Good day everyone and welcome back. In our last sections we were talking about some issues related to screening and assessment. In this section we begin talking about the diagnosis of substance abuse and dependence. Let's begin by going to slide two.

The first thing you need to understand is that clients come from all sorts of different backgrounds when they come in the see you. They are going to be educated/non-educated, rich/poor, black/white, green/whatever. As a consequence they have different languages, cultures, etc. Clients also may be motivated or not motivated to provide accurate information. If the information is going to hurt them they are not going to be very forthcoming. If the information is going to help them they will be more forthcoming in fact they will probably provide more information than you need. This continually occurs throughout the treatment and assessment process. Ideally, what one should use when examining a client is a variety of data sources. This will allow you to determine if some problem exists and if a problem does exist how severe it is.

So what are some of these data sources? As we can see in slide three, information comes from the client and that is usually where most of the information comes from. However, information can come from the client’s family, their employer, friends and neighbors, and many other groups of individuals. One group that is often overlooked is the medical community. The medical community provides a wide variety of information related to the client’s health, to liver functioning if the client is an alcoholic, maybe brain disorders and many other things. These can all have major impacts when assessing the client. Further, the medical community is needed when assessing a person who is an intravenous drug user because you absolutely need to have the person checked for HIV, STDs, Hepatitis, and other things.

So what are the goals of screening, assessment, and diagnosis? First of all the initial goal is to determine if the client even needs to be assessed. Once that is determined, then providing a comprehensive overview of the client to determine if the client has a particular problem. If the client does have a problem the counselor needs to place the client in appropriate treatment. And finally, the counselor needs to follow up with the client as treatment is progressing to ensure that the treatment is actually working.

I have placed a diagram on slide five which shows you what you need to begin to do while you follow a client through treatment. As you can see across the top the client is engaging in some kind of behavior, it then goes into a screening of some sort. If the screening reveals the client has no alcohol or drug problems then you may want to review some other ideas or alternatives including counseling, psychotherapy, etc. If the screening it is determined the client has a drug or alcohol problem then we do an assessment and as we can see here the assessment process includes a variety of instruments, interviews, physical workups, psychiatric or psychological workups, interviews with legal people and maybe significant others. Ultimately from all of this a DSM diagnosis is developed and from that diagnosis the client is placed in some appropriate treatment using the ASAM criteria which we will talk about in a little bit.

What are some measurement areas? As we can see on slide six, screening techniques usually use instruments and techniques to determine if some kind of assessment is necessary. Most screenings are very fast and are not very in-depth in the examination of the client. All you are trying to determine is do I need to get more particular information from this client? Assessments, on the other hand, examine multiple areas. They are also very comprehensive and they need to be. The problem is that often time’s assessments only emphasize what the counselor is comfortable with and that may be psychological, medical, etc. As a consequence if the assessment is not thorough you can miss a lot of things.

There are three major areas of assessment that one wants to examine and these are listed on slide seven. They include medical areas, psychological areas, and sociological areas.

Let's talk about some medical indicators first. Medical indicators as seen in slide eight are done at many levels. Some can be done in the counselor’s office including, for example, how the client smells. Smell is very, very important and it is not from the fact that the client may stink. A sweet smell may indicate diabetes while an odiferous smell might indicate homelessness and that is something you may want to follow up on. Medical indicators may also include other types of things including examining a blood alcohol concentration, doing a urinalysis, using visual tracking techniques with the eyes, looking at gaze nystagmus, and looking for needle marks and a variety of other things. Medical indicators even at the counselor level do not have to be very intense however you need to be alert for some of these issues such as chronic cough which can be indicative of TB or other things.

Physician testing from the medical side can be more in-depth and the exams are very thorough and very complete. Examinations include things such as liver functioning and with alcoholics that is a must. However physicians will also examine other types of areas including neurological testing, etc. Further, the physician should know what the problem is when the client enters the door. This ensures that the appropriate tests are conducted and works very, very well when clients are motivated.

You may be asking why one would have to do this? Well, as we can see in slide ten, many disorders occur in conjunction with a variety of different types of alcohol and drug abuse. For example, with alcoholism you can have cirrhosis of the liver, endocrine problems, and a variety of other things. With intravenous drug users an individual could have Hepatitis, HIV, etc. Further, with anyone who is using intravenous drugs they must be screened for these diseases. The reason is that many, many people do not even know they have these diseases. For individuals who do not have a lot of money you could have them use the public health service for free or with a minimal charge.

There are a lot of psychological indicators that need to be examined as well and some of these are shown in slide eleven. The classic one is called the Mental Status Exam. That is, is the client in the here and now? Are they hallucinating? Are they going through withdrawals? Etc. All of that is very, very important. You also need to examine for mental problems including is the client bouncing off the wall? Do they appear depressed, etc? And finally, are these individuals ready for a behavioral change? How motivated are they? Or, don't they even see that they have a problem? That can relate to denial or they do not really have a problem. So one needs to ensure that the person is having a problem when they are doing the evaluation.

Now there are a variety of sociological indicators that one wants to examine as well and some of these are listed in slide twelve. For example, what is going on in the family relationships? What is going on in their other relationships with their friends, etc? Are they employed? Do they have legal issues? Do they have living issues such as homelessness? Or do they have a sanction for the lack of a behavioral change? For example, if they do not make a behavioral change do they lose their spouse? Do they lose their job? Or don't they have any sanctions for anything.

Now ultimately, when one gets through the entire process one will have a variety of results. The results are then used to develop a diagnosis. This diagnosis is based on the DSM-IV. The DSM-IV is the diagnostic and statistical manual of the American Psychiatric Association and it was also developed with the assistance of the American Psychological Association. The DSM-IV views disorders as having both mental aspects and physical components. Ultimately the system is related in part to the International Statistical Classification of Diseases and Related Health Problems or for short, what is called the ICD-9 or ICD-10 codes.

The ICD-10 codes are the official coding system used in the United States. All diagnoses are given a numerical number and these are found in the DSM. These numbers are used to report diagnostic criteria to government agencies, to private insurers, the World Health Organization, etc. This diagnosis is mandated if you want to get any third party payments.

There have been several versions of the DSM and as we can see in slide fifteen earlier versions of the DSM/ considered mental disorders to be different from physical disorders. In addition, the versions of the DSM changed as the areas of psychiatry and psychology changed. For example, the earliest versions of the DSM relied heavily on psychoanalysis while the third edition had more of a behavioral emphasis.

Today as we see in slide sixteen, we recognize that there is a lot of physical information and physical changes which what we call "mental disorders." And, there are a lot of mental changes with "physical disorders. So basically, the newest versions of the DSM recognize that there are no precise boundaries between the concept of mental and physical disorders.

Generally the DSM today recognizes that mental disorders have several major aspects. The first one is that they have behavioral aspects. They also have psychological aspects and physical aspects. Further, there can be overlap between all three groups or they can be totally independent.

The DSM also differentiates other behavior and some of this is shown in slide eighteen. For example, the DSM does not include things such as deviant behavior. These deviant behaviors can be classified as political, religious, or sexual aspects. It also does not recognize issues of conflict between individuals and society unless the deviant behavior is indicative of some kind of dysfunction within the individual.

Further, as seen in slide nineteen, the DSM also does not assume that each category is distinct from every other category. That is, often disorders cross a variety of different categories and cross boundaries as well from both physical and mental aspects.

Regardless of what one thinks about the DSM the DSM classification is only the first step in a comprehensive evaluation. Usually you need lots of other information as well to have a thorough diagnosis and ultimately to place your client correctly. The guidelines in the DSM are only offered as that, guidelines. Basically what the guidelines reflect is a consensus of the field. It does not encompass anything and as time goes on some of the aspects will change.

The DSM as we see in slide twenty-one has five diagnostic categories. I have listed these here for your review. Axis one reflects clinical disorders. Axis two looks at personality disorders and aspects of mental retardation. Aspects of Axis three are generally related to medical conditions such as Hepatitis. Axis four looks at a variety of psychosocial and environmental problems and issues that may be contributing to some of the other aspects in the other diagnostic categories. Axis five has a global assessment of functioning, that is, how well is the client functioning in the here and now? Of course axis four and five and maybe even axis three will have changes as an aspect of a diagnosis.

Substance disorders as seen in slide twenty-two are part of axis one. However, some aspects of the client’s symptoms may also fit into another axis. For example, aspects of Korsakoff's Syndrome which often occurs in alcoholism basically fits into axis three as an organic mental disorder. Secondary Diabetes as a result of a variety of things can fit here as well.

Within the substance disorder category there are basically three major categories and I have listed them on slide twenty-three. They include substance intoxication, substance abuse, and substance dependence.

Let's talk about substance intoxication on slide twenty-four first. Basically substance intoxication refers to the development of a reversible substance-specific symptom due to some kind of ingestion or exposure to some particular substance and that can be a variety of different things. It also has aspects of clinical maladaptive behavior that must occur due to the effect of the substance on the central nervous system. The symptoms of the substance disorder are not due to another medical, pathological, psychological, psychiatric disorder as well.

Substance abuse as we see in slide twenty-five is a little bit different. Basically, what the client has to have one of the following symptoms in the last twelve months. Classic example is substance use that results in a failure to fulfill an important obligation. Classic example is you get drunk too much you miss work. Or, a recurrent substance use in a situation in which it is physically hazardous to do so, such as getting a DWI, or getting some kind of arrest or something. Another symptom on could get is a continued substance use despite having persistent or recurrent social or interpersonal problems caused by the substance. That is, you continue to use the substance despite knowing that it gets you in all sorts of trouble.

Substance dependence is a little different than substance abuse and this is shown in slide twenty-six. Basically what you have here is you have to have had three or more symptoms in the last twelve months, two of these are the key variables. Tolerance which is, you have to have more and more of the drug to get the same effect and withdrawal symptoms that is when you stop taking the drug you start getting a variety of symptoms that are the opposite of the drug you were taking. The other symptoms are there for you to take a look at, as well.

Now, there are other components of the diagnosis that go along with the DSM/ and this is especially true for substance abuse and substance dependence. That is, mental functioning states is very important because there may be various environmental aspects going along with that. For example, as we see in slide twenty-seven, the person, because of their substance abuse or dependence, may not have housing. They may have an environmental issue of being homeless. If the spouse is also a user, that can contribute. So basically axis four and five, as we see at the bottom of slide twenty-seven, helps to qualify the diagnosis we see in axis one, two, and three.

So, what about substance dependence? As we can see in slide twenty-eight, the diagnosis can be included if the client is currently physically dependent on the drug or not physically dependent on the drug. This will have an impact on the placement of the client when placing them in a facility.

The DSM as seen in slide twenty-nine has some limitations. However, just as a point to note, even though it does have some limitations it is probably the best document we have at the current time. So let's talk about some of these limitations. First of all, it has a heavy reliance on clinician judgment. Now these can be reduced with a variety of diagnostic assessments, instruments and tools, however those tools have to be good as well. Furthermore, the diagnostic criteria are less valid with certain populations. It also does not capture levels of drinking involvement. For example, are you really a binge drinker or are you less that that? It also provides little help when looking at motivation aspects or treatment planning aspects. Those are more of a treatment issue.

The DSM does have some advantages and some of these are listed in slide thirty. First of all and probably the most important of all of these is that it provides a common matrix for everyone to use. That is, it has things based on good reporting, etc. I should be able to come up with the same diagnosis as another clinician using the same information. The DSM also has ties to the medical community and it also has tie INS with ASAM Placement Criteria. Finally, and one of the most important aspects for substance abuse is that it measures other psychiatric problems that go along with substance abuse. Substance abuse does not often occur alone. It often occurs in conjunction with various other psychiatric difficulties. And, co-occurrence or what we call co-diagnosis or dual-diagnosis, often times increases the diagnosis complexity. The DSM is also necessary for court cases. And, as we talked about earlier, it is the diagnostic system one has to have for use in third party payments. The DSM diagnosis is not an option anymore, you have to have it and you have to know how to use it.

There are also other scales used with the DSM however they are not designed to replace the DSM. They are used to help in furthering the diagnosis. I have listed some of these on slides thirty-one and thirty-two. As you can see there is a wide variety of different ones and they cover all sorts of different aspects that may be related to substance abuse.

Now one of the major aspects that go along with developing a diagnosis is having the client help you in providing the information. Often times clients are not motivated to do that or clients may not even be ready to make any changes in their use patterns. On of the areas and one of the models that help us with this is what we call motivational interviewing. One aspect of motivational interviewing is what we call Stages of Change. Basically, Stages of Change help us to understand the addictions process and where the client is in the here and now. It has several stages so let's walk through each one of these.

In the pre-contemplation stage as seen in slide thirty-four, the client really has no intent to change. There may be under-awareness of the problem or even what is going on. The pros of consuming basically outweigh the cons. There is also no self-efficacy or what we call self-confidence that one may make a change. The client may be demoralized because of trying to make a change in the past and nothing has worked. Finally, it relates to aspects such as, coercion, denial, and resistance to change as well.

The contemplation stage basically begins to make some changes in the clients thinking. In this stage the client actually begins to think about making a change. They seek information about making some changes and they begin to evaluate the pros and cons of doing so. However, there is no concrete change effort enlisted.

In the preparation stage as seen in slide thirty-six, the client begins to actually develop some kinds of strategies and solutions for a change. There may be a timeline developed. There may actually be some actions being taken. There is also an awareness of lessons from the past. That is, the failed attempts the client has tried to do to make a change and they begin to modify these behaviors a little bit differently. It also links some kind of action plan to contemplation. That is, the client tries to make something to help themselves.

In the action stage as we see in slide thirty-seven, the client becomes actively engaged in some kind of behavioral change usually lasting for six months or more. In this stage the client is beginning to acquire skills. They are employing strategies to help control the particular behavior and the behavioral contexts. That is why we call it transtheoretical because it is using multiple aspects of different models.

Finally, as we see in slide thirty-eight the client enters a maintenance stage. Here the client has made the behavioral change and basically what it is doing is working on sustaining the gains made regarding some particular issue. They also try to prevent or avoid relapse by going back to the previous behaviors. They may terminate when confident or secure in maintaining the change or they may go back to an earlier aspect of the cycle to achieve the particular goal.

So how good is motivational interviewing or transtheoretical change models? As we see in slide thirty-nine they provide a very good framework to determine where the client is in relation to making a behavioral change. This does not necessarily mean for substance abuse, it can be for all sorts of behaviors. However, the model can be used in a wide variety of contexts including prison settings, treatment centers, physician's offices, etc.

Motivational interviewing is also a good way to help the client recognize or do something about the particular problem they are experiencing. It is a very good methodology to use when people are reluctant to change.

Some of the major points of motivational interviewing models are shown in slide forty-one. For example, there is a major de-emphasis on the label. There is an emphasis on personal choice and responsibility for deciding on particular behaviors. Further, and probably more importantly, the treatment goal for the client and the therapist are negotiated. It is not the therapist telling the client what to do. The client’s role and the client’s involvement and the client’s acceptance of the particular treatment program and the treatment plan are vital for any kind of permanent change. If the client does not have "buy in" they probably are not going to do it. So, working together gives a lot of power to making the behavioral change.

Now, there is a wide variety of methods the therapist or counselor can use and some of these are shown in slide forty-two. For example, help the client by just giving some advice or help the client to remove some barriers to making the change. It can provide empathy, provide feedback, and help the client clarify a variety of goals that they are trying to have.

Now we have gone through looking at the client and getting all sorts of information. We've diagnosed him and got some kind of idea about what we think is going on. Once we have this plan assessed then we need to place them in some kind of treatment. This treatment uses what we call the ASAM Criteria which we will talk about in a few minutes. Basically, what it allows us to do is have the client placed on a variety of specific dimensions and put in type of treatment plan or treatment model. Assessment also requires that once the client is in some kind of treatment program is that you continue some kind of ongoing evaluation after treatment placement. If you do not provide this ongoing evaluation you may lose quite a bit of information and really not do your client a whole lot of good.

So, in conclusion as we see in slide forty-four, there are lots of aspects to screening, assessment, and treatment placement for a particular client. However, whatever the process might be it has to be reliable and more importantly as I have talked about earlier in this section it must be able to stand up in court. If your diagnosis can't stand up in court it is not worth any kind of statement.

Well that concludes this section for screening and assessment. In the next section we are going to start talking about screening instruments. So, until then we hope you have a great day and we look forward to talking with you soon.

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