diagnosis seen here is the Diagnostic and Statistical Manual of Mental Disorders IV. It is the major diagnostic manual of the American Psychiatric and American Psychological Associations. It views disorders as having both mental and physical components.

Basically, the /DSM/ conceptualizes Mental Disorders as having behavioral dysfunctions, psychological dysfunctions, and/or physical dysfunctions.

The /DSM/ does not, as seen in slide twenty-one, evaluate deviant behavior, whatever that is be it political, religious, or sexual deviant behavior. It does not include conflicts between individuals and society unless the deviant or conflict is a symptom of a dysfunction.

Ultimately, the diagnosis one develops from the /DSM/IV, and as we see in slide twenty-two, is a first step in a comprehensive treatment plan. Usually it needs a lot of information and the criteria offered in the manual is basically offered as guidelines. In addition the diagnosis talked about in the /DSM/ is a consensus and does not cover everything.

Related to the /DSM/ is the ICD-9 or the ICD-10 codes which are shown on slide twenty-three. These are the International Classifications of Diseases. It is the official coding system used in the United States and other parts of the world as well. Most /DSM/ diagnosis have some kind of numerical Identification that goes along with that and this numerical identification is basically related to the ICD-9 or the ICD-10 codes. It is used to report diagnostic data to government providers, researchers, planners, private insurers, etc. And basically this is the code one needs to have if you want to get reimbursement.

Now once you have gone through the screening, the assessment, the diagnosis, the identifying the treatment plan, etc one has to develop a report and that is shown on slide twenty-four. There is an old saying that the job is never finished until the paperwork is done, and paperwork is extremely important. It is needed for third party payments, it is needed for managed care evaluations, and it is also needed for state statistics.

Furthermore, there is also one other aspect that is extremely important and these are legal/confidentiality issues. It is extremely important to understand the legality, ethical, and confidentiality issues that one may have in a particular agency. The regulations one has for legal/confidentiality issues differ state by state. So you need to know that you understand the rules and regulations of your area.

So in general, as we see in slide twenty-six, there are lots of things you need to be aware of when learning about screening and assessment. You need to be aware of the strengths and problems within the process. And as I discussed earlier, solid training is necessary throughout the entire process. You also need to acquire a variety of information from a wide variety of viewpoints to make sure you have an understanding of what is going on.

Well, that concludes this section. In the next section we are going to begin talking about the diagnosis of substance abuse and dependence. So, until then, we hope you have a great day and we look forward to talking with you soon.

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