Hello everyone and welcome back. In our past sections we have been talking about screening and assessment instruments. In this section I would like to talk about a few other assessment issues that are important. So let's begin by going to slide two.

First of all there are a lot of other issues one needs to consider when one is conducting assessments. Some of these issues relate to dual diagnosis, the elderly, and the juvenile populations.

Let's talk about dual diagnosis first. The basic question that goes along with dual diagnosis issues is whether the alcohol or drug causing the psychiatric or psychological problems or is the psychiatric problem causing the alcohol or drug use? The classic example is bi-polar clients. Bi-polar clients often self-medicate and as a result of that, they may be taking stimulants, mainly methamphetamines, to help control some of the symptoms and to help them to keep on task. When they are not using they feel different. Further, alcohol and other drug problems can cause a lot of other disorders to occur or reoccur. That is, they can cause a lot of psychiatric/psychological problems to begin to manifest symptoms and they can worsen other disorders. In addition, alcohol and drug withdrawal can often times mimic psychiatric problems or psychiatric conditions. For example, individuals undergoing withdrawal from alcohol often develop what are called delirium tremens. These relate often times to looking exactly like hallucinations, delusions, and assorted things. Medications can also interfere with the assessment process too. For example, some of the medications we take to make you more relaxed, etc, can interfere with the way the person is recalling the information or etc.

Now, there are a lot of symptoms that may be interpreted as being resistant to treatment as in relation to identifying individuals that are having alcohol or drug problems. For example, individuals that are having anxiety disorders or are phobic often times do not like to work in groups. For example, if you are putting a person in AA or NA and they do not have a very good time working in groups, what they are going to be identified as is being remote or resistant. In addition, some people with manic or psychotic behavior might actually begin to experience a lot of these behaviors and demonstrate these behaviors when they are in groups and especially when they are in groups.

As a result of both of these kinds of issues the client is often identified as being resistant to treatment and as we see in slide five, this has major implications if the criminal justice system is involved. Often times the symptoms can also be identifies or misidentified as relapse issues that have gone on. So consequently all these things can have an impact on whether the client is basically put back in the prison system or not.

Another big problem that occurs in the alcohol and drug clients, especially if they are having hallucinations or delusions, etc, as a result of their drug use is trying to determine whether or not the drug is causing the behavior or if the behavior is causing the problematic drug use. Here is a classic example, let's take an alcohol drug client. They go to substance abuse treatment land and they are told they need to get their psychotic behavior or disorder under control first and then come back to the substance abuse treatment folk to get help with their substance abuse. So the person goes over to mental health land. And in mental health land they are told to get their substance abuse under control before they come back to see the individuals regarding their other psychotic behavior. So, as a consequence, the client becomes lost in the middle. This often happens when you have a lot of turf battles going on between alcohol treatment land and mental health land. The solution, of course, is gatekeeping. That is, the gatekeeper evaluates both conditions regardless of the door they enter. For example, the individual entering mental health land would also be evaluated for substance abuse disorders. And a person entering substance abuse treatment land would also be evaluated for mental health issues. So, consequently when a person does have one or the other they are referred to the other agency. This ultimately allows a team approach to be given in relation to client treatment and basically what we use is both teams to help the client in relation to treatment planning.

In essence, for an individual who may be dually diagnosed, as we see in slide seven, after screening, basically what you have to do is the full assessment. That full assessment should include medical aspects, mental health aspects, alcohol and drug use, and a wide variety of other issues as well. This also becomes more difficult when the client has some kind of HIV/AIDS related dementia or some other kind of dementias as well. So consequently, memory loss and other behaviors which often occur in substance abuse land can have a major impact of a variety of assessments and ultimately in treatment.

The elderly, as we can see in slide eight, also have other issues one needs to be aware of when doing screenings and assessments. For example, the elderly may be very resistant to assessment and even treatment. They may also have a wide variety of legal issues going on as well including DWI's, etc. These may be related to the problems the client is having. Furthermore the elderly may have related problems that are contributing to the alcohol or drug abuse. For example, depression or if they are on multiple medications, organ failure, brain functioning problems, etc can all have major impacts on whether or not the client is using. Further, the using by the client can have impacts on each of these aspects as well. So basically, it is a reciprocal process. An individual that is depressed due to the loss of a spouse may be drinking very heavily and as a result of that be experiencing even more depression than they were originally.

Further, as we see in slide nine, you need to be careful when working with the elderly. For example, a wide variety of medications, especially combination medications, and other brain disorders can mimic a lot of alcohol and drug abuse symptoms. And a lot of these disorders can mimic a lot of dual diagnosis issues as well. So if you do have a client who is elderly and they are on medications it is best to consult with your general practitioner, your resident psychiatrist or even a pharmacologist/pharmacist to discuss some kind of interactive effects of the particular medications the client may be taking. I have known elderly individuals who were taking twenty to twenty-five different medications each day and as a consequence of that their behavior was extremely psychotic. They were all over the place in relation to the symptoms they were experiencing. And so it took a good general practitioner and pharmacologist working together to get this person stabilized on their medications, by eliminating over fifty percent of them to get them on task.

Juvenile clients as we see in slide ten, also have a wide variety of issues that one needs to be aware of when conducting screening and assessments. First of all you need to remember the juvenile clients are not the same as adults. They also have a wide variety of different protections and different requirements for assessments that one needs to be aware of. And you need to be aware of within your own state. Juveniles are also not to be considered as adults. As a consequence, depending on how old they are they may have no protection in a wide variety of areas so you as the counselor need to know these laws very, very well. Juvenile clients also react differently to questions and a wide variety of assessment instruments. Consequently, their results and their answers may be totally different from a client who is an adult who may have the same kinds of symptoms. Juvenile clients really do not have a large life history except for their childhood history. And they may not have experienced a whole lot of the symptoms or problems found in many adults so consequently when one is working with a juvenile client you need to remember that they are not the same. They are not the same as an adult client and you have to treat them accordingly. You do not have to treat them like a child but you do need to understand about where they are coming from. Consequently, even though we in substance abuse treatment land often put the youngest treatment staff member working with youth clients. Often times an individual who is very experienced may be more applicable for working with them.

So as we see in slide eleven, there are lots of things to consider when conducting screenings and evaluations. It is not as simple as asking a few questions and getting some answers to use toward making a determination if the client has a substance abuse problem or not. Good screening and good assessment requires a lot of training and requires lots and lots and lots and lots of practice before one is very, very good at it. Finally, there is always the client out there that will totally just blow you away with their answers, with their behavior, and you will have no idea where they are coming from. This is not uncommon in this field. So if you are moving into the field just be aware that that occurs.

Well, that concludes this section related to screening and assessing issues. In our next section we are going to talk about client placement and how that is important in relation to putting client appropriately into treatment. So until then, we hope you are having yourself a great day and we look forward to talking with you soon.

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